HESI Exam Review- HA

Flaky, crusty, erythematous skin around areola

mammary Paget disease --> sign of breast cancer

sinuses present at birth

maxillary and ethmoid

Cullen sign (periumbilical ecchymosis) is associated with which disorder?

pancreatitis

Thrill

turbulant blood flow, correlates with murmur, cardiac enlargement (occupies a greater space)

Sigmoid colon is located in which area of the abdomen?

left illiac region

Delayed puberty in males

no testicular growth has occurred by age 14 or no skeletal growth spurt has occurred by age 18

What is Cheyne-Stokes breathing?

periods of deep breathing that alternate with periods of apnea; caused by: heart failure, uremia, drug use, brain damage REGULAR

Barlow maneuver to test for developmental dysplasia

Flex hips to 90 degrees, gently adduct thighs to midline while applying downward and lateral pressure

The nurse is listening to a cardiologist explain the results of a cardiac catheterization to a client and family. The health care provider (HCP) tells the client that a blockage is present in the large blood vessel that supplies the anterior wall of the left ventricle. The nurse determines that the blockage is located in which area? Circumflex coronary artery Right coronary artery (RCA) Posterior descending coronary artery (PDA) Left anterior descending coronary artery (LAD)

Left anterior descending coronary artery (LAD)

The nurse is conducting a health screening clinic and is preparing to test the visual acuity of a client using a Snellen chart. The nurse educates the client about the procedure. Which statement by the client indicates that the teaching has been effective? "Stand 10 feet (3 meters) from the chart and cover 1 eye." "Stand 20 feet (6 meters) from the chart and cover 1 eye." "Stand 30 feet (9 meters) from the chart and read the largest line on the chart." "Stand 40 feet (12 meters) from the chart and read the largest line on the chart."

"Stand 20 feet (6 meters) from the chart and cover 1 eye."

Grading scale for reflexes

4+ = Very brisk, hyperactive, with clonus (rhythmic oscillations between felixion and extension), 3+ = Brisker than average; possibly but not necessarily indicative of disease, 2+ = Average; Normal. 1+ = Somewhat diminished; low normal 0 = No response

A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: A) diarrhea. B) peritonitis. C) laxative use. D) gastroenteritis.

B) peritonitis. Page: 561. Diminished or absent bowel sounds signal decreased motility from inflammation as seen with peritonitis, with paralytic ileus after abdominal surgery, or with late bowel obstruction.

Relaxation or incompetence of the lower esophageal sphincter causes:

GERD

Bronchial Sounds

Heard over breathing airways, not tissue

Dark skinned- visible yellowing of sclera, oral mucosa, palms of hands and soles of feets

Jaundice

"Umbilicus depressed and below abdominal surface"

Specific care is not required

Two sinuses that are accessible to examination?

frontal and maxillary

Borborygmus

- Hyperactive bowel sounds - The sound of hyper peristalsis (stomach growling )

Murphy's Sign

- Place fingers under the liver border and pt holds their breath - Should not elicit pain - Gallbladder inflammation

P-R interval = 0.12 - 0.20 sec (3 - 5 small squares) QRS width = 0.08 - 0.12 sec (2 - 3 small squares) Q-T interval= 0.35 - 0.43 sec

.

Making a purposeful movement toward a target such as reaching for a cup of tea

Intention tremor

Spoon shaped nails and iron deficiency

Koilonychia

Thin nails, depressed and concave

Koilonychia= often associated with anemia

A client is diagnosed with external otitis. Which finding would the nurse expect to note on assessment of the client? A wider than normal ear canal A pearly gray tympanic membrane Redness and swelling in the ear canal An excessive amount of cerumen lodged in the ear canal

Redness and swelling in the ear canal

During an assessment, the nurse uses the "profile sign" to detect: A) pitting edema. B) early clubbing. C) symmetry of the fingers. D) insufficient capillary refill.

B) early clubbing. Page: 506. The nurse should use the profile sign (viewing the finger from the side) to detect early clubbing.

Kyphosis

excessive convex curvature of the thoracic spine

Palpating popliteal pulse

have patient lay in prone position

The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe? A pink-colored tympanic membrane A pearly colored tympanic membrane A transparent and clear tympanic membrane A red, dull, thick, and immobile tympanic membrane

A red, dull, thick, and immobile tympanic membrane

Feels a quarter sized area of pulsation in the left 6th intercostal space along lateral axillary line.

Low frequency gallop heard just before S1

The nurse is caring for a group of clients on the surgical nursing unit. The nurse anticipates that the client who underwent which procedure is most likely to have some long-term residual difficulty with absorption of nutrients? Colectomy Appendectomy Ascending colostomy Small bowel resection

Small bowel resection

Resting tremor is seen in what disease?

Parkinson's

The nurse is performing an ear examination of an 80-year-old patient. Which of these would be considered a normal finding? A) A high-tone frequency loss B) Increased elasticity of the pinna C) A thin, translucent membrane D) A shiny, pink tympanic membrane

A) A high-tone frequency loss Pages: 337-338. A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing loss that occurs with aging. The pinna loses elasticity, causing earlobes to be pendulous. The eardrum may be whiter in color and more opaque and duller than in the young adult.

Patient comes to ER with chest pain that is localized at sternal border and intensifies when palpating the area, what medication would you give them first?

Ibuprofen (Advil)

Fine tremor of the hands when holding arms and hands outstretched, no tremor with resting in the lap or when client is using hand to grasp something

Postural tremor Can be physiological, psychogenic, hyperthryoidism, drugs, caffeine, nicotinic, etc

Tympany or percussion indicates what?

Presence of gas filled bowel loops

Anxiety, dry eyes, palpitations, hot flashes, and weight loss despite having increased appetite, erythema, induration, and thickening of skin overlying shins

Pretibial myxedma associated with Graves disease

The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome? Promote oxygen intake. Strengthen the diaphragm. Strengthen the intercostal muscles. Promote carbon dioxide elimination.

Promote carbon dioxide elimination.

The nurse is assessing a client's muscle strength. The nurse asks the client to hold the arms up and supinated, as if holding a tray, and then asks the client to close the eyes. The client's left hand turns and moves downward slightly. The nurse interprets this to mean that the client has which condition? Ataxia Nystagmus Pronator drift Hyperreflexia

Pronator drift

The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which areas helpful in assessing for pallor or cyanosis? Select all that apply. Sclerae Tongue Nail beds Elbows and heels Mucous membranes

Tongue Nail beds Mucous membranes

Small, round, tense area above clients symphysis pubis is what?

Urinary retention

The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction? "I need to be sure not to go barefoot around the house." "If I cut my toenails, I need to be sure that I cut them straight across." "It is all right to apply lanolin to my feet, but I shouldn't place it between my toes." "I need to be sure that I elevate my leg above the level of my heart for at least an hour every day."

"I need to be sure that I elevate my leg above the level of my heart for at least an hour every day." Rationale: Foot care instructions for the client with peripheral arterial disease are the same as those for a client with diabetes mellitus. The client with arterial disease, however, should avoid raising the legs above the level of the heart unless instructed to do so as part of an exercise program or if venous stasis is also present. The client statements in the remaining options are correct statements, and indicate that the teaching has been effective.

The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome (IBS). Which statement by the client indicates a need for further teaching? "I need to limit my intake of dietary fiber." "I need to drink plenty, at least 8 to 10 cups daily." "I need to eat regular meals and chew my food well." "I will take the prescribed medications because they will regulate my bowel patterns."

"I need to limit my intake of dietary fiber."

A nursing student is asked about the procedure used to elicit Homans' sign. Which response by the student indicates an understanding of this assessment technique? "I will ask the client to raise the legs up to the waist and then to lower the legs slowly." "I will ask the client to raise the legs and to try to lower them against pressure from my hand." "I will ask the client to extend the legs flat on the bed, and I will gently dorsiflex the foot forward." "I will ask the client to extend the legs flat on the bed, and I will grasp the foot and sharply extend it backward."

"I will ask the client to extend the legs flat on the bed, and I will gently dorsiflex the foot forward."

The nurse has provided a client with tuberculosis (TB) instructions on proper handling and disposal of respiratory secretions. The nurse determines that the client demonstrates understanding of the instructions when the client makes which statement? "I will discard used tissues in a plastic bag." "I need to wash my hands at least 4 times a day." "I will brush my teeth and rinse my mouth once a day." "I will turn my head to the side if I need to cough or sneeze."

"I will discard used tissues in a plastic bag."

A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which statement demonstrates that the client correctly understands the instructions for the test? "I will tell you when I see the colored dots." "I will tell you when I see the flash of bright light." "I will tell you when the small object is in my visual field." "I will tell you when the blocks and shapes are in my visual field."

"I will tell you when the small object is in my visual field."

The nurse is performing an assessment on a client with suspected acute pancreatitis. Which complaint made by the client supports the diagnosis? "I have epigastric pain radiating to my neck." "I have severe abdominal pain that is relieved after vomiting." "My temperature has been running between 96°F (35.5°C) and 97°F (36.1°C)." "I've been experiencing constant, severe abdominal pain that is unrelieved by vomiting."

"I've been experiencing constant, severe abdominal pain that is unrelieved by vomiting."

The nurse determines that a client requires further teaching after permanent pacemaker insertion if which statement is made? "My pulse rate should be less than what my pacemaker is set at." "I'll need to call my health care provider if I feel tired or dizzy." "I'll have to avoid carrying the grocery bags into the house for the next 6 weeks." "It's safe to use my microwave as long it is properly grounded and well shielded."

"My pulse rate should be less than what my pacemaker is set at." Rationale: The client should call the health care provider (HCP) if the pulse rate is less than what the pacemaker is set at because this could be a sign of pacemaker or battery failure. Option 1 indicates the client needs further teaching, whereas the remaining options are correct statements.

The nurse is reviewing the procedure for performance of an electrocardiogram (ECG). Which action by the nurse indicates understanding of the correct position for the V1 lead when performing a 12-lead electrocardiogram? "The lead should be placed on the fourth intercostal space left sternal border." "The lead should be placed on the fourth intercostal space right sternal border." "The lead should be placed on the fifth intercostal space left midaxillary line." "The lead should be placed on the fifth intercostal space left midclavicular line."

"The lead should be placed on the fourth intercostal space right sternal border."

The nurse is educating the client about variant angina. Which statement by the client indicates that the teaching has been effective? "Variant angina is induced by exercise." "Variant angina occurs at the same time each day." "Variant angina occurs at lower levels of activity." "Variant angina is less predictable and a precursor of myocardial infarction."

"Variant angina occurs at the same time each day." Rationale: Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, usually in the morning. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower levels of activity than those that previously precipitated the angina. Unstable angina also occurs at rest, is less predictable, and is often a precursor of myocardial infarction.

Hypovolemic shock

- Low BP - High pulse - Cool skin

sensorineural hearing loss

- Signifies pathology of inner ear, cranial nerve VIII, or auditory areas of cerebral cortex - Increase in amplitude may not enable person to understand words -May be caused by presbycusis, which is a gradual nerve degeneration that occurs with aging, and by ototoxic drugs, which affect hair cells in cochlea

Try pulling my arms

- Tricuspid valve - Pulmonary valve - Mitral valve - Aortic valve

Bowel Obstruction S/S

- Vomiting - Absence of stool or gas - Dehydration - Fever - Pressure from excess fluid and gas (distention) - Hypovolemic shock

S3

- ken - tuc - KY - Sometimes called the ventricular gallop - Occurs after s2 - Can be heard in young adults and children, and will usually disappear when sitting up, does not vary with respirations - In adults it can mean heart failure, volume overload, valve problems, high cardiac output states (hyperthyroidism, anemia, pregnancy) - Heard best at apex of heart

The nurse is preparing to perform a Weber test on a client who reports a loss of hearing in one ear. To perform the test, the nurse places the tuning fork in which area? Click on the image to indicate your answer.

1 top of the head Rationale: The Weber test is a valuable assessment test when a client reports hearing that is better with 1 ear than the other. In this test, a vibrating tuning fork is placed on the client's head over the midline of the client's skull. The client is then asked whether the tone sounds the same in both ears or better in one. The client should hear the tone by bone conduction through the skull, and it should sound equally loud in both ears.

tonsil grades

1+ visible 2+ halfway between tonsillar pillars and uvula 3+ touching the uvula 4+ touching each other

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which? Lub-dub sounds Scratchy, leathery heart noise A blowing or swooshing noise Abrupt, high-pitched snapping noise

A blowing or swooshing noise

When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply. An irregularly shaped lesion A small papule with a dry, rough scale A firm, nodular lesion topped with crust A pearly papule with a central crater and a waxy border Location in the bald spot atop the head that is exposed to outdoor sunlight

A pearly papule with a central crater and a waxy border Location in the bald spot atop the head that is exposed to outdoor sunlight Rationale: Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border. Exposure to ultraviolet sunlight is a major risk factor. A melanoma is an irregularly shaped pigmented papule or plaque with a red-, white-, or blue-toned color. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale. Squamous cell carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration.

A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem? A defect in the cochlea A defect in cranial nerve VIII A physical obstruction to the transmission of sound waves A defect in the sensory fibers that lead to the cerebral cortex

A physical obstruction to the transmission of sound waves

The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective? Muffled heart sounds A rise in blood pressure Jugular venous distention Client expressions of dyspnea

A rise in blood pressure Rationale: Following pericardiocentesis, the client usually expresses immediate relief. Heart sounds are no longer muffled or distant and blood pressure increases. Distended neck veins are a sign of increased venous pressure, which occurs with cardiac tamponade.

The nurse is performing a neurological assessment on a client and elicits a positive Romberg's sign. The nurse makes this determination based on which observation? An involuntary rhythmic, rapid, twitching of the eyeballs A dorsiflexion of the ankle and great toe with fanning of the other toes A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed A lack of normal sense of position when the client is unable to return extended fingers to a point of reference

A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed

The nurse is preparing to perform a Weber test on a client. The nurse should obtain which item needed to perform this test? A tuning fork A stethoscope A tongue blade A reflex hammer

A tuning fork

The nurse is preparing to test the sensory function of cranial nerve V in a client. The nurse should obtain which item to test the sensory function of this nerve? Coffee beans A tuning fork A wisp of cotton An ophthalmoscope

A wisp of cotton

The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which of these structures? A) Cerebrum B) Cerebellum C) Cranial nerves D) Medulla oblongata

A) Cerebrum Pages: 621-622 | Page: 660. The cerebral cortex is responsible for thought, memory, reasoning, sensation, and voluntary movement. The other options structures are not responsible for a person's level of consciousness.

During auscultation of breath sounds, the nurse should use the stethoscope correctly, in which of the following ways? A) Listen to at least one full respiration in each location. B) Listen as the patient inhales and then go to the next site during exhalation. C) Have the patient breathe in and out rapidly while the nurse listens to the breath sounds. D) If the patient is modest, listen to sounds over his or her clothing or hospital gown.

A) Listen to at least one full respiration in each location. Pages: 426-427. During auscultation of breath sounds with a stethoscope, it is important to listen to one full respiration in each location. During the examination, the nurse should monitor the breathing and offer times for the person to breathe normally to prevent possible dizziness.

During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. There is no associated rigidity with movement. Which of these statements is most accurate? A) These are normal findings resulting from aging. B) These could be related to hyperthyroidism. C) These are the result of Parkinson disease. D) This patient should be evaluated for a cerebellar lesion.

A) These are normal findings resulting from aging. Page: 659. Senile tremors occasionally occur. These benign tremors include an intention tremor of the hands, head nodding (as if saying yes or no), and tongue protrusion. Tremors associated with Parkinson disease include rigidity, slowness, and weakness of voluntary movement. The other responses are incorrect.

The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply. A) Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. B) As the patient says "ninety-nine" repeatedly, the examiner hears the words "ninety-nine" clearly. C) When the patient speaks in a normal voice, the examiner can hear a sound but cannot distinguish exactly what is being said. D) As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound. E) As the patient says a long "ee-ee-ee" sound, the examiner hears a long "aaaaaa" sound.

A) Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. C) When the patient speaks in a normal voice, the examiner can hear a sound but cannot distinguish exactly what is being said. D) As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound. Page: 446. As a patient says "ninety-nine" repeatedly, normally, the examiner hears sound but cannot distinguish what is being said. If a clear "ninety-nine" is auscultated, then it could indicate increased lung density, which enhances transmission of voice sounds. This is a measure of bronchophony. When a patient says a long "ee-ee-ee" sound, normally the examiner also hears a long "ee-ee-ee" sound through auscultation. This is a measure of egophony. If the examiner hears a long "aaaaaa" sound instead, this could indicate areas of consolidation or compression. With whispered pectoriloquy, as when a patient whispers a phrase such as "one-two-three," the normal response when auscultating voice sounds is to hear sounds that are faint, muffled, and almost inaudible. If the examiners hears the whispered voice clearly, as if the patient is speaking through the stethoscope, then consolidation of the lung fields may exist.

The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are: A) atelectatic crackles, and that they are not pathologic. B) fine crackles, and that they may be a sign of pneumonia. C) vesicular breath sounds. D) fine wheezes.

A) atelectatic crackles, and that they are not pathologic. Pages: 429-430. One type of adventitious sound, atelectatic crackles, is not pathologic. They are short, popping, crackling sounds that sound like fine crackles but do not last beyond a few breaths. When sections of alveoli are not fully aerated (as in people who are asleep or in the elderly), they deflate slightly and accumulate secretions. Crackles are heard when these sections are expanded by a few deep breaths. Atelectatic crackles are heard only in the periphery, usually in dependent portions of the lungs, and disappear after the first few breaths or after a cough.

The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs would reveal: A) dullness. B) tympany. C) resonance. D) hyperresonance.

A) dullness. Pages: 424-425. A dull percussion note signals an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor.

A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble with reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that: A) she may have macular degeneration. B) her vision is normal for someone her age. C) she has the beginning stages of cataract formation. D) she has increased intraocular pressure or glaucoma.

A) she may have macular degeneration. Page: 285. Macular degeneration is the most common cause of blindness. It is characterized by loss of central vision. Cataracts would show lens opacity. Chronic open-angle glaucoma, the most common type of glaucoma, involves a gradual loss of peripheral vision.

The nurse is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition? A. Low serum albumin level B. Low serum transferrin level C. High hemoglobin level D. High cholesterol level

A. Low serum albumin level Rationale: Long-term protein deficiency is required to cause significantly lowered serum albumin levels. Albumin is made by the liver only when adequate amounts of amino acids (from protein breakdown) are available. Albumin has a long half-life, so acute protein loss does not significantly alter serum levels. Option B is a serum protein with a half-life of only 8 to 10 days, so it will drop with an acute protein deficiency. Options C and D are not clinical measures of protein malnutrition.

A client has been treated for pleural effusion with a thoracentesis. The nurse determines that this procedure has been effective if the nurse notes which assessment finding? Absence of dyspnea Increased severity of cough Dull percussion notes over lung tissue Decreased tactile fremitus over lung tissue

Absence of dyspnea Rationale: The client who has undergone thoracentesis should experience relief of the signs and symptoms experienced before the procedure. Typical signs and symptoms of pleural effusion include dry, nonproductive cough; dyspnea (usually on exertion); decreased or absent tactile fremitus; and dull or flat percussion notes on respiratory assessment.

The nurse is caring for a client on a mechanical ventilator who has a nasogastric tube in place. The nurse is assessing the pH of the gastric aspirate and notes that the pH is 4.5. Based on this finding, the nurse should take which action? Document the findings. Reassess the pH in 4 hours. Instill 30 mL of sterile water. Administer a dose of a prescribed antacid.

Administer a dose of a prescribed antacid. Rationale: The client on a mechanical ventilator who has a nasogastric tube in place should have the gastric pH monitored at the beginning of each shift or least every 12 hours. Because of the risk of stress ulcer formation, a pH lower than 5 (acidic) should be treated with prescribed antacids. If there is no prescription for the antacid, the health care provider should be notified. Documentation of the findings should be done after the administration of an antacid. Sterile water instillation is not an appropriate treatment.

In what area of the chest would the nurse expect to auscultate these breath sounds? sound Over the peripheral lung fields Over the manubrium in the large tracheal airways Anteriorly and posteriorly over the major bronchi Throughout the chest and in the bases of the lungs

Anteriorly and posteriorly over the major bronchi

Extensive acne in a body builder

Ask about steroid use and look for other signs of steroid abuse such as male pattern baldness, gynecomastia, decreased testicular volume, hypertension

The nurse is conducting a neurological assessment, including a health history, on a client with a neurological disorder. The nurse observes that the client is having difficulty answering the questions and should perform which action? Ask a second nurse to be present during the interview. Defer both the health history and the neurological examination. Defer the health history and proceed with the neurological examination. Ask the client to give permission for a family member to stay during the interview.

Ask the client to give permission for a family member to stay during the interview.

Which action would the nurse take to test cranial nerve XI, the spinal accessory nerve? Ask the client to clench the teeth. Ask the client to read the letters in a line on a Snellen chart. Ask the client to shrug the shoulders against the nurse's resistance. Ask the client to close the eyes, occlude one nostril, and identify a specific odor such as coffee.

Ask the client to shrug the shoulders against the nurse's resistance. Rationale: The spinal accessory nerve, cranial nerve XI, controls strength of the neck and shoulder muscles. One method of testing this nerve is to palpate and inspect the trapezius muscle as the client shrugs the shoulders against the nurse's resistance. Option 1 tests cranial nerve V, the trigeminal nerve. Option 2 tests cranial nerve II, the optic nerve. Option 4 tests cranial nerve I, the olfactory nerve.

Which is the priority assessment in the care of a client who is newly admitted to the hospital for acute arterial insufficiency of the left leg and moderate chronic arterial insufficiency of the right leg? Monitor oxygen saturation with pulse oximetry. Assess activity tolerance before and after exercise. Observe the client's cardiac rhythm with telemetry. Assess peripheral pulses with an ultrasonic Doppler device.

Assess peripheral pulses with an ultrasonic Doppler device. Rationale: Acute arterial insufficiency is associated with interruption of arterial blood flow to an organ, tissue, or extremity. It is associated with an acutely painful pasty-colored leg. The priority is for the nurse to perform a comprehensive assessment of peripheral circulation. When pulses are difficult to palpate, the Doppler device is useful to determine the presence of blood flow to the area. The Doppler directs sound waves toward the artery being examined, which emits an audible sound. The nurse must document that the pulse was present via Doppler and not palpation. Although the remaining options may be components of the assessment, they are not the priority.

The nurse is teaching breast self-examination (BSE) to a client who has had a hysterectomy. The appropriate instruction regarding when the BSE should be performed is at which time? At ovulation time 7 to 10 days after menses Just before menses begins At a specific day of the month and on that same day every month thereafter

At a specific day of the month and on that same day every month thereafter Rationale: If the client has had a hysterectomy or is no longer menstruating, the BSE should be performed on the same day every month. Options that recommend scheduling related to menses are inappropriate because the client who had a hysterectomy would not be menstruating. It is best not to perform the BSE at ovulation time because of the hormonal changes that occur.

When assessing a client's blood pressure, the nurse hears the first Korotkoff sounds when the reading shows 115 during expiration and 90 during inspiration, what should the nurse do next?

Auscultate client's heart This measured the client's systolic BP Diastolic is when the Korotkoff sounds disappear

The nurse would perform which action to assess for a pulse deficit? Count the carotid pulsations for one full minute. Measure the blood pressure in both the arm and leg. Auscultate the apical heart beat while palpating the radial artery. Place the diaphragm of the stethoscope directly over the skin at the mitral area.

Auscultate the apical heart beat while palpating the radial artery.

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply Auscultating lung sounds Obtaining the client's temperature Assessing the strength of peripheral pulses Obtaining information about the client's respirations Performing a musculoskeletal and neurological examination Asking the client about a family history of any illness or disease

Auscultating lung sounds Obtaining the client's temperature Obtaining information about the client's respirations

During an abdominal assessment, the nurse would consider which of these findings as normal? A) The presence of a bruit in the femoral area B) A tympanic percussion note in the umbilical region C) A palpable spleen between the ninth and eleventh ribs in the left midaxillary line D) A dull percussion note in the left upper quadrant at the midclavicular line

B) A tympanic percussion note in the umbilical region Pages: 539-540. Tympany should predominate in all four quadrants of the abdomen because air in the intestines rises to the surface when the person is supine. Vascular bruits are not usually present. Normally the spleen is not palpable. Dullness would not be found in the area of lung resonance (left upper quadrant at the midclavicular line).

The nurse is attempting to assess the femoral pulse in an obese patient. Which of these actions would be most appropriate? A) Have the patient assume a prone position. B) Ask the patient to bend his or her knees to the side in a froglike position. C) Press firmly against the bone with the patient in a semi-Fowler position. D) Listen with a stethoscope for pulsations because it is very difficult to palpate the pulse in an obese person.

B) Ask the patient to bend his or her knees to the side in a froglike position.

The nurse is assessing the joints of a woman who has stated, "I have a long family history of arthritis, and my joints hurt." The nurse suspects that she has osteoarthritis. Which of these are symptoms of osteoarthritis? Select all that apply. A) Symmetric joint involvement B) Asymmetric joint involvement C) Pain with motion of affected joints D) Affected joints are swollen with hard, bony protuberances E) Affected joints may have heat, redness, and swelling

B) Asymmetric joint involvement C) Pain with motion of affected joints D) Affected joints are swollen with hard, bony protuberances Page: 608. In osteoarthritis, asymmetric joint involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine. Affected joints have stiffness, swelling with hard bony protuberances, pain with motion, and limitation of motion. The other options reflect signs of rheumatoid arthritis.

The nurse needs to perform anthropometric measures of an 80-year-old man who is confined to a wheelchair. Which of the following is true in this situation? A) Changes in fat distribution will affect the waist-to-hip ratio. B) Height measurements may not be accurate because of changes in bone. C) Declining muscle mass will affect the triceps skinfold measure. D) Mid-arm circumference is difficult to obtain because of loss of skin elasticity.

B) Height measurements may not be accurate because of changes in bone. Page: 191. Height measures may not be accurate in individuals confined to a bed or wheelchair or those over 60 years of age because of osteoporotic changes.

During an assessment of a 22-year-old woman who has a head injury from a car accident 4 hours ago, the nurse notices the following change: pupils were equal, but now the right pupil is fully dilated and nonreactive, left pupil is 4 mm and reacts to light. What does finding this suggest? A) Injury to the right eye B) Increased intracranial pressure C) Test was not performed accurately D) Normal response after a head injury

B) Increased intracranial pressure Pages: 662-663. In a brain-injured person, a sudden, unilateral, dilated, and nonreactive pupil is ominous. Cranial nerve III runs parallel to the brainstem. When increasing intracranial pressure pushes the brainstem down (uncal herniation), it puts pressure on cranial nerve III, causing pupil dilation. The other responses are incorrect.

The nurse is preparing to auscultate for heart sounds. Which technique is correct? A) Listen to the sounds at the aortic, tricuspid, pulmonic, and mitral areas. B) Listen by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex. C) Listen to the sounds only at the site where the apical pulse is felt to be the strongest. D) Listen for all possible sounds at a time at each specified area

B) Listen by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex. Pages: 475-476. Do not limit auscultation of breath sounds to only four locations. Sounds produced by the valves may be heard all over the precordium. Inch the stethoscope in a rough Z pattern from the base of the heart across and down, then over to the apex. Or, start at the apex and work your way up. See Figure 19-22. Listen selectively to one sound at a time.

The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply. A) Test for Murphy's sign. B) Test for Blumberg's sign. C) Test for shifting dullness. D) Perform iliopsoas muscle test. E) Test for fluid wave.

B) Test for Blumberg's sign. D) Perform iliopsoas muscle test. Pages: 543-544 | Page: 551. Testing for Blumberg's sign (rebound tenderness) and performing the iliopsoas muscle test should be used to assess for appendicitis. Murphy's sign is used to assess for an inflamed gallbladder or cholecystitis. Testing for a fluid wave and shifting dullness is done to assess for ascites.

During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma? Select all that apply. A) The patient may experience sensitivity to light, nausea, and halos around lights. B) The patient experiences tunnel vision in late stages. C) Immediate treatment is needed. D) Vision loss begins with peripheral vision. E) It causes sudden attacks of increased pressure that cause blurred vision. F) There are virtually no symptoms.

B) The patient experiences tunnel vision in late stages. D) Vision loss begins with peripheral vision. F) There are virtually no symptoms. Pages: 308-309. Open-angle glaucoma is the most common type of glaucoma; there are virtually no symptoms. Vision loss begins with the peripheral vision, which often goes unnoticed because individuals learn to compensate intuitively by turning their heads. The other characteristics are those of closed-angle glaucoma.

The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal? A) A decrease in tear production B) Unequal pupillary constriction in response to light C) The presence of arcus senilis seen around the cornea D) Loss of the outer hair on the eyebrows due to a decrease in hair follicles

B) Unequal pupillary constriction in response to light Pages: 305-308. Pupils are small in old age, and the pupillary light reflex may be slowed, but pupillary constriction should be symmetric. The assessment findings in the other responses are considered normal in older persons.

The nurse keeps in mind that a thorough skin assessment is very important because the skin holds information about a person's: A) support systems. B) circulatory status. C) socioeconomic status. D) psychological wellness.

B) circulatory status. Page: 211. The skin holds information about the body's circulation, nutritional status, and signs of systemic diseases as well as topical data on the integument itself.

The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is aware that this means that the patient's trachea is: A) pulled to the affected side. B) pushed to the unaffected side. C) pulled downward. D) pulled downward in a rhythmic pattern.

B) pushed to the unaffected side. Pages: 262-263. The trachea is pushed to the unaffected side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, and pneumothorax. The trachea is pulled to the affected side with large atelectasis, pleural adhesions, or fibrosis. Tracheal tug is a rhythmic downward pull that is synchronous with systole and occurs with aortic arch aneurysm.

A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he "can't see well" from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include: A) loss of central vision. B) shadow or diminished vision in one quadrant or one half of the visual field. C) loss of peripheral vision. D) sudden loss of pupillary constriction and accommodation.

B) shadow or diminished vision in one quadrant or one half of the visual field. Page: 316. With retinal detachment, the person has shadows or diminished vision in one quadrant or one half of the visual field. The other responses are not signs of retinal detachment.

The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse's intervention? A. The cuff wraps around the girth of the leg. B. The UAP auscultates the popliteal pulse with the cuff on the lower leg. C. The client is placed in a prone position. D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.

B. The UAP auscultates the popliteal pulse with the cuff on the lower leg. Rationale: When obtaining the blood pressure in the lower extremities, the popliteal pulse is the site for auscultation when the blood pressure cuff is applied around the thigh. The nurse should intervene with the UAP who has applied the cuff on the lower leg. Option A ensures an accurate assessment, and option C provides the best access to the artery. Systolic pressure in the popliteal artery is usually 10 to 40 mm Hg higher than in the brachial artery.

A client with a complete heart block has had a permanent demand ventricular pacemaker inserted. The nurse assesses for proper pacemaker function by examining the electrocardiogram (ECG) strip for the presence of pacemaker spikes at what point? Before each P wave Just after each P wave Just after each T wave Before each QRS complex

Before each QRS complex

The nurse is performing a cardiovascular assessment on a client. Which parameter would the nurse assess to gain the best information about the client's left-sided heart function? Breath sounds Peripheral edema Hepatojugular reflux Jugular vein distention

Breath sounds Rationale: The client with heart failure may present with different signs and symptoms according to whether the right or the left side of the heart is failing. Peripheral edema, jugular vein distention, and hepatojugular reflux are all indicators of impaired right-sided heart function. Breath sounds are an accurate indicator of left-sided heart function.

During an examination, the nurse knows that Paget's disease would be indicated by which of these assessment findings? A) Positive Macewen sign B) Premature closure of the sagittal suture C) Headache, vertigo, tinnitus, and deafness D) Elongated head with heavy eyebrow ridge

C) Headache, vertigo, tinnitus, and deafness Paget's disease occurs more often in males and is characterized by bowed long bones, sudden fractures, and enlarging skull bones that press on cranial nerves causing symptoms of headache, vertigo, tinnitus, and progressive deafness

The nurse is assessing a patient's apical impulse. Which of these statements is true regarding the apical impulse? A) It is palpable in all adults. B) It occurs with the onset of diastole. C) Its location may be indicative of heart size. D) It should normally be palpable in the anterior axillary line.

C) Its location may be indicative of heart size. Page: 473 | Page: 492. The apical impulse is palpable in about 50% of adults. It is located in the fifth left intercostal space in the midclavicular line. Horizontal or downward displacement of the apical impulse may indicate an enlargement of the left ventricle.

During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process? A) Hormonal changes causing vasodilation and a resulting drop in blood pressure B) Progressive atrophy of the intramuscular calf veins, causing venous insufficiency C) Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure D) Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities

C) Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure Pages: 504-505. Peripheral blood vessels grow more rigid with age, resulting in a rise in systolic blood pressure. Aging produces progressive enlargement of the intramuscular calf veins, not atrophy. The other options are not correct.

A patient has been admitted for severe psoriasis. The nurse can expect to see what finding in the patient's fingernails? A) Splinter hemorrhages B) Paronychia C) Pitting D) Beau lines

C) Pitting Pages: 248-250. Pitting nails are characterized by sharply defined pitting and crumbling of the nails with distal detachment, and they are associated with psoriasis. See Table 12-13 for descriptions of the other terms.

When using a Doppler ultrasonic stethoscope, the nurse recognizes arterial flow when which sound is heard? A) Low humming sound B) Regular "lub, dub" pattern C) Swishing, whooshing sound D) Steady, even, flowing sound

C) Swishing, whooshing sound Pages: 515-516. When using the Doppler ultrasonic stethoscope, the pulse site is found when one hears a swishing, whooshing sound.

During an assessment the nurse notices that a patient's umbilicus is enlarged and everted. It is midline, and there is no change in skin color. The nurse recognizes that the patient may have which condition? A) Intra-abdominal bleeding B) Constipation C) Umbilical hernia D) An abdominal tumor

C) Umbilical hernia Page: 537. The umbilicus is normally midline and inverted, with no signs of discoloration. With an umbilical hernia, the mass is enlarged and everted. The other responses are incorrect.

When assessing the force, or strength, of a pulse, the nurse recalls that it: A) is usually recorded on a 0- to 2-point scale. B) demonstrates elasticity of the vessel wall. C) is a reflection of the heart's stroke volume. D) reflects the blood volume in the arteries during diastole.

C) is a reflection of the heart's stroke volume. Page: 134. The heart pumps an amount of blood (the stroke volume) into the aorta. The force flares the arterial walls and generates a pressure wave, which is felt in the periphery as the pulse.

The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? "Tactile fremitus: A) is caused by moisture in the alveoli." B) indicates that there is air in the subcutaneous tissues." C) is caused by sounds generated from the larynx." D) reflects the blood flow through the pulmonary arteries."

C) is caused by sounds generated from the larynx." Pages: 422-423. Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the chest wall where they are felt as vibrations. Crepitus is the term for air in the subcutaneous tissues.

The nurse knows that auscultation of fine crackles would most likely be noticed in: A) a healthy 5-year-old child. B) a pregnant woman. C) the immediate newborn period. D) association with a pneumothorax.

C) the immediate newborn period. Pages: 436-437. Fine crackles are commonly heard in the immediate newborn period as a result of the opening of the airways and clearing of fluid. Persistent fine crackles would be noticed with pneumonia, bronchiolitis, or atelectasis.

Which are risk factors for chronic obstructive pulmonary disease (COPD)? Select all that apply. Purified air Cigarette smoking Genetic risk factor Environmental factors Eating plenty of fruits and vegetables Alpha-1 antitrypsin (AAT) deficiency

Cigarette smoking Genetic risk factor Environmental factors Alpha-1 antitrypsin (AAT) deficiency

Nurse is assessing a patient who has decreased LOC. What client response would be expected when pressure is applied to nail bed?

Client pulls away from stimulus

The nurse is planning to test the sensory function of the olfactory nerve (cranial nerve 1). The nurse would gather which items to perform the test? Tuning fork and audiometer Cloves, peppermint, and soap Flashlight, pupil size chart, and millimeter ruler Safety pin, hot and cold water in test tubes, and cotton wisp

Cloves, peppermint, and soap

Wide, convex nail with a nail angle greater than 180 degrees

Clubbing associated with COPD

Anterioposterior to transverse diameter ratio of the chest 1:1, what other finding with the nurse assess for? Increased convexity of the nail fold with a nail base angle > 180 degrees

Consistent with barrel chest--> consistent with someone with COPD --> clubbing Normal anteriorposterior to transverse diameter ratio of the chest is 1:2

The nurse is concerned about the adequacy of peripheral tissue perfusion in the post-cardiac surgery client. Which action should the nurse include within the plan of care for this client? Use the knee gatch on the bed. Cover the legs lightly when sitting in a chair. Encourage the client to cross the legs when sitting in a chair. Provide pillows for the client to place under the knees as desired.

Cover the legs lightly when sitting in a chair. Rationale: Covering the legs with a light blanket during sitting promotes warmth and vasodilation of the leg vessels. The nurse plans postoperative measures to prevent venous stasis. These include applying elastic stockings or leg wraps, use of pneumatic compression boots, and discouraging crossing of the legs. Clients should be encouraged to perform passive and active range-of-motion exercises. The knee gatch on the bed and pillows under the knees should be avoided because they place pressure on the blood vessels in the popliteal area, impeding venous return.

The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery? Cranial nerve I, olfactory Cranial nerve IV, trochlear Cranial nerve III, oculomotor Cranial nerve VII, facial nerve

Cranial nerve VII, facial nerve Rationale: An acoustic neuroma (or vestibular schwannoma) is a unilateral benign tumor that occurs where the vestibulocochlear or acoustic nerve (cranial nerve VIII) enters the internal auditory canal. It is important that an early diagnosis be made because the tumor can compress the trigeminal and facial nerves and arteries within the internal auditory canal. Treatment for acoustic neuroma is surgical removal via a craniotomy. Assessment of the trigeminal and facial nerves is important. Extreme care is taken to preserve remaining hearing and preserve the function of the facial nerve. Acoustic neuromas rarely recur following surgical removal.

Which structure is located in the left lower quadrant of the abdomen? A) Liver B) Duodenum C) Gallbladder D) Sigmoid colon

D) Sigmoid colon Page: 530. The sigmoid colon is located in the left lower quadrant of the abdomen.

While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of: A) a great sense of humor. B) uncooperative behavior. C) inability to understand questions. D) decreased level of consciousness.

D) decreased level of consciousness. Pages: 660-661. A change in consciousness may be subtle. The nurse should notice any decreasing level of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a previously combative person. The other responses are incorrect.

The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to: A) a loud continuous hum. B) a peritoneal friction rub. C) hypoactive bowel sounds. D) hyperactive bowel sounds.

D) hyperactive bowel sounds. Pages: 539-540. Borborygmi is the term used for hyperperistalsis when the person actually feels his or her stomach growling.

new registered nurse (RN) is assigned to the care of a client hospitalized with a diagnosis of hypothermia. After consulting with an experienced RN, which statement by the new RN indicates understanding of likely assessment findings for this client? Increased heart rate and increased blood pressure Increased heart rate and decreased blood pressure Decreased heart rate and increased blood pressure Decreased heart rate and decreased blood pressure

Decreased heart rate and decreased blood pressure Rationale: Hypothermia decreases the heart rate and the blood pressure because the metabolic needs of the body are reduced in this condition. With fewer metabolic needs, the workload of the heart decreases, resulting in decreased heart rate and blood pressure. Therefore, the remaining options are incorrect.

Firm pressure to the nail bed in a patient with decreased LOC

Determines level of consciousness

A group of postmenopausal women are learning to do breast self-examination (BSE) in a teaching session at the clinic. The clinic nurse should teach the group which point about this procedure? Do the exam on the same day every month. Do the exam 7 days after the start of the menstrual cycle. Examine the left breast with the left hand and vice versa. Use the tips of the fingers to increase the likelihood of feeling lumps.

Do the exam on the same day every month. Rationale: Women who are postmenopausal are taught to do BSE on the same day every month. Before menopause, women should do the procedure 7 days after the start of the menstrual cycle, when the breasts are least tender. Each breast is examined with the opposite hand. The pads of the fingers, not the fingertips, should be used for palpation. The client may use a circular, up and down, or wedge method of assessment. Consistency of use of the same method is more important than the actual method used.

The health care provider (HCP) prescribes limited activity (bed rest and bathroom only) for a client who developed deep vein thrombosis (DVT) after surgery. What interventions should the nurse plan to include in the client's plan of care? Select all that apply. Encourage coughing with deep breathing. Place in high Fowler's position for eating. Encourage increased oral intake of water daily. Place thigh-length elastic stockings on the client. Place sequential compression boots on the client. Encourage the intake of dark green, leafy vegetables

Encourage coughing with deep breathing. Encourage increased oral intake of water daily. Place thigh-length elastic stockings on the client.

A patient with chronic pancreatitis should limit what during the diet?

Fat

Older male with scaly spot on the hairline that comes and goes, and sometimes bleeds, what other findings is nurse likely to assess?

Fine lines and wrinkles in skin with rough patches and flat brown marks Squamous cell carcinoma from sun exposure

Nurse evaluating patient with chronic alcohol abuse and cirrhosis

Firm, well defined edge felt at fingertips in RUQ during inspiration

A clinic nurse is performing a cardiovascular assessment on a client and auscultates the chest over the apex of the heart. The nurse should document this finding as which sound? Ventricular gallop First heart sound, S1 Third heart sound, S3 Fourth heart sound, S4

First heart sound, S1

Jumping from one subject to another

Flight of ideas

The nurse in a health care clinic is preparing to test a client for accommodation. Initially, the nurse should ask the client to take which action? Focus on a close object. Focus on a distant object. Close 1 eye and read letters on a chart. Raise 1 finger when the sound is heard

Focus on a distant object.

A client experiencing "skipped heartbeats" is diagnosed with benign premature ventricular contractions and is placed on metoprolol tartrate. The client returns to the health care provider's (HCP's) office 1 month later for a checkup. The nurse should implement which type of database when performing an assessment? Follow-up database Emergency database Complete health database Problem-centered database

Follow-up database

vesicular sounds

Heard over tissue

The nurse has been caring for a client who required a Sengstaken-Blakemore tube because other treatment measures for esophageal varices were unsuccessful. The health care provider (HCP) arrives on the nursing unit and deflates the esophageal balloon. Which assessment finding by the nurse is the most important and should be reported to the HCP immediately? Hematemesis Bloody diarrhea Swelling of the abdomen An elevated temperature and a rise in blood pressure

Hematemesis Rationale: A Sengstaken-Blakemore tube may be inserted in a client with a diagnosis of cirrhosis with bleeding esophageal varices. It has both an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated, the client may begin to bleed again from the esophageal varices, manifested as vomiting of blood (hematemesis). The remaining options are unrelated to deflating the esophageal balloon.

The nurse is performing a neurological assessment on a client who had a stroke (brain attack). The nurse checks for proprioception using which assessment technique? Tapping the Achilles tendon using the reflex hammer Gently pricking the client's skin on the dorsum of the foot in 2 places Firmly stroking the lateral sole of the foot and under the toes with a blunt instrument Holding the sides of the client's great toe and, while moving it, asking what position it is in

Holding the sides of the client's great toe and, while moving it, asking what position it is in

Cranial nerves

I Olfactory (smell) II Optic (sight) III Oculomotor (moves eyelid and eyeball & adjusts the pupil and lens) IV Trochlear (moves eyeballs) V Trigeminal (facial muscles, chewing, facial sensations) VI Abducens (moves eyeballs) VII Facial (taste, tears, saliva, facial expressions) VIII Vestibulocochlear (auditory) IX Glossopharyngeal (swallowing, saliaval, taste) X Vagus (control of PNS, smooth muscles of GI tract) XI Accessory (moving head & shoudlers, swallowing) XII Hypopglossal (tongue muscles - speech and swallowing)

The nurse is testing a client for graphesthesia and asks the client to close his eyes. The nurse should next ask the client to take which action? Identify 3 objects placed in the hand, one at a time. Identify 3 numbers or letters traced in the client's palm. Identify the smallest distance between 2 skin pricks after pricking the skin with 2 pins at varying distances. State whether 1 or 2 skin pricks are felt, after applying sharp stimuli bilaterally to symmetrical areas of the client's skin.

Identify 3 numbers or letters traced in the client's palm.

The nurse is testing a client for astereognosis. The nurse should ask the client to close the eyes and perform which action? Identify an object placed in the client's hand. Identify 3 numbers or letters traced in the client's palm. State whether 1 or 2 pinpricks are felt when the skin is pricked bilaterally in the same place. Identify the smallest distance between 2 detectable pinpricks, made with 2 pins held at various distances.

Identify an object placed in the client's hand.

Teenager with low grade fever and fatigue for x1 month, physical exam positive for cervical lymphadenopathy

Inspection of throat and oral cavity Check for mono and tonsils

The nurse reviews the findings from a physical exam done on a client for ear or hearing disorders and notes documentation that the client has hyperacusis. Which would the nurse expect to note on assessment of the client? Complaints of ringing in the ear An excessive amount of cerumen in the ear canal Intolerance for sound levels that do not bother other people Complaints of dizziness and sensations of being "off balance"

Intolerance for sound levels that do not bother other people

Client has an intentional tremor, what will the nurse most likely assess in this client? Weak hand grasps Poor bicep tone with flexion Involuntary hand shaking when reaching for an item Involuntary mouth and tongue movements

Involuntary hand shaking when reaching for a tremor

A chest x-ray report states that the client has a left apical pneumothorax. The nurse caring for the client monitors the status of breath sounds in that area by placing the stethoscope at which location? Near the lateral 12th rib Just under the left clavicle In the fifth intercostal space Posteriorly under the left scapula

Just under the left clavicle Rationale: The apex of the lung is the rounded, uppermost part of the lung. The nurse would place the stethoscope just under the left clavicle. The other options are incorrect locations.

Gross motor

Larger movements, including whole limb movements and large muscle groups

Maximum impulse or apical pulse is felt where?

Left midclavicular line, fifth intercostal space

The nurse is instructing a client in breast self-examination (BSE). The nurse tells the client to lie down and examine the left breast. The nurse should instruct the client that while examining the left breast she should place a pillow under which area? Left shoulder Right scapula Right shoulder Small of the back

Left shoulder

When auscultating the heart of a patient with mitral stenosis, what position should the patient be in?

Left sided lying

A client sustained a burn from cutaneous exposure to lye. At the site of injury, copious irrigation to the site was performed for 1 hour. On admission to the hospital emergency department, the nurse assesses the burn site. Which findings would indicate that the chemical burn process is continuing? Eschar Intact blisters Liquefaction necrosis Cherry-red, firm tissue

Liquefaction necrosis Rationale: Alkalis, such as lye, cause a liquefaction necrosis, and exposure to fat results in formation of a soapy coagulum. Thick, leathery eschar forms with exposure to acids or heat. Intact blisters indicate a partial-thickness thermal injury. Cherry-red, firm tissue can occur as a result of thermal injury.

The nurse is assessing for the presence of pallor in a dark-skinned client. What finding should the nurse look for? A yellow tinge to the skin Bluish discoloration of the skin Loss of normal red tones in the skin An ashen-gray appearance to the skin

Loss of normal red tones in the skin

A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia? Lying recumbent following meals Consuming small, frequent, bland meals Taking H2-receptor antagonist medication Raising the head of the bed on 6-inch (15 cm) blocks

Lying recumbent following meals

The nurse is reinforcing instructions to a client about the use of an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that which is the primary benefit? Dilate the major bronchi. Increase surfactant production. Maintain inflation of the alveoli. Enhance ciliary action in the tracheobronchial tree.

Maintain inflation of the alveoli. Rationale: Sustained inhalation when using an incentive spirometer helps maintain inflation of the terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such as an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk. The remaining options are not benefits for sustained inhalation.

The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding indicates the presence of this complication? Flat neck veins A pulse rate of 60 beats/minute Muffled or distant heart sounds Wheezing on auscultation of the lungs

Muffled or distant heart sounds Rationale: Assessment findings associated with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention with clear lung sounds, and a falling blood pressure accompanied by pulsus paradoxus (a drop in inspiratory blood pressure greater than 10 mm Hg). The other options are not signs of cardiac tamponade.

The nurse is performing a physical assessment of a client's musculoskeletal system and notes that the client is right-handed. The nurse would document which assessment findings as normal? Select all that apply. Presence of fasciculations Muscle strength graded 5/5 Symmetrical movements bilaterally Increased muscle size on the dominant arm A 1-cm hypertrophy of the right upper arm

Muscle strength graded 5/5 Symmetrical movements bilaterally Increased muscle size on the dominant arm A 1-cm hypertrophy of the right upper arm

A client is admitted to the hospital with a diagnosis of acute diverticulitis. What should the nurse expect to be prescribed for this client? NPO (nothing by mouth) status Ambulation at least 4 times daily Cholinergic medications to reduce pain Coughing and deep breathing every 2 hours

NPO (nothing by mouth) status Rationale: During the acute phase of diverticulitis, the goal of treatment is to rest the bowel and allow the inflammation to subside. The client remains NPO and is placed on bed rest. Pain occurs from bowel spasms, and increased intra-abdominal pressure (coughing and deep breathing) may precipitate an attack. Ambulation and cholinergics will increase peristalsis.

The nurse is providing care to a client admitted for coronary artery disease (CAD) and a history of tobacco use. What is the most important element of the nurse's focused assessment of the client's smoking history? Number of pack-years Desire to quit smoking Brand of cigarettes used Number of past attempts to quit smoking

Number of pack-years

Fungal infection of the nail and nail bed

Onychomycosis Usually causes hyperkeratosis and onycholysis

The nurse is examining a dark-skinned client for the presence of petechiae. The nurse will best observe these lesions in which body area? Sclerae Oral mucosa Sole of the foot Palm of the hand

Oral mucosa

The nurse is assessing a client with a history of cardiac problems. Where should the nurse place the stethoscope to hear the first heart sound (S1) the loudest? Over the second intercostal space at the left sternal border Over the fourth intercostal space at the right sternal border Over the second intercostal space at the right sternal border Over the fifth intercostal space in the left midclavicular line

Over the fifth intercostal space in the left midclavicular line Rationale: The first heart sound (S1) is heard loudest at the lower left sternal border or the apex of the heart. The apex is located at the fifth intercostal space in the left midclavicular line. Therefore, the locations in the remaining options are incorrect.

In what area of the chest would the nurse expect to auscultate these breath sounds? Over the trachea Over the peripheral lung fields Posteriorly at the T4 level medial to the scapula Between the first and second intercostal spaces at the sternal border anteriorly

Over the peripheral lung fields Rationale: Breath sounds are noises resulting from the transmission of vibrations produced by the movement of air in the respiratory passages. Normal breath sounds include bronchovesicular sounds, vesicular breath sounds, and bronchial breath sounds. The sounds that the nurse hears are vesicular breath sounds. Vesicular breath sounds are normally heard over the lesser bronchi, bronchioles, and lobes (peripheral lung fields). These sounds are soft and low pitched and resemble a sighing or gentle rustling; the inspiration phase is longer than the expiration phase. Bronchovesicular breath sounds are normally heard over the first and second intercostal spaces at the sternal border anteriorly and at the T4 level medial to the scapula posteriorly (over major bronchi). These sounds are a mixture of bronchial and vesicular breath sounds and are moderately pitched with a medium intensity. The inspiration and expiration phases are equal. Bronchial breath sounds are loud, high-pitched sounds that resemble air blowing through a hollow pipe. The expiration phase is louder and longer than the inspiration phase, and there is a distinct pause between the inspiration and expiration phases. Bronchial breath sounds are normally heard over the manubrium.

A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which is the best action for the nurse to take? Have one of the client's family members interpret. Have the Spanish-speaking triage receptionist interpret. Page an interpreter from the hospital's interpreter services. Obtain a Spanish-English dictionary and attempt to triage the client.

Page an interpreter from the hospital's interpreter services.

The nurse assesses a client for the presence of Homans' sign. Which could be an indication that this sign is positive? Absent bowel sounds Client complaints of wound pain Pain with dorsiflexion of the foot Crackles on auscultation of the lungs

Pain with doriflexion of the foot Rationale: To elicit Homans' sign, the nurse would dorsiflex the client's foot and assess for pain in the calf area. The presence of pain may indicate a positive Homans' sign. Wound pain and absent bowel sounds are unrelated findings. Crackles on auscultation of the lungs may indicate a respiratory complication. Homan's sign= check for DVT

The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How should the nurse best determine the presence of erythema? Assess for drainage from the wound. Assess for redness around the wound edges. Palpate for swelling around the wound edges. Palpate for increased skin temperature around the wound edges

Palpate for increased skin temperature around the wound edges. Rationale: Erythema is a form of macula characterized by diffuse redness of the skin. In a dark-skinned client, erythema is best determined by palpating for increased skin temperature. Redness around the wound edges may be difficult to note in the dark-skinned client. Swelling and drainage from the wound are not specific indicators of erythema.

Difficulty extending 4th and 5th finger on left hand, what should nurse do next?

Palpate the client's palm to assess for nodules or thickening --> Dupuyten contracture

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? Cyanosis Hypotension Paradoxical chest movement Dyspnea, especially on exhalation

Paradoxical chest movement Rationale: Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest.

Infection of the skin adjacent to the nail

Paronychia

Which assessment technique would the nurse use when determining lung border changes during respiration?

Percussion of the lower posterior lung fields

Nurse is assessing client with type 2 DM, what technique best assess a patients risk for developing foot ulcers Ankle brachial reflex Capillary blood glucose Capillary refill time Pin-prick test

Pin-prick test best assessed for peripheral neuropathy

The nurse is caring for a client after an above-the-knee amputation. The nurse assesses the residual (remaining) limb and expects to note which finding? Pink color to the skin flap Hot feeling on palpation of the skin flap Serous fluid leaking from the skin flap incision Absent pulse at the proximal pulse point site closest to the skin flap

Pink color to the skin flap Rationale: Following above-the-knee amputation, the nurse's primary focus is to monitor for signs indicating that there is sufficient tissue perfusion and no hemorrhage. The skin flap at the end of the residual (remaining) limb should be pink in a light-skinned person and not discolored (lighter or darker than other skin pigmentation) in a dark-skinned person. The area should be warm but not hot. If the area is hot this could indicate inflammation or infection. The incision should be clean and dry with no serous or other fluid leaking from it. There should be a pulse at the closest proximal pulse point. If no pulse is felt, the nurse would assess for a pulse using a Doppler. If no pulse is detected using the Doppler device, this could indicate lack of perfusion and the surgeon would need to be notified.

Which step(s) should the nurse take when administering ear drops to an adult client? (Select all that apply. A. Place the client in a side-lying position. B. Pull the auricle upward and outward. C. Hold the dropper 6 cm above the ear canal. D. Place a cotton ball into the inner canal. E. Pull the auricle down and back.

Place the client in a side-lying position Pull the auricle upward and outward Rationale: The correct answers (A and B) are the appropriate administration of ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the outermost canal (D). The auricle is pulled down and back for a child younger than 3 years of age, but not an adult (E).

The nurse is performing a respiratory assessment and is auscultating the client's breath sounds. On auscultation, the nurse hears a grating and creaking type of sound. The nurse interprets this to mean that client has which type of sounds? Wheezes Rhonchi Crackles Pleural friction rub

Pleural friction rub Rationale: A pleural friction rub is characterized by sounds that are described as creaking, groaning, or grating. The sounds are localized over an area of inflammation on the pleura and may be heard in both the inspiratory and the expiratory phases of the respiratory cycle. Wheezes are musical noises heard on inspiration, expiration, or both and are the result of narrowed airway passages. Rhonchi are usually heard on expiration when there is an excessive production of mucus that accumulates in the air passages. Crackles have the sound that is heard when a few strands of hair are rubbed together and indicate fluid in the alveoli.

The nurse is preparing to interview a client to collect data about the client's health history. The nurse should take which actions to make sure that the physical environment is ready? Select all that apply. Provide sufficient lighting. Set the room temperature at a comfortable level. Ensure that the distance between the nurse and client is no more than 2 feet (60 cm). Arrange seating so that the nurse sits behind the desk across from the client. Make sure that the client will be seated comfortably at eye level with the nurse. Leave equipment needed for the physical exam on the desk so it is readily available.

Provide sufficient lighting. Set the room temperature at a comfortable level. Make sure that the client will be seated comfortably at eye level with the nurse.

The nurse is preparing to perform an otoscopic examination on an adult client. Which action should the nurse take to perform this examination? Pull the pinna up and back before inserting the speculum. Pull the earlobe down and back before inserting the speculum. Tilt the client's head forward and down before inserting the speculum. Use the smallest speculum available to decrease the discomfort of the exam.

Pull the pinna up and back before inserting the speculum.

The nurse is performing an abdominal assessment on a client. The nurse determines that which finding should be reported to the health care provider (HCP)? Absence of a bruit Concave, midline umbilicus Pulsation between the umbilicus and the pubis Bowel sound frequency of 15 sounds per minute

Pulsation between the umbilicus and the pubis Rationale: The presence of pulsation between the umbilicus and the pubis could indicate an abdominal aortic aneurysm and should be reported to the HCP. Bruits normally are not present. The umbilicus should be in the midline with a concave appearance. Bowel sounds vary according to the timing of the last meal and usually range in frequency from 5 to 35 per minute.

The new registered nurse (RN) is orienting on the cardiac unit. Which statement by the new RN indicates an understanding of an early indication of fluid volume deficit due to blood loss? "Pulse rate will increase." "Blood pressure will decrease." "Edema will be present in the legs." "Crackles in the lungs will be present."

Pulse rate will increase Rationale: The cardiac output is determined by the volume of the circulating blood, the pumping action of the heart, and the tone of the vascular bed. Early decreases in fluid volume are compensated for by an increase in the pulse rate. Although the blood pressure will decrease, it is not the earliest indicator. Edema and crackles in the lungs indicate an increase in fluid overload.

What should a nurse do to assess jugular venous distention in a client with heart failure?

Raise head of the bed from 0-45 degree angle, measure from the highest point of visible venous distention to sternal angle

Nurse assesses audible expiratory wheezes over clients lower lobes, what should the nurse do first after completing this assessment? Assist the client in a lying position Raise the head of the bed at a 60 degree angle Sit the client on the side of bed to dangle Lower the head of the bed and add a pillow

Raise the head of the bed at 60 degree angle Client is demonstrating bilateral lower lobe wheezes, first thing to do is raise the bed to improve ventilation

Newborn with dehydration is associated with what finding? Bulging fontanel Acrocyanosis Warm, clammy skin Rapid pulse

Rapid pulse Other signs of dehydration in newborn are: cool, white skin dry mucous membranes sunken fontanel decreased capillary refill increased breathing frequency

After performing an initial abdominal assessment on a client, the nurse documents that the bowel sounds are normal. Which description best describes normal bowel sounds? Waves of loud gurgles auscultated in all 4 quadrants Low-pitched swishing auscultated in 1 or 2 quadrants Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants Very high-pitched loud rushes auscultated especially in 1 or 2 quadrants

Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants

Child that aspirated a penny, where would it be located?

Right main bronchus

When assessing a client's liver during an assessment, the nurse should palpate which abdominal quadrant? Left upper quadrant Left lower quadrant Right upper quadrant Right lower quadrant

Right upper quadrant

The school nurse has conducted a class on testicular self-examination (TSE) at the local high school. The nurse determines that the information was correctly interpreted if one of the students states that which action should be performed? Perform the exam after a cold shower. Expect the exam to be slightly painful. Perform the self-examination every other month. Roll the testicle between the thumb and forefinger.

Roll the testicle between the thumb and forefinger. Rationale: TSE is an excellent self-screening examination for testicular cancer, which predominantly affects men in their late teens and 20s. The examination is performed once a month, as is breast self-examination. As an aid to remember to do it, the examination should be done on the same day each month. The scrotum is held in one hand, and the testicle is rolled between the thumb and forefinger of the other hand. The examination should not be painful. It is easiest to do either during or after a warm shower (or bath), when the scrotum is relaxed.

The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse implement to test the motor function of this nerve? Ask the client to puff out the cheeks. Separate the client's jaw by pushing down on the chin. Place a small amount of sugar on the client's tongue and ask him or her to identify the taste. Ask the client to rotate the head forcibly against resistance applied to the side of his or her chin.

Separate the client's jaw by pushing down on the chin. Rationale: The motor function (muscles of mastication) of cranial nerve V (trigeminal nerve) is assessed by palpating the temporal and masseter muscles as the person clenches the teeth. The muscles should feel equally strong on both sides. The nurse should try to separate the client's jaws by pushing down on the chin; normally, the jaws cannot be separated. Asking the client to puff out the cheeks tests the facial nerve. Placing an object on the client's tongue tests sense of taste and the sensory function of the facial nerve. Checking for equal strength by asking the person to rotate the head forcibly against resistance applied to the side of the client's chin assesses cranial nerve XI, the spinal accessory nerve.

The nurse identifies that a client is having occasional premature ventricular contractions (PVCs) on the cardiac monitor. The nurse reviews the client's laboratory results and determines that which result would be consistent with the observation? Serum chloride level of 98 mEq/L (98 mmol/L) Serum sodium level of 145 mEq/L (145 mmol/L) Serum calcium level of 10.5 mg/dL (2.75 mmol/L) Serum potassium level of 2.8 mEq/L (2.8 mmol/L)

Serum potassium level of 2.8 mEq/L (2.8 mmol/L) Rationale: The nurse should check the client's serum laboratory study results for hypokalemia. The client may experience PVCs in the presence of hypokalemia because this electrolyte imbalance increases the electrical instability of the heart. The values noted in the remaining options are normal.

The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply. Set the room temperature at a comfortable level. Remove distracting objects from the interviewing area. Place a chair for the client across from the nurse's desk. Ensure comfortable seating at eye level for the client and nurse. Provide seating for the client so that the client faces a strong light. Ensure that the distance between the client and nurse is at least 7 feet (2.1 meters).

Set the room temperature at a comfortable level. Remove distracting objects from the interviewing area. Ensure comfortable seating at eye level for the client and nurse.

The post-myocardial infarction client is scheduled for a technetium-99m ventriculography (multigated acquisition [MUGA] scan). The nurse ensures that which item is in place before the procedure? A urinary catheter Signed informed consent A central venous pressure (CVP) line Notation of allergies to iodine or shellfish

Signed informed consent Rationale: MUGA is a radionuclide study used to detect myocardial infarction and decreased myocardial blood flow and to determine left ventricular function. A radioisotope is injected intravenously; therefore, a signed informed consent is necessary. A urinary catheter and CVP line are not required. The procedure does not use radiopaque dye; therefore, allergies to iodine and shellfish are not a concern

The nurse is providing preoperative teaching with the client about the use of an incentive spirometer in the postoperative period. Which instructions should the nurse include? Select all that apply. Sit upright in the bed or in a chair. Inhale as deeply and quickly as possible. Hold the device in a downward position. Place the mouthpiece in your mouth and seal your lips tightly around it. After maximum inspiration, hold the breath for 2 to 3 seconds and exhale.

Sit upright in the bed or in a chair. Inhale as deeply and quickly as possible. Sit upright in the bed or in a chair. Inhale as deeply and quickly as possible. Rationale: client should assume a semi Fowler's or high Fowler's position while holding the incentive spirometer in an upright position.

When auscultating the heart of patient with aortic regurgitation what position should they be in?

Sitting up and leaning forward, accentuates second heart sound

The nurse is performing a physical examination on an assigned client. Which item should the nurse select to test the function of cranial nerve II? Flashlight Snellen chart Reflex hammer Ophthalmoscope

Snellen chart Rationale: Cranial nerve II (the optic nerve) is responsible for visual acuity. This may be tested by using a Snellen chart to assess distant vision. Another item that may be used to evaluate the optic nerve function is a Rosenbaum card to evaluate near vision. This is a hand-held card used to test visual acuity. The nurse records the smallest line seen as well as the distance that the card is held from the client. A flashlight is used to test the pupillary reaction. A reflex hammer is used to test reflexes. An ophthalmoscope is used to examine the retina

The nurse is caring for a hearing-impaired client. Which approach will facilitate communication? Speak loudly. Speak frequently. Speak at a normal volume. Speak directly into the impaired ear.

Speak at a normal volume.

The nurse notes that the health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action should the nurse take? Speak loudly, but mumble or slur the words. Speak loudly and clearly while facing the client. Speak at normal tone and pitch, slowly and clearly. Speak loudly and directly into the client's affected ear.

Speak at normal tone and pitch, slowly and clearly.

The nurse is evaluating a client's cardiac rhythm strip to determine if there is proper function of the VVI mode pacemaker. Which denotes proper functioning? Spikes precede all P waves and QRS complexes. There are consistent spikes before each P wave. Spikes occur before QRS complexes when intrinsic ventricular beats do not occur. Spikes occur before all QRS complexes regardless of intrinsic ventricular activity.

Spikes occur before QRS complexes when intrinsic ventricular beats do not occur. Rationale: When a pacemaker is operating in the VVI mode, pacemaker spikes will be observed before the QRS complex if the client does not have his or her own intrinsic beat; therefore, options 1, 2, and 4 are incorrect.

The nurse conducting a health screening is performing hearing assessments on clients. Senior nursing students are assisting the nurse with the assessments. The nurse instructs the students to perform a voice test by taking which action? Whisper a statement while the client blocks both ears. Quietly whisper a statement and test both ears at the same time. Whisper a statement with the examiner's back to the client. Stand 1 to 2 feet (30 to 60 cm) away from the client and ask the client to block 1 external ear canal.

Stand 1 to 2 feet (30 to 60 cm) away from the client and ask the client to block 1 external ear canal. Rationale: To perform a voice test, the examiner stands 1 to 2 feet (30 to 60 cm) away from the client and asks the client to block 1 external ear canal. The nurse quietly whispers a statement and asks the client to repeat it. Each ear is tested separately. The client is not asked to block both ears, and the examiner should face the client during the test.

The nurse is performing a neurological assessment on a client with a head injury. The nurse should use which technique to assess the plantar reflex? Stroking the foot from the heel to the toe Gently inserting a gloved finger in the rectum Directing a flashlight onto the pupils of the eyes Using a tongue depressor and stimulating the back of the throat

Stroking the foot from the heel to the toe

The nurse is preparing to perform an abdominal examination on a client. The nurse should place the client in which position for this examination? Sims' position Supine with the head and feet flat Supine with the head raised slightly and the knees slightly flexed Semi Fowler's position with the head raised 45 degrees and the knees flat

Supine with the head raised slightly and the knees slightly flexed

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye? Test the corneal reflexes. Test the 6 cardinal positions of gaze. Test visual acuity, using a Snellen eye chart. Test sensory function by asking the client to close the eyes and then lightly touching the forehead, cheeks, and chin.

Test the 6 cardinal positions of gaze.

The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure? To examine the testicles while lying down That the best time for the examination is after a shower To gently feel the testicle with 1 finger to feel for a growth That TSEs should be done at least every 6 months

That the best time for the examination is after a shower

The nurse is documenting the findings of a physical examination in a client's record. Which findings should the nurse determine to be objective data? The client experiences migraine headaches. The client has a rash on the chest and arms. The client reports having difficulty urinating. The client reports taking atenolol for blood pressure.

The client has a rash on the chest and arms.

The nurse in an ambulatory clinic is preparing to administer a tuberculin skin test to a client who may have been exposed to a person with tuberculosis (TB). The client reports having received the bacillus Calmette-Guérin (BCG) vaccine before moving to the United States from a foreign country. Which interpretation should the nurse make? The client has no risk of acquiring TB and needs no further workup. The client is at increased risk for acquiring TB and needs immediate medication therapy. The client's test result will be negative, and a sputum culture will be required for diagnosis. The client's test result will be positive, and a chest x-ray study will be required for evaluation.

The client's test result will be positive, and a chest x-ray study will be required for evaluation. Rationale: The BCG vaccine is routinely given in many foreign countries to enhance resistance to TB. The vaccine uses attenuated tubercle bacilli, so the results of skin testing in persons who have received the vaccine will always be positive. This client needs to be evaluated for TB with a chest radiographic study. The remaining options are incorrect interpretations.

Lactulose is prescribed for a hospitalized client with a diagnosis of hepatic encephalopathy. Which assessment finding indicates that the client is responding to this medication therapy as anticipated? Vomiting occurs. The fecal pH is acidic. The client experiences diarrhea. The client is able to tolerate a full diet.

The fecal pH is acidic Rationale: Lactulose is an osmotic laxative used to decrease ammonia levels, which are elevated in hepatic encephalopathy. The desired effect is 2 or 3 soft stools per day with an acid fecal pH. Lactulose creates an acid environment in the bowel, resulting in a fall of the colon's pH from 7 to 5. This causes ammonia to leave the circulatory system and move into the colon for excretion. Diarrhea may indicate excessive administration of the medication. Vomiting and ability to tolerate a full diet do not determine that a desired effect has occurred.

The nurse is preparing to check the breath sounds of a client. When auscultating for bronchovesicular breath sounds, the nurse should place the stethoscope over which area? The major bronchi The trachea and larynx The peripheral lung fields The lower posterior thorax

The major bronchi Rationale: Bronchovesicular breath sounds are heard over major bronchi. The upper sternum area is where major bronchi are located. Bronchial (tracheal) breath sounds are heard over the trachea and larynx. Vesicular breath sounds are heard over the peripheral lung fields.

A nursing student who is researching a medication at the nurses' station asks the registered nurse (RN) what the function of an alpha-adrenergic receptor is, and where the receptors are primarily found. The RN educates the nursing student. Which statement by the nursing student indicates that teaching has been effective? "The peripheral arteries and veins; when stimulated they cause vasoconstriction." "Arterial and bronchial walls; when stimulated they cause vasodilation and bronchodilation." "The heart; when stimulated it causes an increase in heart rate, atrioventricular node conduction, and contractility." "Several tissues; when stimulated they cause contraction of smooth muscle, inhibition of lipolysis, and promotion of platelet aggregation."

The peripheral arteries and veins; when stimulated they cause vasoconstriction."

The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test? The right eye is tested, followed by the left eye, and then both eyes are tested. Both eyes are assessed together, followed by an assessment of the right eye and then the left eye. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the largest line on the chart. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the line that can be read 200 feet (60 meters) away by an individual with unimpaired vision.

The right eye is tested, followed by the left eye, and then both eyes are tested. Rationale: Visual acuity is assessed in 1 eye at a time, and then in both eyes together, with the client comfortably standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes are then tested together. Visual acuity is measured with or without corrective lenses and the client stands at a distance of 20 feet (6 meters) from the chart.

Client with a burning sensation in one eye for 6 days is diagnosed with conjunctivitis. One eye is red, client recalls feeling under the weather 3 weeks ago, what is the cause? Bacterial Viral Toxic Allergic

Toxic One eye being red suggests toxic, chemical or mechanical Both eyes= bacterial, viral or allergic

The nurse is caring for a client with a diabetic ulcer. What discharge instructions should the nurse provide to the client? Select all that apply. Wash feet with hot water daily. Use a mild soap when washing the feet. Use lanolin on the feet to prevent dryness. Wear open-toed shoes to allow air flow to the feet. Exercise the feet daily by walking and flexing at the ankle.

Use a mild soap when washing the feet. Use lanolin on the feet to prevent dryness. Exercise the feet daily by walking and flexing at the ankle.

If the nurse is unable to determine if patient has jugular vein distention, what would you use?

Use tangential lighting

The nurse is caring for a client admitted to the hospital with suspected acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? White blood cell (WBC) count of 4000 mm3 (4 × 109/L) WBC count of 8000 mm3 (8 × 109/L) WBC count of 18,000 mm3 (18 × 109/L) WBC count of 26,000 mm3 (26 × 109/L)

WBC count of 18,000 mm3 (18 × 109/L) Rationale: Laboratory findings do not establish the diagnosis of appendicitis, but there is often a moderate elevation of the WBC count (leukocytosis) to 10,000 to 18,000 mm3 (10 to 18 × 109/L) with an increased number of immature WBCs. An inflammatory process causes a rise in the WBC count. A rise to 26,000 mm3 (26 × 109/L) may indicate a perforated appendix (greater than 20,000 mm3 [20 × 109/L]).

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client? Stridor Crackles Wheezes Diminished

Wheezes

A nurse notices several reddish purple, nonblanchable spots of different sizes on the arms and legs of a patient with a low platelet count. How does the nurse distinguish ecchymosis from purpura? a. Ecchymosis is variable in size and a purpura is greater than 0.5 cm in diameter. b. Ecchymosis does not blanch and purpura does blanch. c. Ecchymosis has raised lesions and purpura has flat lesions. d. Ecchymosis is irregularly shaped and purpura is round.

a. Ecchymosis is variable in size and a purpura is greater than 0.5 cm in diameter. A Ecchymosis is variable in size and a purpura is greater than 0.5 cm in diameter. This is an accurate statement. B Ecchymosis does not blanch and purpura does blanch. Both of these lesions are nonblanchable. C Ecchymosis has raised lesions and purpura has flat lesions. Both of these lesions are flat. D Ecchymosis is irregularly shaped and purpura is round. There is no specified shape for either type of lesion.

presbycusis

age related hearing loss

Supine in low Fowlers

anterior lung fields

What do herbal remedies interact with?

anti hypertensives

The patient with a respiratory rate that is within normal limits is the _____ whose respiratory rate is _____ breaths/min. a. 16-month-old; 36 b. 6-year-old; 20 c. 14-year-old;26 d. 40-year-old; 10

b. 6-year-old; 20 A A toddler's respiratory rate ranges from 24 to 32. B A school-age child's respiratory rate ranges from 18 to 26. C An adolescent's respiratory rate ranges from 12 to 16. D An adult's respiratory rate ranges from 12 to 20.

A nurse calculates a patient's body mass index (BMI) as 33. This measurement indicates which class of weight? a. Overweight b. Obesity class I c. Obesity class II d. Obesity class III

b. Obesity class I A Overweight is a BMI of 25 to 29.9. B Obesity class I is a BMI of 30 to 34.9. C Obesity class II is a BMI of 35 to 39.9. D Obesity class III is a BMI greater than 40

VSD=ventricular septal defect

murmur between S1 and S2

"pop" sensation in the ear

sign of Eustachian tube collapse TM perf- decreased hearing, tinnitus, vertigo, and bloody discharge

Malnutrition is associated with

skin breakdown and poor wound healing

Bronchiovesicular sounds

where airway meets tissue

Transverse nail groves that occur after severe illness

Beau's lines

Opening a pack of sugar is what motor skill?

Fine motor

Repeating 99 during respiratory exam tests for what?

Bronchophony and tactie fremitus

A 52-year-old male client is seen in the health care provider's (HCP's) office for a physical examination after experiencing unusual fatigue over the last several weeks. The client's height is 5 feet, 8 inches (173 cm) and his weight is 220 pounds (99.8 kg). Vital signs are as follows: temperature, 98.6°F (37°C) orally; pulse, 86 beats/minute; and respirations, 18 breaths/minute. The blood pressure reading is 184/100 mm Hg. A random blood glucose level is 122 mg/dL (6.8 mmol/L). Which question should the nurse ask the client first? "Do you exercise regularly?" "Are you considering trying to lose weight?" "Is there a history of diabetes mellitus in your family?" "When was the last time you had your blood pressure checked?"

when was the last time you had your blood pressure checked?

Limited abduction and internal rotation of the right hip joint

Hip disease

The nurse has provided self-care activity instructions to a client after insertion of an implanted cardioverter-defibrillator (ICD). The nurse determines that further instruction is needed if the client makes which statement? "I need to avoid doing anything that could involve rough contact with the ICD insertion site." "I can perform activities such as swimming, driving, or operating heavy equipment as I need to." "I should try to avoid doing strenuous things that would make my heart rate go up to or above the rate cutoff on the ICD." "I should keep away from electromagnetic sources such as transformers, large electrical generators, and metal detectors, and I shouldn't lean over running motors."

"I can perform activities such as swimming, driving, or operating heavy equipment as I need to." Rationale: Postdischarge instructions typically include avoiding tight clothing or belts over the ICD insertion sites; rough contact with the ICD insertion site; and electromagnetic fields such as with electrical transformers, radio/TV/radar transmitters, metal detectors, and running motors of cars or boats. Clients also must alert health care providers (HCPs) or dentists to the presence of the device because certain procedures such as diathermy, electrocautery, and magnetic resonance imaging may need to be avoided to prevent device malfunction. Clients should follow the specific advice of a HCP regarding activities that are potentially hazardous to self or others, such as swimming, driving, or operating heavy equipment.

The community health nurse who is conducting a teaching session about the risks of testicular cancer has reviewed a list of instructions regarding testicular self-examination (TSE) with the clients attending the session. Which statement by a client indicates a need for further instruction? "TSE is performed once a month." "TSE should be performed on the same day each month." "It is best to do TSE first thing in the morning before a bath or shower." "The scrotum is held in 1 hand and the testicle is rolled between the thumb and forefinger of the other hand."

"It is best to do TSE first thing in the morning before a bath or shower."

A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching? "I should notify my doctor if my feet or legs start to swell." "My doctor told me to call his office if my pulse rate decreases below 60." "Avoiding grapefruit juice will definitely be a challenge for me, since I usually drink it every morning with breakfast." "My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning."

"My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning."

The nurse is participating in a class on rhythm strip interpretation. Which statement by the nurse indicates an understanding of a PR interval of 0.20? "This is a normal finding." "This is indicative of atrial flutter." "This is indicative of atrial fibrillation." "This is indicative of impending reinfarction."

"This is a normal finding." Rationale: The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The normal range for the PR interval is 0.12 to 0.20 second. The remaining options are incorrect and indicate that further education is needed.

A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg, and a nursing student is assigned to provide care for the client. The nursing instructor asks the student to describe this diagnosis. Which answer demonstrates the student's understanding of the diagnosis? "It is an acute superficial infection." "It is an inflammation of the epidermis." "Staphylococcus is the cause of this epidermal infection." "This skin infection involves the deep dermis and subcutaneous fat."

"This skin infection involves the deep dermis and subcutaneous fat."

Systole

- "emptying stage" - ventricular pressure rises - AV valves close!! - semilunar valves open - blood is ejected from heart into Pulmonary artery or Aorta - Ventricles contract - s1 sound

Diastole

- "filling stage" - Blood moves from atria to ventricles (third heart sound). = S3 - AV valves open - passive filling into ventricles - ventricles dilate, & rest - Causes complete emptying of atria (fourth heart sound). = S4

Presbycusis

Age related hearing loss, normal physical exam

What should a nurse do first in a client with a rapidily decreasing level of consciousness

Assess airway and breathing

A client is experiencing chronic pruritus. To promote hydration of the skin, the nurse should tell the client to take which measure? Maintain room humidity at less than 40%. Use very hot or very cold water for bathing. Apply emollients once the skin is thoroughly dry. Avoid bathing in the shower or tub more than once daily

Avoid bathing in the shower or tub more than once daily Rationale: Several things may be done to promote hydration of the skin. The client should limit tub or shower bathing to once daily or every other day and should sponge bathe on the other days. Room humidity should be maintained at greater than 40%. Bath water should be between 95°F and 100°F (35°C to 37.8°C) (tepid) and not very hot or very cold. Harsh soaps should be avoided, and emollients should be applied generously to skin while it is still damp.

A client with Ménière's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo? Increase sodium in the diet. Avoid sudden head movements. Lie still and watch the television. Increase fluid intake to 3000 mL a day.

Avoid sudden head movements.

Patient that is not able to sleep for several nights exhibits which of these symptoms: Select all that apply! Slurred speech Flat facial affect Muscle twitching Rhinorrhea Red conjunctiva

Slurred speech, flat facial affect, and red conjunctiva

When assessing an AV fistula of a client with diabetes, the nurse notes a low-pitched, soft machine like murmur over the fistula site? What intervention should the nurse implement?

Document assessment in client's file AV fistula should be assessed before every hemodialysis session- inspection for erythema and swelling, palpation of the fistula site (fistula should be soft and non-tender), and pulse (very little pulse), palpation of extremity pulse, thrill assessment (a palpable thrill should be felt) and auscultation ( bruit should be heard over AV fistula) low pitched soft machine like murmur indicates a bruit

An 87 year old male has a reduced upward gaze, sluggish pupil reflex on both sides, high frequency hearing loss and an absent ankle reflex, what should the next action be?

Document finding Seen with aging If symptoms were unilateral then further investigation is required

What test to perform for strabismus?

Cover/uncover eye test cross eyed- hinders visual acuity

Popping, non-musical sounds, like cellophane being crumbled

Crackles

The community health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? Select all that apply. Dyspnea Headache Night sweats A bloody, productive cough A cough with the expectoration of mucoid sputum

Dyspnea Night sweats A bloody, productive cough A cough with the expectoration of mucoid sputum Rationale: Tuberculosis should be considered for any clients with a persistent cough, weight loss, anorexia, night sweats, hemoptysis, shortness of breath, fever, or chills. The client's previous exposure to tuberculosis should also be assessed and correlated with the clinical manifestations.

A client with chronic obstructive pulmonary disease (COPD) is being evaluated for lung transplantation. The nurse performs the initial physical assessment. Which findings should the nurse anticipate in this client? Select all that apply. Dyspnea at rest Clubbed fingers Muscle retractions Decreased respiratory rate Increased body temperature Prolonged expiratory breathing phase

Dyspnea at rest Clubbed fingers Muscle retractions Decreased respiratory rate Prolonged expiratory breathing phase

Irregular menstrual periods, weight gain, and hirsutism, what system is this a disorder of?

Endocrine

An older client is lying in a supine position. The nurse understands that the client is at least risk for skin breakdown in which body area? Heels Sacrum Back of the head Greater trochanter

Greater trochanter

The nurse is evaluating fluid resuscitation attempts in the burn client. Which finding indicates adequate fluid resuscitation? Disorientation to time only Heart rate of 95 beats/minute +1 palpable peripheral pulses Urine output of 30 mL over the past 2 hours

Heart rate of 95 beats/minute Rationale: When fluid resuscitation is adequate, the heart rate should be less than 120 beats/minute, as indicated in option 2. In addition, adequacy of fluid volume resuscitation can be evaluated by determining if urine output is at least 30 mL/hour, peripheral pulses are +2 or better, and the client is oriented to client, place, and time.

The nurse has obtained a personal and family history from a client with a neurological disorder. Which factors in the client's history are associated with added risk for neurological problems? Select all that apply. Allergy to pollen History of headaches Previous back injury History of hypertension History of diabetes mellitus

History of headaches Previous back injury History of hypertension History of diabetes mellitus

Bright red patch in lateral side of left eye Presence of allergies History of trauma Use of blood thinner Recent URI

History of trauma consistent with subconjunctival hemorrhage

The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? The client rigidly extends the arms with pronated forearms and plantar flexion of the feet. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.

The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.

The nurse is testing the coordinated functioning of cranial nerves III, IV, and VI. To do this correctly, what should the nurse test? The corneal reflex The 6 cardinal fields of gaze The pupillary response to light Pupillary response to light and accommodation

he 6 cardinal fields of gaze Rationale: Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) have only motor components and control, in a coordinated manner, the 6 cardinal fields of gaze. This is tested by moving an object in 6 directions (involving horizontally and diagonally). Corneal reflex is the function of the trigeminal nerve (cranial nerve V). Pupillary response to light and accommodation is the function of cranial nerve III (oculomotor) alone.

Abdominal girth increases in size by 7.5cm over 3 days, what is this a sign of?

Ascites

High pitched, wheezing sound heard during inspiration over the trachea

Stridor

Loss of balance when standing with eyes closed

Positive Romberg sign

The nurse is assisting a radiologist to facilitate a thoracentesis. The nurse assists the client to a position that widens the spaces between the ribs to help drain which area? Alveoli Trachea Pleural space Main bronchi

Pleural space

Allen Test

- Constrict blood in arm - Release ulnar artery first to see if blood flow returns- avoid radial cannulation

Patient with COPD has a barrel chest, what is this consistent with?

Chronic hyperinflation

The nurse is preparing to measure the apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope over which cardiac site? Mitral area Right atrium Right ventricle Pulmonic valve

Mitral area

Dark skinned- ashen grey tone on the lips

Pallor

what test do you use to evaluate cranial nerve II

Snellen chart

Sharp, right sided abdominal pain provoked by eating a large meal and clay colored with fatty streaks

cholelithiasis or gallstone colic

The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time? At the onset of menstruation Every month during ovulation Weekly at the same time of day 1 week after menstruation begins

1 week after menstruation begins

S4

- Heard best at base of heart - TEN - nes- see - Sometimes called atrial gallop - Older adults (elderly) after exercise would be a normal variation - In adults it can mean CAD, cardiomyopathy, aortic stenosis, HTN

A stage I ulcer is characterized by a reddened area and intact skin. A stage II ulcer is characterized by partial-thickness skin loss, and the wound may appear as an abrasion, a shallow crater, or a blister. Stage III ulcers are full-thickness lesions of the skin. Stage IV ulcers also are full-thickness lesions, with exposed muscle, bone, or supportive tissue.

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The registered nurse (RN) is educating a new RN on how to interpret vision tests using a Snellen chart. After the client's vision is tested with a Snellen chart, the results of testing are documented as 20/40. Which statement by the new RN indicates that the teaching has been effective? "The client's vision is normal, but the client may require reading glasses." "The client is legally blind, and glasses or contact lenses will not be helpful." "The client can read at a distance of 40 feet (12 meters) what a person with normal vision can read at 20 feet (6 meters)." "The client can read at a distance of 20 feet (6 meters) what a person with normal vision can read at 40 feet (12 meters)."

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Loud, long continuous gurgling in all four quadrants Presence of abdominal bruit Hypoactive bowel sounds Friction rub Boborbygmi

Answer: Boborbygmi Abdominal bruit= pulsating blowing sound Hypoactive bowel sounds= slow and sluggish Friction rub= rough, grating sound caused by rubbing together of organs or an organ rubbing on peritoneum

Bacterial infection that has spread to the axillary lymph nodes, what would the nurse most likely assess in this client? Painless enlarged lymph nodes Pain and edematous lymph nodes Warm and tender lymph nodes Cold hardened lymph nodes

Answer: Warm and tender lymph nodes Painless lymph nodes= malignancy Pain and edematous= lymphangitis Cold hardened= infiltrated intravenous infusion

The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which action to obtain the assessment data? Turn the flashlight on directly in front of the eye and watch for a response. Ask the client to follow the flashlight through the 6 cardinal positions of gaze. Instruct the client to look straight ahead, and then shine the flashlight from the temporal area to the eye. Check pupil size, and then ask the client to alternate looking at the flashlight and the examiner's finger.

Ask the client to follow the flashlight through the 6 cardinal positions of gaze.

A client's electrocardiogram shows that the ventricular rhythm is irregular and there are no discernible P waves. The nurse recognizes that this pattern is associated with which condition?

Atrial fibrillation

What are Kussmaul respirations?

Deep and slow breaths Amplitude increased- typically seen in patients with DKA

Organs located in the left lumbar region on the abdomen

Descending colon and lower half of left kidney

The emergency department nurse is performing an assessment on a child suspected of being sexually abused. Which assessment data obtained by the nurse most likely support this suspicion? Poor hygiene Difficulty walking Fear of the parents Bald spots on the scalp

Difficulty walking

The nurse should ask a client to take which action when testing the function of the spinal accessory nerve (CN XI)? Elevate the shoulders. Swallow a sip of water. Open the mouth and say "aah." Vocalize the sounds "la-la," "mi-mi," and "kuh-kuh."

Elevate the shoulders.

The nurse is reviewing the results of serum laboratory studies for a client admitted for suspected hepatitis. Which laboratory finding is most associated with hepatitis, requiring the nurse to contact the health care provider? Elevated serum bilirubin level Below normal hemoglobin concentration Elevated blood urea nitrogen (BUN) level Elevated erythrocyte sedimentation rate (ESR)

Elevated serum bilirubin level Rationale: Laboratory indicators of hepatitis include elevated liver enzymes, serum bilirubin level, and ESR. However, ESR is a nonspecific test that indicates the presence of inflammation somewhere in the body. The hemoglobin concentration is unrelated to this diagnosis. An elevated BUN level may indicate renal dysfunction.

The nurse is planning care for a client with deep vein thrombosis of the right leg. Which interventions would the nurse plan, based on the health care provider's (HCP's) prescriptions? Select all that apply. Elevation of the right leg Administration of acetaminophen Application of moist heat to the right leg Monitoring for signs of pulmonary embolism Ambulation in around the nursing unit every hour

Elevation of the right leg Administration of acetaminophen Application of moist heat to the right leg Monitoring for signs of pulmonary embolism Ambulation in around the nursing unit every hour

Male client experiencing urinary dribbling, frequency, and difficulty starting to stream

Enlarged prostate gland

The nurse is performing an abdominal assessment and inspects the skin on the client's abdomen. Which assessment technique should the nurse perform next? Palpate the abdomen for size. Palpate the liver at the right rib margin. Listen to bowel sounds in all 4 quadrants. Percuss the right lower abdominal quadrant.

Listen to bowel sounds in all 4 quadrants.

Snoring and rattling sound on both inspiration and expiration in central airways

Rhonchi caused by obstruction or secretions in larger airways

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding? Rhythmic respirations with periods of apnea Regular rapid and deep, sustained respirations Totally irregular respiration in rhythm and depth Irregular respirations with pauses at the end of inspiration and expiration

Rhythmic respirations with periods of apnea

A confrontation test is prescribed for a client seen in the eye and ear clinic. How should the nurse perform this test? Arrange the actions in the order that they should be performed. All options must be used.

Stand 2-3 feet in front of and faces the client Ask the client to cover 1 eye Examiner covers the eye opposite to the eye covered by client Examiner brings an object gradually from periphery Asks the client to report when object is first noted

A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which method describes the accurate procedure to perform this test? The client is asked to discriminate numbers from a chart composed of colored dots. The room is darkened, and the client is asked to identify colored blocks and shapes when they appear in the visual field. The examiner and client cover their right eyes and stare at each other's left eyes, and a small object is brought into the visual field. The examiner and client cover the eyes directly opposite to one another and stare at each other's uncovered eye, and a small object is brought into the visual field.

The examiner and client cover the eyes directly opposite to one another and stare at each other's uncovered eye, and a small object is brought into the visual field.

The clinic nurse is preparing to perform a Romberg test on a client being seen in the clinic. The nurse would perform this test for the purpose of determining which status? The client's ability to ambulate The intactness of the tympanic membrane The intactness of the retinal structure of the eye The functional status of the vestibular apparatus in the inner ear

The functional status of the vestibular apparatus in the inner ear

A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear? Pruritus Tinnitus Hearing loss Burning in the ear

Tinnitus Rationale: Tinnitus is the most common complaint of clients with otological disorders, especially disorders involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear, which can go unnoticed during the day, to a loud roaring in the ear, which can interfere with the client's thinking process and attention span. Options 1, 3, and 4 are not associated specifically with disorders of the inner ear.

The nurse is developing a plan of care for a client recovering from pulmonary edema. The nurse establishes a goal to have the client participate in activities that reduce cardiac workload. The nurse should identify which client action as contributing to this goal? Using a bedside commode Sleeping in the supine position Elevating the legs when in bed Using seasonings to improve the taste of food

Using a bedside commode Rationale: Using a bedside commode decreases the work of getting to the bathroom or struggling to use the bedpan. The supine position increases respiratory effort and decreases oxygenation. Elevating the client's legs increases venous return to the heartthus increasing cardiac workload. Seasonings may be high in sodium and promote further fluid retention.

Low pitched sounds, like the wind blowing through the trees, loudest during inspiration and fade during expiration

Vesicular breath sounds

The nurse is caring for a client with pernicious anemia. Which prescription by the health care provider (HCP) should the nurse anticipate? Iron Folic acid Vitamin B6 Vitamin B12

Vitamin B12 Rationale: Pernicious anemia is caused by a deficiency of vitamin B12. Treatment consists of administration of high doses of oral vitamin B12. Monthly injections of vitamin B12 can also be administered but are less comfortable when compared to oral administration. Thiamine is most often prescribed for the client with alcoholism, folic acid is prescribed for folic acid deficiency, and vitamin B6 is ordered when there is pyridoxine deficiency.

McBurney's sign

appendicitis (McBurney's Point is 2/3 of the way from the umbilicus to anterior superior iliac spine)

Mild aching, swelling in groin consistent with inguinal hernia

ask the client to strain while holding breath --> Valsalva maneuver --> shows hernia better

Conjunctival pallor

associated with anemia, anemia can be associated with patients that have colorectal cancer or IBD such as Crohn's and UC

Rebound tenderness is a sign of

peritonitis and can present in clients with appendicitis, cholangitis, and bowel perforation