Client Health Assessment Flashcards
7 cards from real CPNRE practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Client Health Assessment flashcards as text
While assessing a client's respiratory status, the practical nurse hears a high-pitched, musical sound on expiration. This finding is best described as:
Answer: Wheezing
Wheezing is a high-pitched, musical sound heard on expiration caused by narrowed airways, commonly associated with asthma or bronchospasm.
A practical nurse is assessing a client's level of consciousness using the Glasgow Coma Scale (GCS). A client who opens eyes to verbal stimulation, makes confused verbal responses, and localizes pain would receive which score?
Answer: 11
Eyes open to voice = 3, confused verbal response = 4, localizes pain = 5, totaling a GCS score of 12.
When assessing a client's lymph nodes, the practical nurse finds nodes that are hard, non-tender, and fixed. This finding is most consistent with:
Answer: Malignancy
Hard, non-tender, fixed lymph nodes are characteristic of malignancy and require immediate follow-up.
A client reports pain that is 8/10 in severity, and the practical nurse observes the client laughing and chatting on the phone. What is the most appropriate nursing action?
Answer: Accept the client's self-report as the most reliable pain indicator
Self-report is the gold standard for pain assessment; behavioral cues do not always correlate with pain intensity, especially in clients using coping strategies.
The practical nurse is assessing capillary refill in a client. Which finding requires immediate follow-up?
Answer: Capillary refill of 4 seconds
Capillary refill greater than 3 seconds indicates poor peripheral perfusion and requires immediate assessment and intervention.
During a nutritional assessment, the practical nurse uses the MUST tool. What does MUST stand for?
Answer: Malnutrition Universal Screening Tool
MUST stands for Malnutrition Universal Screening Tool and is used to identify adults who are malnourished or at risk of malnutrition.
A practical nurse is performing a functional assessment on an older adult. Which tool is most appropriate for assessing the client's ability to perform basic activities of daily living?
Answer: Barthel Index
The Barthel Index measures a client's performance in ten basic activities of daily living such as feeding, bathing, dressing, and mobility.
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