CPNRE Client Health Assessment 4 — Questions and Answers
Question 1: A practical nurse is assessing a client's peripheral pulses. Which site is most appropriate for assessing circulation to the foot?
- Popliteal artery
- Femoral artery
- Dorsalis pedis artery (Correct answer)
- Posterior tibial artery
Correct answer: Dorsalis pedis artery
The dorsalis pedis artery on the dorsum of the foot is the primary site used to assess distal circulation to the foot.
Question 2: When performing a mental status assessment, which component does the practical nurse evaluate by asking the client to subtract serial 7s from 100?
- Memory
- Concentration and calculation (Correct answer)
- Orientation
- Abstract reasoning
Correct answer: Concentration and calculation
Serial 7 subtraction tests concentration and calculation ability, which is a component of cognitive function in a mental status exam.
Question 3: A practical nurse notes that a client's trachea is deviated to the left. Which condition should the nurse suspect?
- Left-sided pleural effusion
- Right-sided tension pneumothorax (Correct answer)
- Left-sided atelectasis
- Right-sided pneumonia
Correct answer: Right-sided tension pneumothorax
A right-sided tension pneumothorax creates pressure that pushes the trachea away from the affected side, toward the left.
Question 4: During abdominal assessment, the practical nurse should perform the techniques in which order?
- Inspection, palpation, percussion, auscultation
- Auscultation, inspection, percussion, palpation
- Inspection, auscultation, percussion, palpation (Correct answer)
- Percussion, inspection, auscultation, palpation
Correct answer: Inspection, auscultation, percussion, palpation
Abdominal assessment follows the order of inspection, auscultation, percussion, and palpation to avoid altering bowel sounds before listening.
Question 5: A practical nurse is assessing skin turgor in an elderly client. Which finding is expected due to normal aging?
- Skin returns to place within 1 second
- Skin tents briefly and returns within 3 seconds (Correct answer)
- Skin tents and remains elevated for more than 5 seconds
- Skin appears moist and returns immediately
Correct answer: Skin tents briefly and returns within 3 seconds
Decreased skin elasticity in older adults causes mild tenting with a slightly delayed return, which is a normal age-related change rather than a sign of dehydration.
Question 6: Which assessment finding indicates early hypoxia in a client?
- Cyanosis of the lips
- Restlessness and confusion (Correct answer)
- Bradycardia
- Decreased respiratory rate
Correct answer: Restlessness and confusion
Restlessness and confusion are early signs of hypoxia as the brain is highly sensitive to decreased oxygen levels.
Question 7: A practical nurse is assessing deep tendon reflexes and documents a '4+' response. What does this indicate?
- Normal reflex response
- Absent reflex
- Hyperreflexia with clonus (Correct answer)
- Diminished reflex
Correct answer: Hyperreflexia with clonus
A 4+ reflex response indicates hyperreflexia with clonus, which may suggest an upper motor neuron disorder.
CPNRE Client Health Assessment 4
A practical nurse is assessing a client's peripheral pulses.
Which site is most appropriate for assessing circulation to the foot?