A client is being cared for after a traumatic brain injury. During an initial assessment, the nurse performs the Glasgow Coma Scale and gives the client a score of 8. Which of the following responses from the nurse is appropriate to manage the client’s respiratory rate?

• Administer oxygen via non-rebreather mask
• Remove oxygen and assess the client's pulse oximetry
• Prepare for intubation
• Administer oxygen via nasal cannula

In which situation would it be most appropriate to perform a comprehensive health history assessment on a client?

• A client needs an adjustment on his asthma medications
• A client is being seen for complaints of fatigue
• A client is being seen for a follow-up appointment after surgery
• A client is seeking care for a broken arm

When listening to a client’s heart sounds during auscultation, which sounds would most likely be heard using the bell of the stethoscope?

• S1
• S2
• S3
• High-frequency murmurs

A nurse needs to assess posterior lung sounds in a client. In which position would it be most appropriate to place this client?

• Semi-Fowler's
• Sims' position
• High Fowler's
• Dorsal recumbent

The nurse is performing an assessment of a client’s abdomen. Upon palpation, the nurse feels an abnormal lump in the left upper quadrant that is extremely painful for the client. The nurse is likely palpating which of the following?

• Bilious gallbladder
• Inflamed spleen
• Inflamed appendix
• Enlarged liver

The nurse is performing an initial assessment on a new client in the clinic. Which of the following elements would be included as part of the general survey? Select all that apply.

• Cooperative behavior
• Height and weight
• Prescription medications for heart failure
• Clean appearance
• Complaints of abdominal pain

A nurse is performing an initial assessment on a client who is being admitted to the hospital for exacerbation of heart failure. During the client interview, the nurse wants to assess the client’s background and health history. Which of the following are examples of leading questions that the nurse should avoid? Select all that apply.

• Who do you live with?
• You don't miss doses of your medication, do you?
• Where are you working right now?
• You feel pretty good right now, right?
• Do you have a history of heart disease?

The nurse is caring for a client who arrives at the emergency department after falling down multiple times. Upon initial assessment, the client states, “I am so dizzy I can’t stay standing up.” What is the nurse’s first priority?

• Vital Signs
• Get an EKG (ECG)
• Full neurological exam
• Draw blood

While at a routine clinic appointment, the nurse notes a client with lung cancer is breathing heavily, wearing dirty clothes, and looking disheveled. The client has lost 15 pounds since the last visit. Which of the following statements by the nurse therapeutically assesses the client’s functional capacity? Select all that apply.

• "I am going to arrange for someone to come to your home to wash your clothes"
• "Can you tell me how you are doing at home managing your daily activities?"
• "I am going to contact the social worker since you can't afford to purchase food"
• "Tell me more about your support system at home"
• "Have you noticed that you are more short of breath than usual lately?"

A nurse is palpating a client’s abdomen to check for an abdominal aortic aneurysm during a physical assessment. Which part of the hand would the nurse most likely use to palpate for this finding?

• The palmar surface
• The ball of the hand
• The pads of the fingers
• The dorsum of the hand