NR302 final exam

to prevent pneumonia

coughing and deep breathing incentive spirometer

pneumonia

crackles labored breathing accessory muscles nasal flaring in children percussion with pneumonia is a dull tone

test sensory function by asking the client to close the eyes and then lightly toughing the forehead, cheeks, and chin

cranial nerve V- trigeminal

stridor sounds like

crowing-inspiration, upper airway epiglotitis croup obstructed airway

corneal reflexes

use a light or to see if the nerves are intact

snellen chart used for

visual acuity

bronchial lung sounds

trachea and larynx expiratory

rine test

tuninf fork on porcess na dbring it to side of ear

the nurse is preparing to perform a weber test on a client. the nurse should obtain which item needed to perform this test? a. a tuning fork b. stethescope c. tongue blade d. reflex hammer

a. a tuning fork put on top of head

the nurse notes documentation that a client is exhibiting cheyne-strokes respirations. on assessment of the client, the nurse should expect to note which finding? a. increasing rate and depth of respirations with periods of apnea b. regular rapid and deep, sustained respirations c. totally irregular respiration in rhythm and depth d. irregular respirations with pauses at the end of inspiration and expiration

a. increasing rate and depth of respirations with periods of apnea (p 435 in textbook)

the nurse is providing care to a client admitted for coronary artery disease and a history of tobacco use. what is the most important element of the nurse's focused assessment of the client's smoking history? a. number of pack years b. desire to quit smoking c. brand of cigarettes used d. number of past attempts to quit smoking

a. number of pack years

the nurse is preparing to perform an otoscopic examination on an adult client. which action should the nurse take to perform this examination? a. pull the pinna up and back before inserting speculum b. pull the earlobe down and back before inserting the speculum c. tilt the client's head forward and down before inserting the speculum d. use the smallest speculum available to decrease teh discomfort of the exam

a. pull the pinna up and back before inserting the speculum

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? a. the major bronchi b. the trachea and larynx c. the peripheral lung fields d. the lower posterior thorax

a. the major bronchi equal

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? a. turn the flashlight on directly in front of the eye and watch for a response b. ask the client to follow the flashlight through the six cardinal positions of gaze c. instruct the client to look straight ahead, and then shine the flashlight from the temporal area to the eye d. check pupil size, and then ask the client to alternate looking at the flashlight and the examiner's finger

b. ask the client to follow the flashlight through the six cardinal positions of gaze

pleuracy

inflammation of pleural lining friction rub sound

bradypnea

irregular respirations with pauses at the end of inspiration and expiration

sensory neuro hearing loss

issue with cranial nerves, defect in cochlea and sensory fibers

2200

legally blind

vescicular

periferal lung sounds inspiratory

diminished

poor oxygenation

crackles

popping sounds pneumonia air passing through liquid

tachypnea

regular rapid and deep, sustained respirations

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? a. focus on a close object b. focus on a distant object c. close one eye and read letters on a chart d. raise one finger when a sound is heard

b. fucus on a distant object

the nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V. which technique should the nurse implement to test the motor function of this nerve a. ask the client to puff out the cheeks b. separate the client's jaw by pushing down on the chin c. place a small amount of sugar on the client's tongue and ask him or her to identify the taste d. ask the client to rotate the head forcibly agains resistance applied to the side of his or. her chin

b. separate the client's jaw by pushing down on the chin

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 a. test the corneal reflexes b. test the 6 cardinal positions of gaze c. test visual acuity, using a snellen eye char d. test sensory function by asking the client to close the eyes and then lightly toughing the forehead, cheeks, and chin

b. test the 6 cardinal positions of gaze

the nurse if reviewing a client's record and notes that the result of a vision test using a snellen chart is 20/30. how should the nurse explain these results to the client? a. "you have normal vision" b. "you have some degree of blindness" c. "you can read at a distance of 20 feet what a person with normal vision can read at 30 feet" d. "you can read at a distance of 30 ft what a person with normal vision can read at 20 feet"

c. "you can read at a distance of 20 feet what a person with normal vision can read at 30 feet"

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. a defect in the cochlea b. a defect in cranial nerve VIII c. a physical obstruction to the transmission of sound waves d. a defect in the sensory fibers that lead to the cerebral cortex

c. a physical obstruction to the transmission of sound waves (conductive- something blocking the noise from getting through)

a nursing student is performing a respiratory assessment on a female adult client and is assessing for tactile fremitus. which action by the nursing student indicated a need for further teaching a. palpating over the lung apices in the supraclavicular area b. asking the client to repeat the word "99" during palpation c. palpating over the breast tissue to assess and compare vibrations from one side to the other d. comparing vibration from one side to the other as the client repeats the word "99"

c. palpating over the breast tissue to assess and compare vibrations from one side to the other

a client is diagnosed with external otitis. which finding would the nurse expect to note on assessment of the client? a. a wider than normal ear canal b. a pearly gray tympanic membrane c. redness and swelling in the ear canal d. an excessive amount of cerumen lodged in the ear canal

c. redness and swelling in the ear canal

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 respiratory assessment on this client? a. stridor b. crackles c. wheezes d. diminished

c. wheezes-expiration