228 final review

level of consciousness

A 10-year-old client was hit in the head by a baseball. He was brought to the emergency room with a diagnosis of rule out head injury. The nurse uses the Glasgow coma scale to evaluate his

acute appendicitis

A 27-year-old woman comes to the emergency department reporting severe right lower quadrant pain. Her temperature is 101.5°F (38.6°C), BP 122/80 mm Hg, pulse 95 beats/min, and respirations 22 breaths/min. What might the nurse suspect the client has?

Rheumatoid arthritis

A 38-year-old woman presents with multiple small joints that are symmetrically involved with pain, swelling, and stiffness. Which of the following is the most likely explanation?

All of the Above

A 45 year old African American male client presents to the ER with complaints of not feeling well the last two days and new onset of breathing difficulty. VS are: BP 188/90mmhg, HR 102, Resp 32, Temp 103.2F, SpO2 86%. Pt is a full code, no allergies, and is alone due to COVID-19 Precuations. As the RN administers oxygen via a NC and completes the assessment what labs do they anticipate being ordered for this patient.

Gastrointestinal bleeding or use of iron supplements or Pepto-Bismol.

A client complains of having black foul-smelling stools. The nurse is aware this may be an indication of:

Heart failure

A client has sought care with complaints of increasing swelling in her feet and ankles, and the nurse's assessment confirms the presence of bilateral edema. The nurse's subsequent assessment should focus on the signs and symptoms of what health problem?

dyspnea

A client in the ED tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding?

meningitis

A client presents to the health care clinic with a three (3) day history of fever, chills, neck pain and stiffness, and headache. The nurse observes an elevated temperature of 102.5° F and pain with rotation of the head side to side and decrease ability to flex the head forward. The nurse recognizes these findings as most likely the onset of what infectious process?

Hemodynamics of the right side of the heart.

A nurse assesses a client's jugular venous pulse to gather information about which of the following?

Eat foods low in sodium. Walk for at least 30 minutes/day Limit alcohol intake to 2 or less drinks per day. Use relaxation techniques to manage stress.

A nurse is preparing a class for a local community group on coronary heart disease. Which of the following recommendations would the nurse include as appropriate for reducing a person's risk? Select all that apply.

The stethoscope's diaphragm should be held firmly against the skin.

A nurse is preparing to perform the physical exam of an adult client. Which of the following statements should guide the nurse's use of a stethoscope during this phase of assessment?

gonnorrhea

A nurse works at a public health clinic and has a client with yellow discharge from his penis. She obtains a culture and sends it to the lab. She knows this is typically associated with what?

occipital

A patient is in for her yearly exam. The patient states "It is difficult for me to read and understand the newspaper anymore." The nurse is completing the assessment and is aware the structure of the brain that influences the ability to read with understanding and is the primary visual receptor center is located in what lobe of the brain?

BP 100/60 mmHg, P 96 BPM, R 20 breaths per min

A woman is brought to the ER complaining of chest and jaw pain. Her vital signs are: Blood Pressure (BP) 150/90 mmHg, Pulse (P) 88 BPM, Respirations (R) 20 breaths per minute. The nurse administers Nitroglycering 0.4mg sublingually. To evaluate the effectiveness of this medication, the nurse assesses for the relief of chest pain and expects to note which of the following changes in vital signs?

Avoiding use of illegal drugs.

As you conduct a health history related to the nervous system, it is important to consider common risk reduction teaching tips for your client. Which is a risk reduction teaching tip for a client at risk for a cerebrovascular accident?

Start at the anterior apices, comparing bilaterally for each site, while moving down to the bases. Continue in the same pattern posteriorly, avoiding auscultation over bony prominences. Listen for a full breath sound at each site.

Auscultation of the client's lungs should be done in a consistent sequence. What is the best way to do this?

Notes that the client demonstrates no response to any stimuli.

During the assessment, the nurse determines that the client's Glasgow Coma Scale total score is 3/15 and:

Have the client identify the aroma of coffee beans.

How would the nurse check the function of CN I (Olfactory)?

Nasal flaring

In a small child, what early sign of respiratory distress would signal the nurse to investigate further

obesity

In assessing the client, the nurse knows the increased risk factors of gastroesophageal reflex disease (GERD). One of them being

An irregular apical pulse.

In your assessment of a newly admitted adult client with symptomatic premature ventricular contractions (PVC's), the client begins complaining about feeling light headed. Upon auscultation of the heart, which of the following findings would you anticipate hearing?

Fifth intercostal space near the left midclavicular line

In your assessment of an adult client, where would you expect to auscultate the mitral area heart sound?

Osteoporosis

Loss of bone density that occurs with greatest frequency in postmenopausal women is called?

breast cancer

Modifiable risk factors such as breastfeeding or exercise decrease the risk of:

Troponin1

Mr. Jones enters the emergency room complaining of chest pain for over 3 hours he is diaphoretic and short of breath. The admitting nurse quickly takes Mr. Jones back to the exam room. The physician orders a lab test to determine if Mr. Jones is having a heart attack. What test is specific to heart damage 2-6 hours after a heart attack?

bronchial

Normal breath sounds auscultated mainly over the trachea area are what type of breath sounds?

emphysema

On inspection of the chest of a 68-year-old Hispanic male patient with a history of COPD, you note the client is barrel chested, thin and having retractions of the intercostal spaces while breathing, he is in tripod position. You note that his lung sounds are quiet and there is a reddish/pink tone to his dark skin. The nurse understands that COPD is an umbrella term for different lung conditions. Which condition do these symptoms point to?

Radial and ulnar arteries

The Allen test is used to assess what artery for patency?

Frequently assess the client using the Glasgow Coma Scale (GCS).

The ICU nurse cares for a patient after a skateboarding accident. This accident resulted in a brief episode of unconsciousness. The patient's scalp and facial lacerations were treated and a dressing was placed on them. Which nursing care measure is the highest priority?

Hyperactive bowel sounds

The client is experiencing diarrhea. Upon auscultation of the abdomen, what would the nurse expect to hear?

Temporomandibular

The client presents to the nurse stating that his jaws feel "stuck". What joint should the nurse assess?

New presence of crackles in lower lobes of the lungs bilaterally.

The client with valvular heart disease is at risk for developing Heart Failure. When monitoring the patient for symptoms of Heart Failure, which assessment finding would be most concerning?

ABG-Arterial Blood Gas

The emergency room nurse is assessing Mrs. Smith. She knows the patient has a history of respiratory illnesses and is presently on oxygen. The physician ordered lab work and the results are in the patients chart. What lab work would the physician review to help determine the best treatment for Mrs. Smith's respiratory status?

Stand erect with feet together, arms resting at sides, eyes open and then eyes closed, note any swaying.

The nurse asks the client to do the Romberg test by asking the client to perform which activity?

tachypnea

The nurse assesses shallow respirations of 35 breaths/minute in a client with extreme anxiety. What would be a correct description of this assessment?

This is decerebrate posturing and results from disruption of motor fibers in the midbrain and brainstem.

The nurse assesses the patient diagnosed with a head injury and notes the patient's arms are stiffly extended, abducted and hyper pronated. The patient's legs are hyperextended with plantar flexion of the foot. Which is the best way for the nurse to interpret the patient's position?

fine crackles

The nurse hears a high pitched, short popping sound during inspiration of a client with pneumonia. The nurse would document what type of lung sound?

The client places a thumb over the pulse point.

The nurse instructs the client to take his own pulse? Which action indicates to the nurse that further instruction is needed?

Empty their urinary bladder.

The nurse is about to conduct an abdominal assessment on the client. Before beginning an abdominal assessment, what should the nurse ask the client to do?

Superior and inferior vena cava into the right atrium, right ventricle, pulmonary arteries, lungs, pulmonary veins, into left atrium, left ventricle, out the aortic arch.

The nurse is assessing Mr. Jones' heart. She remembers the normal blood flow through the heart is:

Respiratory Rate of 50-60 breaths per minute

The nurse is assessing a 3 day old infant who has been diagnosed with respiratory distress syndrome (RDS). Which assessment finding indicates that the infants respiratory status is improving?

tenderness

The nurse is assessing a client with joint pain and is trying to decide whether is it inflammatory or non-inflammatory. Which of the following symptoms is consistent with an inflammatory process?

ureter

The nurse is assessing the abdomen of a patient in the emergency room. The patient is complaining of left upper quadrant tenderness. The nurse has an educated guess on what organ is causing the pain based on the location. He documents what structure

Pitting Edema

The nurse is assessing the client's left lower extremity and knows the client has a history of heart failure. When assessing the extremity, the nurse notes an edematous area on the lower leg in a dependent position. After pressing with the fingertips on the client's left ankle, the depression does not rapidly refill and the skin remains indented in that area. The nurse knows this can be recognized as:

14/15

The nurse is completing the neurological assessment of the patient. The nurse documents the assessment on the Glascow Coma Scale. The patient opens their eyes spontaneously, orientated x4, and moves to localized pain. The GCS score for this patient is:

Tachycardia.

The nurse is conducting a cardiac assessment on her adult client and notes an apical pulse rate of 120 beats per minute. The nurse knows this heart rate is referred to as:

Popliteal pulse

The nurse is conducting a peripheral vascular assessment on the major pulse sites on the client. The nurse knows for this pulse it is commonly difficult to detect on palpation, while circulation remains adequate and intact:

Auscultation should be performed before palpation and percussion

The nurse is conducting an assessment of the client's abdomen. First, she inspects the abdomen for contour, symmetry, color, scars, and movement. Next, she percusses the abdomen. She performs light and deep palpation, palpating tender areas last. She then auscultates for bowel and vascular sounds. Critique the nurse's technique

Normal and educate the patient with this fact.

The nurse is educating her patient on self-breast examinations. The client explains that she has pain and tenderness of her breasts just before and during menstruation The nurse knows that this finding is:

Lumbar lordosis

The nurse is evaluating an expecting mother of twins. The mother has gained several pounds during her pregnancy. The nurse notes the patient's spine has an exaggerated curve and is considered normal for pregnant or obese patients. This would be documented as:

CN VII - facial

The nurse is examining the client and asks him to smile, frown, puff out his cheeks and close his eyes tightly as the nurse tries to open them. What cranial nerve is the nurse assessing?

Dorsalis pedis pulse

The nurse is examining the client's peripheral pulses and knows palpation on the client's foot lateral to and along the side of the extensor tendon of the big toe, reveals the status of which peripheral pulse?

Ask the client to close their eyes and identify what number the nurse writes in the palm of their hand with a blunt ended object.

The nurse is going to test graphesthesia on the client. What should the nurse explain to the client about the test

hypoxia

The nurse is inspecting the color of the patient's nails. They appear pale or cyanotic looking. The nurse would know that this may indicate:

"Your risk for heart disease will drop greatly if you're able to stop smoking."

The nurse is integrating health promotion education into the assessment of a client's heart and neck vessels. What teaching point addresses the most significant risk factor for coronary artery disease?

Mitral and tricuspid

The nurse is listening to the client's apical pulse and knows S1, the first heart sound, is produced by the closure of which valves?

Aortic and Pulmonic

The nurse is listening to the client's apical pulse and knows S2, the second heart sound, is produced by the closure of which two valves?

hemoglobin A1C

The nurse is obtaining information from Mr. Jones related to his nutritional diet. He states he eats "a lot of fast food". The nurse is concerned about Mr. Jones becoming a diabetic. What lab value would she review to see if Mr. Jones is at risk for being a diabetic?

crepitus

The nurse is palpating during the thorax and lung assessment. She feels a crackling sensation, like bubble wrap or hairs rubbing against each other. She documents this as:

Palpate each artery individually to compare.

The nurse is preparing to assess a client's carotid arteries. Which nursing action would be most appropriate?

Symmetric, strong contraction of the trapezius muscles.

The nurse is ready to document a normal response to testing cranial nerve XI (spinal accessory). What would represent the best description?

Sodium 135-145 mmol/L

The nurse is reviewing the lab values for her patient. She understands that when electrolytes are imbalanced this can cause heart arrhythmias. What lab value would indicate that the patient s electrolytes are within a safe range?

Use a Doppler device to locate the pulse.

The nurse is unable to palpate the dorsalis pedis pulse on an elderly client post-operation. What should her next action be?

Produces red blood cells

The nurse is working with a client who has leukemia, which affects the red marrow of the bones. The nurse understands that which of the following is characteristic of red marrow?

The nurse places a stethoscope over the point of maximal impulse and counts the number of heartbeats for one full minute.

The nurse takes the apical pulse of the client receiving Digoxin, which requires the nurse to know the most accurate heart rate. Which nursing procedure is correct?

In the future, I will lift heavy objects by bending at the knees and keeping my back straight.

The nurse teaches the client about proper body mechanics. Which statement made by the client indicates to the nurse that the teaching has been successful?

Document respirations are WNL (within normal limits)

The nurse walks into the patient's room and discovers that the patient's respiratory rate is regular at 16 breaths/minute. The nurse should:

Palpation may increase or slow the heart rate, changing the strength of the carotid impulse heard.

The preceptor explains to the nursing student that you should always auscultate the carotid arteries before palpating because

So that the client's pattern of bowel sounds is not altered.

The sequence for assessment of the abdomen differs from the typical order of assessment. The main reason auscultation precedes percussion and palpation of the abdomen is:

Eye, motor, and verbal response.

The three components of the Glasgow coma scale include:

spleen

The triage nurse in the ER calls in the next patient to find out the chief complaint. The patient states, "I was playing dodgeball and got hit on the left side of my stomach with a ball. I am having so much pain on the left upper side of my stomach." The nurse can make an assumption that which organ is causing her pain related to the sports trauma?

Vagus Nerve (CN 10)

What cranial nerve facilitates the parasympathetic vasovagal response that occurs when an individual performs the Valsalva maneuver?

A Bruit.

When auscultating a carotid or midline artery, the nurse hears a blowing or swishing sound caused by turbulent blood flow through a narrowed vessel. The nurse knows that this is:

Comparing one side to the other

When determining a client's strength, it is necessary to implement what assessment?

pain

When developing a plan of care for a newly admitted client with a diagnosis of acute myocardial infarction (MI), which of the following would be the priority nursing diagnosis?

Aortic, Pulmonic, Erb's point, Tricuspid, Mitral.

When listening to the client's apical pulse, the nurse knows that she can listen to five areas. These traditional areas of auscultation include:

Increase intake of vitamin D and calcium.

When preparing an education session for a group of women who have been identified as postmenopausal, the nurse should include which teaching point?

Have the child help by placing his hand under yours

When the nurse palpates the abdomen of a child, the child begins to giggle and draw up his legs to his abdomen. Which action by the nurse is best?

Listen at each site for at least one complete respiratory cycle.

Which action by a nurse demonstrates the proper technique for auscultation of the lung fields?

They are heard in the peripheral lung fields.

Which is a correct statement regarding the location of the vesicular breath sounds?

Moist dry skin, non- tenting

You are assessing an 89-year-old client at the community clinic. The patient states they have had diarrhea for the last 24 hours. You complete your assessment. You are aware patients with diarrhea are at risk for several complications except:

An umbilical hernia

You are assessing the patient's abdomen and notice their umbilicus is enlarged, everted and protruding more than 0.5 cm. This may suggest the patient has

Tripod position

You are assessing your patient with a diagnosis of chronic obstructive pulmonary disease. Upon entering the room, you note he is sitting forward with his arms to support his weight. You would document this as:

wheezes

You are assessing your patient's respiratory status. You auscultate and note musical pitched sounds upon expiration. The documentation would be:

biot's respirations

You are performing care for your patient with severe meningitis and brain damage. You notice the respiratory pattern is irregular characterized by varying depth and rate, with periods of apnea. You would document this as:

Asking questions that are straightforward and non judgemental while allowing the patient to voice any concerns throughout the assessment.

You are preparing to assess a 23-year-old male patient who presented with complaints of penile discharge and burning when he urinates. As the RN you understand that the patient may be embarrassed in discussing these problems. It is important to ease the patient s anxiety by:

Document your findings and continue to assess for bowel tones.

You just recieved your patient from the O.R. (operating room) after an abdominal aortic aneurism (AAA) repair. Upon assessment of bowel tones you note that they are absent in all four quadrants. You should

Are high-pitched, musical sounds heard primarily during expiration.

Your client has notable wheezing when you auscultate his lungs. Wheezes (sibilant) are adventitious breath sounds that:

adduction

Your client is being assessed for range of motion on his hip. The client's leg is positioned away from his body and you ask him to move his extended leg toward midline of his body. This range of motion test being assessed is called:

kussmaul

Your patient has just been admitted, they are confused and you notice a fruity scent to his breathe as you lean down to ausculate his lungs. While auscultating you note that his breathing pattern is rapid, deep, and labored. You know that this type of hyperventilation is associated with diabetic ketoacidosis. You document this type of respiratory pattern as:

bradypnea

Your patient just returned from surgery. He complains of pain, you complete your vital signs and note his respiratory rate is 9 breaths per minute. You would document this as:

stress incontinence

a 74 yr old female client reports that she is hesitant to participate in post-operative coughing and deep breathing exercises because coughing makes her urinate. Th nurse understands that she is experiencing:

BRCA gene carrier age sedentary lifestyle alcohol use fibrocystic breasts

breast cancer risk factors include:

perform deep palpation of the abdomen

the nurse is caring for a client with a pulsing abdominal mass, which is suspected to be an abdominal aortic aneurysm. what assessment should the RN avoid while caring for this client?

AST, ALT, Bilirubin

the nurse is performing an abdominal assessment. The male patient has a very distended abdomen due to ascites. The RN understands that this is typically associated with liver failure. What liver function tests would the RN expect to be ordered/monitored?

male clients 15-35 yrs of age

the rn understands that there are no regular screening process in place for testicular cancer and it is important to educate male clients about regular self exams. What age group is most at risk for this type of cancer?

a 62 yr old African American, with family history

what male client would be at highest risk for prostate cancer? According to the ACS (2015) some of the risk factors for prostate cancer are:

Human papillomavirus

when teaching a high school health ed class, the nurse states that which sexually transmitted infection can lead to cervical cancer?