NR-302 Health Assessment I - Set 2 - Part 2

Correct Answer: Explain that repeated readings on separate visits are needed

Classification rests on the average of two or more properly taken readings on two or more occasions, so a single elevated value prompts repeat measurement rather than a diagnosis. Option a is incorrect because one visit cannot separate a true elevation from white coat anxiety, pain, a full bladder, or a technique fault. Labeling a client hypertensive on that basis risks unnecessary treatment. Option b is incorrect because validated upper arm home devices actually predict cardiovascular outcomes better than office readings do. Guidelines lean on them heavily to confirm a diagnosis and to expose masked hypertension. Option c is incorrect because dismissing the value invites the client to skip follow up. A reading in that range needs rechecking, lifestyle counseling, and a plan, even before any label is applied.

Correct Answer: Ancestry, family history and testing guide screening

Race is a social category, not a biological one, and it maps poorly onto genetic ancestry. Sickle cell disease is identified by newborn screening, family history and testing, in clients of any appearance. Option a is incorrect because genetic variation inside any racial group exceeds the average difference between groups. Predicting a hemoglobin disorder from a category built on appearance produces both false alarms and missed cases. Option b is incorrect because how someone looks tells the nurse nothing about which alleles they carry. The defensible questions concern where the family came from, who else is affected, and what the test showed. Option d is incorrect because the sickle allele is frequent in populations from the Mediterranean, the Middle East and parts of India as well. Filing the disease under one racial label is how the second client gets missed.

Correct Answer: It keeps the client unaware of the count

Breathing is normally automatic and unnoticed, so telling a client that respirations are being counted changes both rate and depth. Keeping the fingers on the wrist disguises the count and preserves an accurate result. Option a is incorrect because finger temperature has no bearing on how a chest rises and falls. Warming the hands matters for client comfort during palpation of the abdomen, not for counting breaths. Option c is incorrect because the pulse count is already complete before the respiratory count begins. Repeating it would waste the interval the nurse needs for observing chest movement, and no second rate is being recorded. Option d is incorrect because arm steadiness is not what the technique protects. Voluntary control over breathing returns the moment a client realizes the nurse is watching, and that awareness is the real threat to accuracy.

Correct Answer: Wait fifteen to thirty minutes before measuring

Hot or cold intake changes the sublingual pocket temperature, so an oral reading taken right afterward is unreliable. Waiting fifteen to thirty minutes lets the mouth return to the client's true temperature. Option b is incorrect because a footnote does not repair a falsely elevated number. Once the value enters the record, other clinicians will read it as the client's temperature and may act on it. Option c is incorrect because the rectal route is invasive, uncomfortable, and reserved for infants or unstable clients who need a true core value. A short wait solves this problem without any of that burden. Option d is incorrect because rinsing swaps one artifact for another and cools the mouth below the client's actual temperature. The tissue itself needs time to equilibrate, and no rinse shortens that interval.

Correct Answer: Tympany from air within the bowel

Tympany is a loud, high pitched, drum like note produced over an air filled viscus. Air normally predominates in the bowel, so tympany is the expected note across all four abdominal quadrants. Option a is incorrect because a full bladder gives a soft, muffled thud rising above the symphysis pubis. Dullness marks a fluid filled or solid structure, and it would not extend across every quadrant. Option b is incorrect because flatness comes from tissue holding no air whatsoever, such as bone or the muscle of the thigh. Nothing in a normal abdomen produces that dead stop quality. Option c is incorrect because hyperresonance is a booming note heard over a chest holding too much air. It belongs to emphysema or pneumothorax, and the abdomen is not the region being described.

Correct Answer: The dorsal surface of the hand

Skin on the back of the hand is thinner and carries more thermoreceptors than the palm, which makes the dorsal surface the most sensitive area for judging warmth and comparing one limb against the other. Option a is incorrect because finger pads carry the densest touch receptors and the finest two point discrimination, which suits texture, moisture, lumps and pulsation. Thermal sensitivity is not their strength. Option b is incorrect because the broad bony edge below the little finger transmits low frequency vibration well. Nurses reach for it to feel a thrill or tactile fremitus, not to judge warmth. Option d is incorrect because surrounding a structure between fingers and thumb reveals its position, shape, consistency and mobility. Opposition tells the nurse how a mass moves, yet it adds nothing about heat.

Correct Answer: Behavior, speech, and dress

Behavior gathers facial expression, mood and affect, speech, dress, and hygiene. A flat expression, monotone speech, poor eye contact, and carelessly fastened clothing all sit in that single category. Option a is incorrect because physical appearance is limited to apparent age, sexual development, consciousness, skin color, facial symmetry, and visible distress. Expression and clothing choices are behavioral rather than anatomic observations. Option b is incorrect because nutritional state, stature, and symmetry describe the build of the body itself. How a shirt is fastened tells the nurse nothing about weight distribution or skeletal proportion. Option c is incorrect because mobility rests on gait and on smooth, coordinated, painless joint movement. The client in this scenario has not been observed walking, and no limitation of movement was described.

Correct Answer: "Who would you like involved in decisions about your care?"

Group knowledge is legitimate only as a hypothesis checked with the individual. Asking who the client wants involved keeps the inquiry open and lets this client describe how decisions are actually made at home. Option a is incorrect because it announces a conclusion about the family role before anyone has been asked. Presenting a group trait as settled fact is the definition of stereotyping, and it closes the conversation. Option b is incorrect because bypassing the client to talk with relatives acts on the assumption instead of testing it. Disclosure preferences belong to the client, who has not yet been offered any say. Option d is incorrect because it applies a group label to explain a delay in care. Reading about a culture becomes harmful the moment the nurse treats the reading as a fact about this person.

Correct Answer: Avoid caffeine and smoking for thirty minutes beforehand

Caffeine and nicotine both raise pressure acutely, so the client waits at least thirty minutes after either one and rests quietly for five minutes before the cuff goes on. Option b is incorrect because exertion lifts pressure for several minutes afterward, and stairs count as exertion. A reading taken then reflects the climb rather than the client's resting circulation. Option c is incorrect because fabric under the bladder distorts how pressure reaches the artery, and a sleeve pushed up above the cuff acts as a tourniquet. The cuff belongs on bare skin. Option d is incorrect because cherry picking the lowest number hides the pattern the provider needs. Home monitoring asks for two readings morning and evening across a week, with the whole set averaged.

Correct Answer: Cultural blindness that erases real differences

Claiming not to see cultural difference sounds fair and works as erasure. It defaults every client to the dominant culture's norms and makes disparities impossible to see, name or correct. Option a is incorrect because relativism means understanding a behavior within the client's own cultural context. That requires seeing the difference first, which this nurse has explicitly refused to do. Option c is incorrect because humility begins with examining one's own lens and redressing the power gap with each client. Identical treatment for everyone skips both steps and leaves individual needs unasked. Option d is incorrect because imposition is active pressure to adopt the nurse's beliefs or practices. The statement describes a refusal to acknowledge difference, not an attempt to override a client's practice.

Correct Answer: A Doppler probe with conducting gel

A Doppler probe locates a pulse that cannot be felt. Gel is applied, the probe is held at a shallow angle to the vessel, and the nurse listens for the whooshing arterial signal. Option a is incorrect because the low frequency fork screens vibratory sensation on bony prominences such as the great toe. That test maps posterior column function and reveals nothing about arterial flow. Option b is incorrect because that instrument inspects the interior of the eye, where the examiner searches for the red reflex, the optic disc and retinal vessels. It has no role at the foot. Option c is incorrect because a beam of light aimed across a surface throws shadows that reveal contour, and it also checks pupils and the mouth. Light cannot detect blood moving through a vessel.

Correct Answer: Hyperthermia with an unchanged hypothalamic set point

In hyperthermia the hypothalamic set point stays normal while heat gain outruns heat loss, so antipyretics have nothing to lower. Active external and internal cooling is the treatment for heat stroke. Option a is incorrect because pyrogens raise the set point, and a client in that state shivers and feels cold as the temperature climbs. Hot dry skin after collapse in the sun describes the opposite process. Option b is incorrect because dosing is not the barrier here. Antipyretics work only by resetting a set point that pyrogens have moved, so no larger dose would bring this temperature down. Option d is incorrect because hypothermia means a core value below 95 degrees Fahrenheit, and this client is far above that. Heat exposure drives temperature up, and no rebound cooling phenomenon is described.

Correct Answer: Inspection, palpation, percussion, then auscultation

Every region except the abdomen follows inspection, palpation, percussion, then auscultation. The sequence moves from least invasive to most invasive, so each technique gathers data before the next one disturbs the client. Option b is incorrect because this reversed order belongs to the abdomen alone, where touching the gut first would change bowel sounds. The thorax carries no such risk, so listening stays last. Option c is incorrect because hands reaching the chest wall before the eyes have studied it destroy the resting posture and muscle tone that only looking can capture. Observation must lead. Option d is incorrect because placing the stethoscope first skips the visual survey that tells the examiner where to listen. Percussion also belongs after palpation, not at the very end of this order.

Correct Answer: Physical appearance, under level of consciousness

Level of consciousness sits inside physical appearance. An alert client attends and responds appropriately, while drowsiness with slowed thinking that arouses to voice is lethargy and counts as an abnormal appearance finding. Option a is incorrect because mood and affect describe the emotional tone a client displays, such as anxious, hostile, or tearful. Arousability is a neurologic state, not an emotional one. Option c is incorrect because position and posture record how a client holds the body, for example sitting upright to breathe or lying rigidly still. Neither describes how readily the client can be roused. Option d is incorrect because range of motion is tested by asking a client to move joints fully and without pain. A drowsy response to voice is a level of consciousness finding instead.

Correct Answer: Lift all but the middle finger off

Only the hyperextended middle finger touches the skin, pressed firmly at the distal interphalangeal joint. The palm and remaining fingers absorb vibration and muffle the note, so they are lifted clear of the surface. Option a is incorrect because the blow lands with the fingertip just below the nail bed, which delivers a sharper and more focused strike. A soft pad spreads the force and blurs the note. Option b is incorrect because motion comes from the wrist alone, quick and springy, with the forearm held still. Driving from the elbow makes the tap heavy and inconsistent between one site and the next. Option d is incorrect because a plexor left in contact damps the vibration it just created. Withdrawing immediately after each sharp tap lets the sound develop fully so it can be judged.

Correct Answer: The hard palate and sclera near the limbus

Melanin masks yellow discoloration in the skin, so the least pigmented sites are used. The hard palate and the sclera close to the limbus show bilirubin staining earliest and most reliably in dark skin. Option b is incorrect because forearm skin carries heavy pigmentation that hides a yellow cast entirely. Inspecting it produces a false reassurance, and the nurse would report no jaundice while bilirubin continues to climb. Option c is incorrect because chest wall inspection belongs to a general skin survey rather than a color specific check. Pigment there is dense, and early bilirubin staining will be invisible until the level is very high. Option d is incorrect because the legs and feet are watched for edema, stasis changes and perfusion, not for bilirubin. Pigmented lower limb skin masks yellowing, and chronic stasis discoloration confuses the picture further.

Correct Answer: Social conditions and unequal care drive the difference

Higher rates of hypertension, diabetes and kidney disease in this population are driven mainly by food environment, income, neighborhood, chronic stress from discrimination and unequal access, not by inherited biology. Option a is incorrect because race is a social construct with no consistent vascular anatomy behind it. Treating vessel structure as a racial property is the reasoning that removed race coefficients from kidney function reporting. Option b is incorrect because no single gene set accounts for a gap that persists across income and education levels. Attributing it to inherited salt handling steers attention away from causes that can be changed. Option c is incorrect because carrying one sickle allele is usually silent and is not a recognized cause of chronic hypertension. Mixing an unrelated inherited trait into this explanation compounds the student's original error.

Correct Answer: Hold the dose and notify the provider

An apical rate under 60 beats per minute in an adult is the threshold for withholding digoxin. The nurse holds the dose, notifies the provider, and documents the rate and the action. Option a is incorrect because giving the drug at this rate risks driving the heart slower still. Digoxin lowers conduction speed, and a client can look comfortable right up to the point of symptomatic bradycardia. Option c is incorrect because nurses cannot alter a prescribed dose on their own authority. Splitting the tablet substitutes an unordered amount for a clinical decision that belongs to the prescriber. Option d is incorrect because the apical count already gives the most accurate heart rate available. A shortened radial count is less reliable than what the nurse has, and repeating it only postpones the decision.

Correct Answer: Ask her to show how she uses the inhaler

Nodding may be politeness rather than comprehension, and an inhaler is a hands on skill. Return demonstration through the interpreter is the only evaluation that shows whether she can actually use the device. Option b is incorrect because a yes or no question invites the same agreeable answer the nodding already gave. Clients who understood nothing still say yes, which produces false documentation of comprehension. Option c is incorrect because written material supports teaching only after reading ability in that language is confirmed. Even a perfect handout cannot show whether this client can coordinate a breath with the actuation. Option d is incorrect because charting understanding without evidence records something the nurse never verified. If the technique is wrong at home the drug never reaches the airway, and the chart hides that.

Correct Answer: Start opposite the pain and finish there

Painful areas are palpated last. Provoking pain early makes the client guard for the rest of the examination, so every finding gathered afterward becomes unreliable. Starting on the opposite side preserves a relaxed abdominal wall. Option a is incorrect because heavy pressure on the sore spot at the outset guarantees voluntary guarding within seconds. Every quadrant examined after that will feel rigid whether or not disease is present. Option b is incorrect because skipping the symptomatic area removes the very data the assessment exists to gather. Tenderness, masses and guarding at that site guide the plan, so the region is examined gently last. Option c is incorrect because that maneuver tests rebound tenderness, which hurts a great deal and adds little. It belongs at the end of an examination and only when a provider specifically requests it.