1. The nurse documents on the facility’s electronic documentation system located in each client’s room. Which actions by the nurse maintain confidentiality of the documented information? (Select all that apply.)
• Refuse to leave the computer screen open so that family can review.
• Shut of the computer after documenting and before leaving the room.
• Use the nurse’s personal password for access to the client’s record.
• Share a password so a colleague can document on the client’s record.
• Explain to visitors that information about the client cannot be shared.

2. Upon assessment, the nurse notes a client has an enlarged thyroid gland. Which other assessment information does the nurse expect to find from the health history related to this condition? Select all.
• Bradycardia
• Nervousness
• Weight loss
• Constipation
• Dry coarse skin
• Exophthalmos

3. The nurse interviews a client diagnosed with substance abuse. The nurse knows which populations are at risk for abusing substances. (Select the correct answer)
• Persons who try substances at an early age.
• Persons undergoing significant stress.
• Persons who are or have been abused.
• Persons with a genetic predisposition to addiction.
• Persons living in a family with addiction.
• Persons diagnosed with clinical depression.

4. The nurse teaches the UAP about hand hygiene. Which statements does the nurse make? Select the correct answers.
• Wash hands during client care if contaminated with body fluids.
• Perform hand hygiene before removing gloves will be worn.
• Perform hand hygiene even if gloves will be worn.
• Soap and water must be used for all hand hygiene.
• Wash the hands before exiting the client’s room.

5. The nurse provides care for four clients. Which client does the nurse assess first?
• A client diagnosed with sepsis and who has a fever and needs antibiotics started.
• A client with lower back pain and who is requesting pain medication.
• A client diagnosed with syncope and who reports having “heart palpitations.”
• A client diagnosed with asthma and whose oxygen saturation has dropped to 90%.

6. The nurse assesses the skin of an older adult client. Which finding is of great concern to the nurse? (Select all that apply.)
• Petechiae on upper chest.
• Striae on lower abdomen.
• Cherry angioma on back.
• Red area that does not blanch.
• Seborrheic keratosis on arm.

7. The nurse assesses a client’s visual fields. Which action does the nurse take first to determine if the peripheral vision is normal?
• Brings two fingers from the left side while the client covers the right eye.
• Asks the client to follow the nurse’s fingers in a W-shaped pattern.
• Asks the client? look up, down, and side-to-side in the nurse’s direction.
• Brings a wiggling finger from behind the client’s head forward.

8. The nurse obtains the BP reading of 142/78 mm Hg on an older adult client. Which statement best describes the interpretation of this result?
• The readings are indicative of the category of an “elevated” BP.
• The client’s systolic reading indicates that the client is retaining fluid.
• The systolic reading is most likely related to decreased vessel elasticity.
• The systolic and diastolic reading both support the presence of stage 2 hypertension.
9. The nurse intervenes a new client who states that everything is fine and there is no reason to be in the hospital. Which client behavior indicates a need for the nurse to investigate further before creating the plan of care? Select the correct answer.
• The client looks at the floor when discussing the living arrangements.
• The client begins to cry when talking about a family member that died of cancer
• The client continuously swings the right leg while talking about the disease.
• The client laughs and grimaces when the right arm is moved.
• The client is dressed in tattered clothing, and there is a strong body odour
• The client stares angrily at the nurse when talking about the partner.

10. The nurse plans the assessment of a client’s knee. Which actions does the nurse plan? Select all that apply.
• Requests the client to swing the leg in a circle when standing.
• Asks client to swing the lower leg forward and backward when sitting.
• With the client relaxed with leg extended, moves the patella up and down.
• Asks the client to return to a standing position after squatting.
• Asks the client to squat to the floor from a standing position.
• Supports the flexed knee and has the client extend the leg against the nurse’s hand.

11. The nurse completes a client assessment using the Romberg test. Which observation indicates normal client response?
• Stands and sways for 20 seconds with eyes closed.
• Stands without swaying for 60 seconds with eyes open.
• Stands and sways for 10 seconds with eyes open.
• Stands without swaying for 30 seconds with eyes closed.

12. The nurse provides care for an older adult client who has left-sided weakness. Which action does the nurse include in the client’s plan of care to decrease the risk for falls? (Select all that apply.)
• Assess if the client has experienced any falls in the recent past.
• Assess the client’s level of consciousness and ability to understand verbal commands.
• Evaluate the client’s degree of muscle strength and sensation in all extremities.
• Note abnormalities in vital signs that may place client at risk for falls.
• Monitor the client’s ability to ambulate and determine if assistance is needed.

13. The nurse assesses a client’s chest and back. Which assessment is included as part of the nurse’s inspection? (Select all that apply.)
• integrity of the integument of the thorax.
• Deformities of the anterior thorax.
• Shape of the anterior thorax
• Retractions of the posterior thorax
• Symmetry of the anterior and posterior thorax.