CPNRE Client Health Assessment 5

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:

Accepted Answer

Wheezing

Answer

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?

Accepted Answer

11

Answer

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:

Accepted Answer

Malignancy

Answer

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?

Accepted Answer

Accept the client's self-report as the most reliable pain indicator

Answer

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?

Accepted Answer

Capillary refill of 4 seconds

Answer

Capillary refill greater than 3 seconds indicates poor peripheral perfusion and requires immediate assessment and intervention.

CPNRE - Canadian Practical Nurse Registration Examination Practice Test

CPNRE - Canadian Practical Nurse Registration Examination Practice Test

CPNRE Client Health Assessment 5