HA 4

A teenage boy is embarrassed by his tender and enlarged breast. What would be the most appropriate nursing intervention to help the teen manage this problem

Reassuring the boy that it is both expected and temporary

A client has sustained an injury to the brainstem. Which area would be the primary area for assessment?

vital signs

An 88-year-old woman has been admitted to the acute medical unit for the treatment of a urinary tract infection that is thought to be progressing to urosepsis. When assessing the client's orientation, how should the nurse best gauge the client's orientation to time?

Are you able to month and the year that we are in

The nurse explains to a woman who is 8 months pregnant that her posture shift to compensate for the enlarging fetus is called

Lordosis

Gait observation

arm swing posture weight- bearing stability foot position stride length and cadence of stride base of support

In delivering a presentation on osteoporosis to a high school gym class, the nurse should include the fact that:

Asian population has a higher bone density than the Caucasian population

The nurse is performing a neurologic assessment of a client whose injuries have rendered her unable to follow verbal commands. How should the nurse proceed with assessing the clients level of consciousness (LOC)

Assess clients eye opening and response to stimuli

While completing a neurologic examination the client, the nurse assesses cranial nerve VIII. The nurse would be correct in identifying the function of this nerve as what

Heating and equilibrium

The nurse suspects a client has carpal tunnel syndrome and ask the patient to perform Phalen's test. To perform this test, the patient would

Hold both hands back to back while flexing the wrist 90 degrees and hold for 60 seconds

A 25- year old male presents to the clinic with complaints of pain in the right knee and a locking of the joint. He states he fell and bumped his knee the day before. The nurse suspects a torn meniscus and performs which of the following test

McMurray's

A nurse planning the neurologic assessment of an aging adult. Which age related changes should the nurse be aware of

Reduction of cerebral blood flow

A 72 year old man has been brought to his primary care provider by his daughter, who claims that he has been experiencing uncharacteristic lapses in memory. What principle should the nurse consider in the assessment of this client

Thorough assessment is necessary because changes in cognition

A nurse instructor is teaching a group of students about assessing a client's orientation. The instructor determines that the teaching was successful when the students state that the ability to identify which of the of the following usually is lost first?

Time

A client who has rheumatoid arthritis for many years finds her fingers are drifting to the side. This is referred to as

Ulnar deviation

When reviewing a client's chart the nurse notes a diagnosis of pes planus. The nurse would anticipate the client has:

flat fleet

During a mental health assessment, how can the nurse obtain subjective data? select all that apply.

from the client Listening to the client say something to someone else

The wife of a 65-year-old man tells the nurse that she is concerned because she has noted a change in her husband's personality and ability to understand. He also cries and becomes angry very easily. The nurse recalls that the cerebral lobe responsible for these behaviors is which of the following?

frontal

A client reports having "knock knees". The nurse documents the medical term for is:

genu valgum

A client is brought to the emergency department following a motor vehicle accident in which he sustained head trauma. Assessment reveals a vision deficit in the clients left eye. The nurse should associate this abnormal finding with trauma to what cerebral lobe

occipital

An 85-year-old client comments during his annual physical that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because:

of the shortening of the vertebral column

A group of student is preparing for a quiz on breast cancer and common findings associated with the breast examination. The student demonstrate understanding of the material when they identify which of the following

orange- peel like appearances irregular firm hard lumps dimpling and nipple retraction

A group of students is reviewing material about assessing mental status. The students demonstrated understanding of the material when they identify which of the following as a cognitive ability to be assessed? select all that apply.

orientation thought process judgement memory speech

While inspecting the penis of a client, the nurse suspects herpes progenitalis based on which assessment finding?

painful clear vesicles that erupt

In assessing a client for range of motion of the spine the nurse would observe for flexion, hypertension, lateral bending and:

rotation

A group of students is reviewing information about the male genitalia in preparation for a test. The students demonstrate understanding of the material when they identify which of the following as external genitalia?

scrotum

An adult client has asked the nurse about actions that she can take to reduce her future risk of stroke. What health promotion activity should the nurse prioritize?

smoking cessation

During morning report the nurse learns that an assigned client needs assistance with ambulation due to an unexpected finding of gait. The nurse would document the diagram as which gait? (hook arm picture)

spastic hemiparesis

The nurse is assessing the genitalia of an older adult male client. What would the nurse document as a normal finding?

testes hanging lowing in the scrotum

The nurse is teaching a group of women at a community center. Which of the following statements indicates proper breast self-examination (BSE) instruction?

the best time to perform BSE is 4-7 days after the first day of the menstrual period.

A parent tells the nurse, "I am worried about my 13-year-old daughter. She hasn't started her menstrual cycle yet and my older daughter did when was 11 years old. Which response by the nurse would be most appropriate?

the menstrual cycle usually begins between 10 and 15 years

The nurse is preparing to teach clients at a community center. The nurse notes that the majority of breast. cancers are located in which breast quadrant

upper outer quadrant

The nurse is caring for a client who responds with inappropriate words. The nurse understands which area of the brain integrates the understanding of spoken and written words?

wernicke's area

The nurse notes in order for a client to be able to move her hand to her mouth, she must be able to perform which movement

Flexion

The nurse is collecting subjective data from an 11-year-old girl. After some initial shyness she finally asks, "am i normal? I don't seem to need a bra yet and all my friends do. What if I never get breasts?" The nurse best response would be:

"I understand that it is hard to feel different form your friends. Breasts usually develop between ages 8 and 13 years."

The nurse assessing a client using the Glasgow Coma Scale and obtains a score of 14. The nurse interprets this as indicating which of the following?

Alert and oriented

A mother visits the clinic for a routine visit with her 11 year old daughter. The mother tells the nurse that her daughter has just started puberty. The mother ask the nurse when can she expect her daughter to begin menstruation. The nurse should explain to the mother that menstruation usually begins:

2.5 years after onset of puberty

When evaluating a client's risk for cerebrovascular accident, which client would the nurse identify as being at highest risk?

68- year old African American with hypertension

An aging client is being discharged home. The client lives alone and has atrophy of his olfactory organs. The nurse tells the clients family that it is essential that the client have what installed at home

A smoke detector

The nurse asks a client to explain the saying, "people in glass houses shouldnt throw stones". Which of the following is the nurse assessing?

Abstract Reasoning

During the health history a client reports a decreases in his ability to see. During the physical assessment, the nurse would make sure to assess which cranial nerve?

CN II

The nurse asks the client to move his jaw forward and sideways against resistance and to open his mouth against resistance. This test the integrity of:

CN V Trigeminal

The nurse performs the technique shown when assessing the client. What cranial nerve is the nurse assessing? (face picture)

CN VII

A nurse notices a client is unable to jump rope. In order to be able to jump rope, the shoulder must be capable of skeletal muscle movement

Circumduction

A nurse is taking a health history on a client with musculoskeletal dysfunction. What should the nurse prioritize during this phase of the assessment

Evaluating the effects of the musculoskeletal disorder of the clients disorder

The nurse is performing the Romberg test as part of a client's focused neurological assessment. What finding would constitute a positive Romberg test?

The client moves her feet apart to prevent herself from falling.

A woman has accompanied her 80-year-old husband to a scheduled clinic visit and expresses concern about subtle declines in his cognition. Which principles would guide the nurse's assessment of the client's mental status?

The nurse must different between age-related changes and the sign and symptoms of dementia

When assessing an adult clients rang of motion, the clients is not able to shrug her shoulders against resistance. The nurse would suspect a lesion of cranial nerve

XI

Assessment of a client who has suffered a recent stroke reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the client's level of consciousness as which of the following?

coma

A nurse is performing a nursing assessment of a client suspected of having a musculoskeletal disorder. What should the nurse prioritize during the assessment of a client who has a musculoskeletal disorder

activities of daily living

The nurse is providing care to an older adult female who remakes that she just can't believe that her breasts sag so much. She states it must be from lack of exercise. What explanation should you offer her?

after menopause, the slander and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breast that sag

The nurse is taking the sexual history of an adolescent who has come into the free clinic. What question best assesses the clients need for further information

are you involved in a sexual relationship at this time

While inspecting the vagina, the nurse observes a thin, grayish-white vaginal discharge with a fishy odor. What would the nurse suspect?

bacterial vaginosis

The client record state a client has Heberden's and Bouchard's nodes. The nurse understands these are:

bony overgrowths of the interphalangeal joints seen with osteoarthritis

The nurse is assessing the client for dietary factors that may influence her risk for osteoporosis. The nurse should question the client about her intake of what nutrients

calcium vitamin D

While bathing a client, the nurse observes a thick white cheesy discharge. What would the nurse suspect?

candidiasis

The nurse is asks the client to perform the action shown. What is the nurse assessing? (foot picture)

cerebellar function

When explaining how the nurse would test graphesthesia, which of the following would the nurse include?

client will close the eyes and identify what number the nurse writes in the palm of the clients hand with a blunt- ended object

The nurse is assessing the sexual-reproductive functional health pattern of a 32-year-old woman. Which question is most effective in determining the client's sexual orientation and related risk factors?

do you have sex with men, women, or both

During the nursing musculoskeletal assessment, the nurse assesses the joint movements. On the nurse's instruction, the patient flexed the ankle and toes toward the shin. As what should the nurse record this movement.

dorsiflexion

A client has presented to the emergency department (ED) with a lower leg laceration that she suffered in a motor vehicle accident (MVA). The nurse recognizes the need to screen for alcohol use and will implement the CAGE questions. What question(s) will the nurse ask during the assessment? select all that apply.

have you ever felt guilty about your alcohol use has anyone told you to cut back on your drinking has anyone been annoyed about your alcohol use

In performing range of motion (ROM) with a client, the nurse puts each joint through its full movement. Which joint are capable of abduction and adduction? select all that apply.

hip, thunb

The nurse is preparing to assess clients scheduled for appointments in the community clinic. For which client risk factors will the nurse assess for substance abuse? select all that apply.

history of abuse poverty

As a class project a group of student nurses are developing a care plan for a patient being screened for cervical cancer. When teaching patients about the risk factors of cervical cancer what would the nurse identify as the most important risk factor

human papillomavirus (HPV)

The nurse is describing how to perform a testicular self examination to a patient. Which of the following statements is most appropriate?

if you notice an enlarged testicle or a painless lump, call your health care provider

Muscle strength evaluation in a client with rheumatoid arthritis reveals a grade of 4+. This finding indicates

mild weakness