Assessments exam 3

A client is supine with the head of the examination table at a 30-degree angle. What should the nurse assess at this time? A. hand grasps B. carotid arteries C. cranial nerves D. bowel sounds

b

A student nurse asks the instructor why it is necessary to do a comprehensive health assessment on a new client. What would be the instructor's best response? A. "The comprehensive health assessment integrates all body systems and helps give the nurse an overall impression of the client's condition." B. "It is a better assessment than any other assessment." C. "A new client needs a more complete assessment." D. "You need to know what is going on with the client at that point in time."

A

A nurse is performing a head-to-toe examination of a client. At which point should the nurse first put on gloves? A. Just before the mouth and throat assessment B. Just before the rectal assessment C. Just after the general survey D. Just after the mental status examination

a

An adult client complains of dark stools for the past 3 days. Which lab should the nurse review right away? A. Complete blood count B. Electrolyte panel C. Coagulation studies D. Liver function panel

a

The nurse notes that a client suffers from chronic obstructive pulmonary disease (COPD). Which assessment finding is the nurse most likely to observe in this client? A. Barrel chest B. Positive Babinski sign C. Thyroid enlargement D. Skeletal scoliosis

a

What type of assessment would a nurse perform on a client being admitted to the hospital? A. Comprehensive B. Acute C. Focused D. Screening

a

While performing a scheduled round, the client states he is having pain in his lower back rates it at a 9 our of 10. What is the best response of the nurse? A. Administer ordered pain medication B. Review x-rays on back C. Offer to assist client to bathroom D. Reposition the client and check on him in one hour

a

The nurse should include which important safety checks before leaving a hospitalized client's room? (Select all that apply.) A. Correct tubes and drains intact B. Wearing client identification bracelet C. Bed at mid-level, locked position D. Call bell within reach E. Correct intravenous lines and fluids

a, b, d, e

The nurse is conducting a physical examination of a client who has congestive heart failure. The general survey can provide the nurse with which information? A. edema of the face and limbs B. apical heart rate C. presence of cyanosis D. respiratory rate E. presence of fluid in the lungs

a, c, d

A client has been assigned a nursing diagnosis of fatigue related to anemia as evidenced by pale skin, statements of tiredness, and low hematocrit and hemoglobin values. What would be an appropriate nursing intervention for this client? A. Evaluate adequacy of exercise B. Collaborate with the physician to treat anemia C. Evaluate urinary patterns D. Have the client explain an energy-conservation plan to offset the effects of fatigue

b

Before beginning a physical assessment it is important for the nurse to A. explain to the client in detail how each body system will be assessed. B. acquire your client's written permission to perform the physical examination. C. acquire your client's verbal permission to perform the physical examination. D. explain to the client the purpose of every physical assessment technique you will be using.

b

The nurse is documenting the description and amount of wound drainage present in a Stage III pressure ulcer. Which term should the nurse use to describe bloody drainage observed when the dressing was removed? A. Fibrinous B. Sanguineous C. Purulent D. Serous

b

When doing a shift assessment on a new client, the nurse notes that the popliteal pulses are within normal limits (WNL). How would the nurse chart this? A. Popliteal pulses 3-4+ B. Popliteal pulses 2-3+ C. Popliteal pulses 4+ D. Popliteal pulses 1-2+

b

What symptom(s) found during assessment would cause the nurse to suspect the client may be experiencing sepsis? Select all that apply. A. Blood pressure 124/72 B. Respiratory rate 36 breaths per minute C. Heart rate 75 beats per minute D. Documented or suspected infection E. Temperature greater than 102 °F (38.9 °C) F. Altered mental state

b, d, e, f

An adult client states she has been drinking a very large amount of water since she has begun walking everyday. She has been transported to the emergency room due to acute confusion. Which electrolyte imbalance is most likely the cause of this client's symptoms? A. Hypernatremia B. Hypokalemia C. Hyponatremia D. Hyperkalemia

c

An adult female client is about to undergo a physical assessment conducted by a nurse practitioner at the gynecology clinic. The nurse is preparing the room for a complete head-to-toe examination, along with a genitalia and rectal assessment and screening through the Papanicolaou test. What should the nurse do next before proceeding?A A. Decide whether to alter the process of starting at the head and proceeding to the feet B. Ask if the client wants an observer for the assessment C. Ask for the client's permission to perform the assessment D. Uncover only the part being examined, covering everything else

c

At the beginning of the exam the nurse performs a general survey. What would the nurse assess at this time? A. Oxygen saturation B. Hearing acuity C. Safety D. Pedal pulses

c

The client has decreased sensation in his legs. What additional assessment should the nurse include? A. Surgical site B. Bloodstream infection C. Fall D. Sepsis

c

What type of assessment would the nurse perform when assessing pain after medicating? A. Shift B. Comprehensive C. Focused D. Urgent

c

During which part of a head-to-toe physical examination should the nurse palpate the epitrochlear lymph nodes? A. Head and face B. Neck C. Anterior chest D. Arm, hands, and fingers

d

In order to assess a client's abdominal reflexes, what should the nurse include in the physical examination? A. percussion for abdominal sounds B. auscultation of bowel sounds C. light palpation of each quadrant D. light stroking inward from all quadrants

d

The nurse has reviewed the previous physical assessment notes on a client and sees the following documentation: PERRLA, L 6-4, R 6-4. What is the nurse's best action for follow-up care on this client? A. Perform the Weber test. B. Conduct the Romberg test. C. Refer for ophthalmologist consult. D. Re-assess as needed.

d

The nurse is preparing to assess a client's reflexes. At which point during the assessment should this be completed? A. after assessing the abdomen B. after assessing the anterior and posterior thorax C. after assessing cranial nerve function D. after assessing the motor function of the lower extremities

d

When collecting subjective data, the nurse gives the client time and encouragement to do what? A. Express complaints B. List common findings C. Tell stories about his or her family D. Tell about the client's concerns

d

During the eye assessment, a nurse performs part of the neurologic examination for which cranial nerve? A. XI B. IX C. X D. VII

d facial corneal reflex

The nurse completes the assessment of a client's heart. What should be assessed next? A. abdomen B. lower extremities C. back D. breasts

dd

Epitrochlear nodes are located

the medial surface of the arm 3cm above the elbow