CPNRE Client Health Assessment 5 — Questions and Answers
Question 1: While assessing a client's respiratory status, the practical nurse hears a high-pitched, musical sound on expiration. This finding is best described as:
- Stridor
- Wheezing (Correct answer)
- Rhonchi
- Crackles
Correct answer: Wheezing
Wheezing is a high-pitched, musical sound heard on expiration caused by narrowed airways, commonly associated with asthma or bronchospasm.
Question 2: 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?
- 9
- 11 (Correct answer)
- 12
- 13
Correct answer: 11
Eyes open to voice = 3, confused verbal response = 4, localizes pain = 5, totaling a GCS score of 12.
Question 3: 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:
- Infection
- Inflammation
- Malignancy (Correct answer)
- Normal variation
Correct answer: Malignancy
Hard, non-tender, fixed lymph nodes are characteristic of malignancy and require immediate follow-up.
Question 4: 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?
- Document the pain rating as inconsistent with behavior
- Administer a lower dose of pain medication than ordered
- Accept the client's self-report as the most reliable pain indicator (Correct answer)
- Reassess the client in one hour without intervention
Correct 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.
Question 5: The practical nurse is assessing capillary refill in a client. Which finding requires immediate follow-up?
- Capillary refill of 1 second
- Capillary refill of 2 seconds
- Capillary refill of 4 seconds (Correct answer)
- Capillary refill that varies between fingers
Correct answer: Capillary refill of 4 seconds
Capillary refill greater than 3 seconds indicates poor peripheral perfusion and requires immediate assessment and intervention.
Question 6: During a nutritional assessment, the practical nurse uses the MUST tool. What does MUST stand for?
- Malnutrition Universal Screening Tool (Correct answer)
- Minimum Undernutrition Status Test
- Multi-level Undernutrition Scoring Tool
- Malnutrition and Underweight Systematic Tool
Correct 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.
Question 7: 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?
- Mini-Mental State Examination (MMSE)
- Barthel Index (Correct answer)
- Geriatric Depression Scale
- Timed Up and Go Test
Correct 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.
CPNRE Client Health Assessment 5
While assessing a client's respiratory status, the practical nurse hears a high-pitched, musical sound on expiration.
This finding is best described as: