160 Exam 4
Loss of bone density that occurs with greatest frequency in postmenopausal women is called? A. Osteoporosis B. Scoliosis C. Kyphosis D. Lordosis
A. Osteoporosis
The nurse walks into a client's room and finds that the client is disoriented to time and place but is awake and responsive. What term best describes this client? A. Confused B. Alert C. Lethargic D. Comatose
A. Confused
When percussing the abdomen, the nurse notices a dullness at the anterior right costal margin at the right midclavicular line. Which organ is most likely involved? A. Liver B. Spleen C. Sigmoid colon D. Kidney
A. Liver
A patient with a tympanic abdomen complains of pain in the RUQ. Which sign would the nurse expect to be positive? A. Murphy sign B. Psoas sign C. Rovsing sign D. Obturator sign
A. Murphy sign
The client tells the nurse that she has benign breast disease and so she is not worried about any lumps or nodules in her breasts. How would the nurse best respond? A. "It is important to perform self breast examinations as there could be changes or additional lumps in your breasts that would need further examination." B. "With benign breast disease, breast cancer does not occur." C. "You can still get breast cancer with benign breast disease." D. "With all of the lumps you have, performing a self breast examination will be useless."
A. "It is important to perform self breast examinations as there could be changes or additional lumps in your breasts that would need further examination."
The client tells the nurse "I am so glad I had a mastectomy and I will never have breast cancer again." How should the nurse best respond?" A. "We need to continue to perform examinations. Breast cancer can reoccur." B. "You are at higher risk for other cancers because of the breast cancer." C. "You are correct, you can never have breast cancer again." D. It is important that you discuss your breast cancer diagnosis with your family members."
A. "We need to continue to perform examinations. Breast cancer can reoccur."
The nurse palpated a fine, round, mobile, no fender nodule and suspects that it is A. A fibroadenoma B. A cyst C. A fibrocystic breast change D. Breast cancer
A. A fibroadenoma
Moving a part of the body away from the midline is called? A. Abduction B. Adduction C. Rotation D. Extension
A. Abduction
A patient reports that a previous right hip replacement is suddenly painful. Which hip assessment technique should you omit? A. Adduction B. Hyperextension C. Extension D. Circumduction
A. Adduction
an older patient reports feeling dizzy right before falling. Which action by the nurse indicates an understanding of how dizziness can be triggered? Select all that apply. A. Assess the patients blood pressure B. Review the patients diet for sufficient calcium intake C. Review the patients medical history for previous head injuries D. Ask "had you been taking any nonprescription meds before the fall?" E. Ask "did it feel like the room was spinning when you experienced your dizziness?"
A. Assess the patients blood pressure C. Review the patients medical history for previous heady injuries D. Ask "had you been taking any nonprescription medications before the fall?"
A 70 year old man presents with the following symptoms: straining to void, nocturia, dribbling, and hesitancy when voiding. These signs are consistent with what condition? A. Benign prostatic hypertrophy (BPH) B. Prostatitis C. Testicular cancer D. Phimosis
A. Benign prostatic hypertrophy (BPH)
Peau d'orange appearance is highly suggestive of what? A. Breast cancer B. Gynecomastia C. Papillomas D. Colostrum
A. Breast cancer
A client comes to the clinic and reports a sore knee. The nurse notes popping and cracking noises when the client attempts to bend the knee. The client exhibits signs of pain by facial expression. The nurse knows that the pooping and cracking noises should be charted as what? A. Crepitus B. Grating noise C. Tactile emphysema D. Popping and cracking noises
A. Crepitus
The patient with a head injury and increasing ICP is likely to have which assessment findings? A. Decreased LOC with sluggish pupil B. Left sided weakness and facial droop C. Right ptosis and right sided loss of vision D. Dilated left pupil and receptive aphasia
A. Decreased LOC with sluggish pupil
Which nursing actions would be effective when managing an older adult patients risk for injury related to falling? (Select all that apply) A. Encourage patient to wear prescription glasses B. Present patient with fluids regularly throughout the day C. Offer to take the patient to the toilet every 2-3 hours D. Limit the patients fluid intake after the last meal of the day E. Measure the patients blood pressure both when sitting and upon standing
A. Encourage patient to wear prescription glasses B. Present the patient with fluids regularly throughout the day C. Offer to take the patient to the toilet ever 2-3 hours E. Measure the patients blood pressure both when sitting and upon standing
Risk factors in which of the following areas are most readily changed to reduce the potential risk for falls? a) Environmental b) Cognitive c) Social d) Physiological
A. Environmental
When documenting a finding over the stomach, the nurse most accurately identified the region as A. Epigastric B. Hypogastric C. RUQ D. LUQ
A. Epigastric
Which technique should the nurse use to perform scoliosis screening in a school age child? A. Have the child bend forward at the waist B. Measure the length of each of the child's legs C. Measure the distance between the child's knees and ankles D. Ask the child to walk across the room
A. Have the child bend forward at the waist
Assessment of the musculoskeletal system usually proceeds from general to specific and from? A. Head to toe B. Right to left C. Bottom to top D. Anterior to posterior
A. Head to toe
Which of the following assessment tasks can you appropriately delegate to an unlicensed care provider? A. Height, weight, and vital signs B. Active and passive ROM C. History of current complaint D. Muscle strength
A. Height, weight, and vital signs
When assessing the rectum, the nurse observed what appear to be engorged areas near the rectal opening. The nurse would most likely document this finding as which of the following? A. Hemorrhoids B. Anal crypts C. Rectovesical pouch D. Fibroids
A. Hemorrhoids
When preparing an education session for a group of women who have been identified as postmenopausal, the nurse should include with teaching point? A. Increase intake of vitamin D and calcium B. Minimize weight lifting exercises C. Drink two to three glasses of red wine per day D. Stop taking proton pump inhibitor medication
A. Increase intake of vitamin D and calcium
The nurse is assessing an older adult. Which assessment finding would the nurse recognize as a finding associated with aging? A. Kyphosis B. Heberden nodes C. Hip contracture D. Increased ROM
A. Kyphosis
A 26 year old man was in a motor vehicle accident and suffered a complete spinal cord injury to L3. The nurse assesses the patient for loss of motor function in the: A. Legs B. Abdomen C. Chest D. Arms
A. Legs
What is considered a modifiable risk factor for breast cancer? A. Obesity B. Age C. Genetics D. Asthma
A. Obesity
Lifestyle can play a big part in developing risk factors for stroke. Which of the following can greatly reduce a clients risk for stroke? Select all that apply. A. Quitting smoking B. Regularly exercising C. Maintaining a healthy weight D. Eating a high sodium diet E. Following a sedentary lifestyle
A. Quitting smoking B. Regularly exercising C. Maintaining a healthy weight
As part of an abdominal assessment, the nurse must palpate a client's liver. In which quadrant is this organ located? A. RUQ B. RLQ C. LUQ D. LLQ
A. RUQ
A young male presents for a sports physical examination. In addition to examining for hernias, it would be appropriate for you to do which of the following? A. teach testicular self-examination B. evaluate for urinary retention C. examine for prostate cancer D. draw blood to measure prostatic surface antigen
A. Teach testicular self-examination
A 20 year old male patient presents with scrotal pain. A suspected diagnosis that required immediate referral is A. Testicular torsion B. Hydrocele C. Epididymitis D. Inguinal hernia
A. Testicular torsion
Gynecomastia may occur in an older male secondary to: A. Testosterone deficiency B. Lymphatic engorgement C. Trauma D. Decreased activity level
A. Testosterone deficiency
While interviewing a client, a nurse asks the client whether she has ever noticed any lumps or swelling in the breasts. What other area associated with the possible risk for breast cancer should she ask about regarding the presence of lumps or swelling? A. Underarm B. Neck C. Abdomen D. Shoulder
A. Underarm
The nurse is preparing to palpate the breasts of a female client. Which technique would be most appropriate? A. Use the flat pads of 3 fingers B. Use the fingertips of both hands C. Palpate over the clients own hand D. Use the palm of one hand
A. Use the flat pads of 3 fingers
an older patient has fallen and sustained a bruise to the forehead. Although there appears to be no significant injury, the family is concerned when the provider orders a mini-cog assessment and asks, "why are you testing her memory and mental abilities?" Which explanation best meets the family's expressed needs? A. Your mothers fall may have hurt the frontal lobe of her brain. That is the part that controls memory, reasoning, and judgement B. This has been a traumatic experience for all of you. Let's talk about your concerns related to your mothers health. C. The provider is concerned about how the head injury has affected your mothers mental status, considering her advanced age D. The test results have shown no significant trauma to your mothers head, so I am confident that the mini cog will show no dysfunction either.
A. Your mothers fall may have hurt the frontal lobe of her brain. That is the part that controls memory, reasoning, and judgement
A middle aged female tells the nurse that she is concerned because her breasts are not as firm as they used to be and asks what might be causing this. What is an appropriate response by the nurse? A. "A firmer bra will help to uplift your breasts and prevent sagging." B. "Firmness of the breasts decreases with age as estrogen levels decrease." C. "Prior pregnancies cause a decrease in firmness as you age." D. "Estrogen replacement therapy will stop this process"
B. "Firmness of the breasts decreases with age as estrogen levels decrease."
When evaluating a clients risk for cerebrovascular accident, which client would the nurse identify as being at highest risk? A. 42 year old Caucasian woman who smokes B. 68 year old African American male with hypertension C. 55 year old Caucasian male who has 2 beers a week D. 35 year old African American who had sleep apnea
B. 68 year old African American male with hyper tension
A neurological change associated with normal aging is A. Loss of long term memory B. A decrease in reaction time C. Swaying or shuffling gait D. A significant decline in judgement and cognition
B. A decrease in reaction time
Which of the following patients is at highest risk for osteoporosis? A. A young man, weight lifter, who drinks deer 3x a week, with a stable job B. A middle age woman of lower socioeconomic status who is a heavy smoker and drinks alcohol 6x a week C. A woman who works as a Vice President, takes a shot of vodka 6x a week, and exercises regularly D. A retired man, non smoker, who drinks socially
B. A middle age woman of lower socioeconomic status who is a heavy smoker and drinks alcohol 6x a week
Of the following changes, which is the earliest sign of progressing brain hernia toon that originates in the cerebral hemispheres? A. An enlarging pupil that is sluggishly reactive to light B. Altered mentation C. Widening pulse pressure with bradycardia D. Reflex posturing of extremities
B. Altered mentation
A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN 1. Which of the following would the nurses do? A. Use a Snellen chart to test visual acuity B. Ask a client to identify scents C. Test extraocular eye movements D. Perform the Weber test
B. Ask a client to identify scents
Which nursing actions are associated with conducting a Glasgow coma scale assessment on a patient who has fallen and sustained a possible brain injury? (Select all that apply) A. Assess the patients vital signs B. Ask the patient to identify where he or she is C. Request that the patient rate his or her pain level D. Request that the patient squeeze the nurses hand E. Observe which stimuli cause the patient to open his or her eyes
B. Ask the patient to identify where he or she is D. Request that the patient squeeze the nurses hand E. Observe which stimuli cause the patient to open his or her eyes
While the nurse performs formal patient assessment, assistive personnel often observe changes when obtaining vital signs or assisting patients with ADLs. When discussing care for a patient with back pain, the nurse should particularly alert the assistant to watch for: A. Dizziness B. Bowel/bladder incontinence C. Difficulty swallowing D. Arm weakness
B. Bowel/bladder incontinence
Mr. Brown was playing soccer and hurt his right knee. It appears swollen. What is the first assessment the nurse should make? A. Palpate for crepitus in the knee. B. Compare the swollen knee with the other knee C. Assess active ROM in the knee D. Feel the knee for warmth
B. Compare the swollen knee with the other knee
which nursing actions demonstrate an understanding of the components required when conducting the objective portion of a neurological assessment? (Select all that apply). A. Conduct the mental status exam as the initial part of the assessment to minimize anxiety B. Evaluate cranial nerve XI function by asking the patient to shrug the shoulders C. Assess the patients coordination by conducting the Romberg test D. Use a reflex hammer to elicit superficial tendon responses E. Test for tactile discrimination using a door key
B. Evaluate cranial nerve XI function by asking the patient to shrug the shoulders E. Test for tactile discrimination using a door key
The nurse performs BP screening at the local community center. As part of the health promotion intervention, the nurse also discusses the following risk factors for stroke: A. Low BP, lack of exercise, and diet high in fat B. High BP, diet high in fat, and smoking C. Diet high in fat, smoking, and walking 5x weekly D. Obesity, swimming 5x weekly, high BP
B. High BP, diet high in fat, and smoking
To correctly document that ROM in the fingers is full and active, you would write that the patient can A. Perform rotation, lateral flexion, and hyperextension B. Make a fist, spread and close fingers, and do finger-thumb opposition C. Touch finger to own nose and to examiner's finger back and forth D. Perform supination, pronation, and lateral deviation
B. Make a fist, speead and close fingers, and do finger-thumb opposition
A patient with a history of cirrhosis tells the nurse that his abdomen seems to be getting larger and that he has gained 9.7 kg (20lb) in the past 6 months. How will the nurse determine whether the abdominal enlargement is from accumulation of fluid or fat from the weight gain? A. Listen for a fluid wave B. Percussion the abdomen for shifting dullness C. Auscultation for lymph nodes D. Stroke the abdomen to elicit the abdominal reflex
B. Percuss the abdomen for shifting dullness
A 20-year-old Caucasian man complains of a mass in his left testicle. In addition to his age and race, what else is a risk factor for testicular cancer? A. colon cancer in his mother B. personal history of cryptorchidism C. urinary tract infection last month D. congenital hydrocele
B. Personal history of cryptorchidism
A patient in a nursing home was admitted with a diagnosis of dementia. He started a fire because he was cooking at home and forgot that he left a pan on the stove. The nursing diagnosis that is highest priority is: A. Ineffective brain tissue perfusion B. Risk for injury C. Acute confusion D. Impaired memory
B. Risk for injury
A 47 year old woman states she is having vertigo and some difficulty with balance. The nurse should assess: A. Accommodation B. The whisper test C. Shoulder strength D. Soft touch
B. The whisper test
A patient undergoing a neurological assessment fears a serious diagnosis. Which action by the nurse will best ensure that the patient will comply with the assessment process? A. Approach the assessment in a positive and professional manner B. Treat the patients concerns and fears with both sensitivity and empathy C. Be aware that dizziness and headaches are the most commonly reported complaints D. Focus the assessment on an in-depth nursing history and interview
B. Treat the patients concerns and fears with both sensitivity and empathy
A patient complains of a soft, irregular mass on the left side of the scrotum he noticed while walking. The nurse palpated a mass that feels like "a bag of worms". These finding are consistent with which condition? A. Hydrocele B. Variocele C. Spermatocele D. Epididymitis
B. Variocele
Use of the GCS provides relatively objective assessment of LOC, The three functions assessed are: A. Pupil reaction, orientation, and sensation B. Verbal response, eye opening, and motor response C. Eye opening, motor response, and sensation D. Verbal response, pupil reaction, and motor response
B. Verbal responde, eye opening, and motor response
A patient reports changes in bowel pattern. Which is the best question to determine normal bowel habits? A. How often do you have a bowel movement? B. What was your bowel pattern before you noticed the change? C. Is there a family history of irritable bowel syndrome? D. Have any of your parents or siblings had cancer of the colon?
B. What was your bowel pattern before you noticed the change?
It is important to examine the upper outer quadrant of the breast because it is A. More prone to injury and calcifications B. Where most breast tumors develop C. Where most of the suspensory ligaments attach D. The largest quadrant of the breast
B. Where most breast tumors develop
A woman appears restless and is wringing her hands prior to having a clinical breast examination performed. Which statement by the nurse would be most appropriate? A. "I know you are worried, but your risk for cancer is low." B. "You need to pay attention to these instructions so we can finish as quickly as possible." C. "You seem to be anxious. Can you tell me what you are thinking?" D. "You appear restless but I can assure you that your doctor is very good."
C. "You seem to be anxious. Can you tell me what you are thinking?"
When examining the breast of a 75-year-old woman, the nurse would expect to find which of the following? A.enlarged axillary lymph nodes B. Multiple large firm lumps C. A granular feel to the breast tissue D. Pale areola
C. A granular feel to the breast tissue
An older adult patient who lives alone is hospitalized after falling and sustaining a broken arm. Which nursing action will best determine whether the patient is experiencing any cognitive dysfunctions that may have contributed to the fall? A. Inquire of family members as to whatever they are comfortable with the patient living alone B. Ask the patient to explain what "raining cats and dogs" mean C. Administer an assessment tool such as the mini cog D. Evaluate the patient using the Glasgow coma scale
C. Administer an assessment tool such as the mini-cog
The nurse is assessing an older adult client who had lost 2.27 kg (5lb) since her last visit 1 year ago. The client tells the nurse that her husband died 2 months ago. The nurse should further assess the client for A. Peptic ulcer B. Bulimia C. Appetite changes D. Pancreatic disorders
C. Appetite changes
When examining the scrotum of an adult Hispanic male, a normal finding is A. Symmetrical scrotal sac with two movable testes B. Smooth, rubbery, saclike surface that is sensitive to gentle compression C. Asymmetrical sac with left side lower than right side D. Reddish colored skin that is darker than general body skin and has sebaceous cysts
C. Asymmetrical sac with left side lower than right side
A 23-year-old nulliparous woman is concerned that her breasts seem to change in size all month long and they are very tender around the time she has her period. The nurse should explain to her that A. No pregnant women usually do not have these breast changes and this is cause for concern B. Breasts often change in response to stress, so it is important to assess her life stressors C. Cyclical breast changes are normal D. Breast changes normally occur during pregnancy and she should have a pregnancy test.
C. Cyclical breast changes are normal
The nurse is assessing a 51 year old morbidly obese client who is seeking care for the recent loss of sensation in his feet and toes. The client also complains of intermittent burning and tingling in his feet that radiate up his legs. For which of the following health problems should the nurse first assess? A. Lead poisoning B. Multiple sclerosis C. Diabetic peripheral neuropathy D. Alcohol abuse
C. Diabetic peripheral neuropathy
During a routine visit, an older patient shared that recently he has had "trouble remembering things; little things like where I put my keys." Which interview question will the nurse ask to best in dentist a possible physical cause for the lapses in memory? A. How long have you been experiencing these memory lapses? B. Have you had any major traumatic events in your life lately? C. Have you ever had any kind of head injury during your lifetime? D. What medications are you currently prescribed for chronic illness?
C. Have you ever had any kind of head injury during your lifetime?
A clinical nurse is assessing a patient's knowledge and understanding of bone health and maintenance. Which of the following responses of the patient indicates adequate understanding to maintain musculoskeletal health? A. I will take calcium supplementation as prescribed and eat plenty of citrus fruits. B. I will expose myself to sunlight at least 1 hour daily and eat plenty of green, leafy vegetables. C. I will take calcium supplementation and vitamin D as prescribed D. I will exercise daily and take vitamins E as prescribed
C. I will take calcium supplementation and vitamin D as prescribed
A patient with a history of kidney stones presents with complaints of pain, hematuria, and nausea eith vomiting. What assessment technique will elicit kidney pain? A. Inspection with indirect lighting B. Iliopsoas muscle sign C. Indirect percussion for CVA tenderness D. Blumberg sign
C. Indirect percussion for CVA tenderness
A nurse is providing client education to a group of prepubescent girls at a local elementary school. What would the nurse be most likely to include in the presentation? A. Information ab breast cancer screening B. Information ab the lymphatic system C. Information ab the stages of breast development D. Information ab lactation
C. Information ab the stages of breast development
A group of students is preparing for the clinical experience, for which they are required to demonstrate the techniques for examining the abdomen. The students demonstrate the techniques in which order? A. Palpate, percussion, inspect, auscultate B. Auscultate, inspect, palpate, percussion C. Inspect, auscultate, percussion, palpate D. Percuss, inspect, auscultate, palpate
C. Inspect, auscultate, percussion, palpate
When performing an abdominal assessment, what is the correct sequence? A. Inspection, palpation, percussion, auscultation B. Palpation, percussion, auscultation C. Inspection, auscultation, percussion, palpation D. Auscultation, inspection, palpation, percussion
C. Inspection, auscultation, percussion, palpation
On inspecting a newborn's breasts, the nurse notes that they are enlarged and engorged, with a white liquid discharge. The infants mother is concerned about it. Which of the following should the nurse tell the mother regarding this finding? A. It is due to an infection and should resolve on administration of an antibiotic B. It is due to a rare form of breast cancer in infants, treatable by surgery C. It is due to the influence of the maternal hormones and should resolve in a few days D. It is due to a chromosomal disorder that results in premature puberty
C. It is due to the influence of the maternal hormones and should resolve in a few days
When doing an assessment of the spine of an older adult, you can expect to see which variation? A. Lordosis B. Torticollis C. Kyphosis D. Scoliosis
C. Kyphosis
A young adult marathoner reports of right food third metatarsal pain (6/10) and swelling for more than 4 weeks. An X-ray was ordered, and it did not show abnormal findings. Which of the following imagine might the nurse expect the physician to order? A. Repeat X-ray B. CT scan C. MRI D: nuclear scintigraphy
C. MRI
When teaching the breast self-examination, you would inform the woman that the best time to conduct breast self-examination is: a) just before the menstrual period b) just after the menstrual period c) on the 4th to 7th day of the cycle. d)on the 10th day of the menstrual cycle
C. On the 4th to 7th day of the cycle
A client calls the clinic and asks to speak to the nurse. The client tells the nurse that she has just started taking morphine for advanced cancer, is constipated, and wonders what is causing this. What would be the nurses best response? A. "People can become constipated for no reason at all." B. "People can become constipated when they eat a lot of fiber." C. "People can become constipated when taking certain medications" D. "People can become constipated when they are more active than usual."
C. People can become constipated when taking certain medications."
To promote relaxation of the abdominal muscles, which of the following would be most appropriate for the nurse to do? A. Encourage the client to hold his or her breath B. Cover the client in a warm blanket C. Place a pillow under both of the clients knees D. Assure the client that painful areas will not be examined
C. Place a pillow under both of the clients knees
An adult male client reports hesitancy when urinating. The nurse would further assess the client for which complication? A. Scrotal hernia B. Sexually transmitted infection C. Prostate enlargement D. Testicular tumor
C. Prostate enlargement
A nursery nurse is assessing the neurological status of a newborn. What area would the nurse be assessing? A. Pain B. Weight and length C. Reflexes D. Ability to eat
C. Reflexes
When auscultating the abdomen, the nurse hears a bruit to the right of the midline slightly below the umbilicus. The nurse documents this finding as a bruit of which of the following? A. Right renal artery B. Right femoral artery C. Right iliac artery D. Abdominal aorta
C. Right iliac artery
The patient's muscle tone is hypertonic so the muscles are stiff and the movements are awkward. The nurse documents these findings as A. Atony B. Tremors C. Spasticity D. Fasciculation
C. Spasticity
The nurse is preparing to perform the Romberg test on an adult male client. The nurse should instruct the client to: A. Squat down as far as he is able to do so B. Keep his eyes open while he bends at the knees C. Stand erect with arms at the sides and feet together D. Touch the tip of his nose with his finger
C. Stand erect with arms at the sides and feet together
The correct position in which to place the patient to palpate the breasts is A. Left lateral position with arm over head B. Sitting forward with hands on hips C. Supine with arm over head D. Supine with arms at side
C. Supine with arm over head
Which of the following would you recognize as an unexpected finding while examining the male genitalia? A. Smegma is present on the uncircumcised patient B. Testes are palpable and firm within the scrotal sac C. You note an impulse at the tip of your finger during hernia examination D. The urethral meatus has a slit like opening central to the distal tip of the glans
C. You note an impulse at the tip of your finger during hernia examination
A nurse is inspecting a client's nipples. Which of the following findings should the nurse regard as a cause for concern? A. Nipples that have been flat for many years B. Supernumerary nipples C. Nipples that are nearly equal in size D. A recently retracted nipple that was previously everted
D. A recently retracted nipple that was previously everted
If the great toe extends upward and the other roes fan out in response to stroking the lateral aspect of the sole of the foot, this is documented as which of the following? A. Hyporeflexia B. Normal plantar reflex C. Cushing response D. Babinski sign
D. Babinski sign
You note that an adolescent has uneven shoulder height. To differentiate functional from structural scoliosis, you ask the patient to A. Stand up straight while you check the height of the iliac crest B. Flex the elbow and pull against your resistance C. Shrug both shoulders while you provide resistance D. Bend forward at the waist while you palpate the spine
D. Bend forward at the waist whole you palpate the spine
A man had a motor vehicular accident and fractured his right ankle. He was transferred from the emergency department to the orthopedic nursing unit for further observation and possible surgery in the next 12 hours. What is the priority nursing assessment of the admitting orthopedic nurse? A. Temperature B. Capillary refill proximal to the injury of the right ankle C. Capillary refill distal to the injury of the left ankle D. Capillary refill distal to the injury of the right ankle
D. Capillary refill distal to the injury of the right ankle
A male patient presents to the clinic with a complaint of a hard, irregular, nontender mass on his chest under the are areola. Upon examination, the nurse noted that the mass is immobile and suspects a. Gynecomastia B. Benign lesion C. Paget disease D. Carcinoma
D. Carcinoma
A client has sustained an injury to the cerebellum. Which area should be the nurses primary focus for assessment? A. Vital signs B. Respiratory status C. Cardiac function D. Coordination
D. Coordination
During a physical assessment, using the handle of the reflex hammer, you gently stroke the inner left thigh of the patients, which cause the ipsilateral test idle to rise. What superficial reflex is demonstrated? A. Abdominal reflex B. Babinski reflex C. Brachioradialis reflex D. Cremasteric reflex
D. Cremasteric reflex
A patient with benign breast condition is likely to A. Develop breast cancer later in life B. Require hormone replacement therapy C. Be a teenager D. Have it resolve after menopause
D. Have it resplve after menopause
Which sexually infection presents with painful red superficial vesicles along the penis or on the glans? A. Gonorrhea B. Chlamydia C. Syphilis D. Herpes simplex virus 2 (HSV-2)
D. Herpes simplex cirus 2 (HSV-2)
The nurse is reviewing patient data from a neurological assessment and notes that the patients history includes several recent falls. Which nursing action will the nurse take immediately to address the patients risk for injury? A. Review the patients meds for possible triggers that could cause falls B. Alert the staff to the patients increased risk for injury due to falls C. Instruct the patient to ride slowly from a supine position D. Implement the facilities universal fall precautions
D. Implement the facilities universal fall precautions
The nurse is preparing to assess the abdomen of a hospitalized client 2 days after abdominal surgery. The nurse should first A. Palpate the incision site B. Auscultate for bowel sounds C. Percuss for tympany D. Inspect the abdominal area
D. Inspect the abdominal area
Which assessment technique best confirms splenic enlargement? A. Deep palpation under the left costal margin B. First percussion of the spleen with the patient in a sitting position C. Deep palpation over the RUQ with the patient lying on the right side D. Percussion along the left MAL spleen and gentle palpation
D. Percussion along the left MAL spleen and gentle palpation
Mrs. Johnson, a transcriptionist, reports pain and burning in her right hand. What assessment procedures should the nurse perform next? A. Trendelenburg and drawer signs B. McMurray and Thomas tests C. Bulge test and ballottement D. Phalen and Tinel tests
D. Phalen and Tinel tests
You are inspecting the groin of an older adult man who lives in a long term care facility. Which of the following is an expected finding that you will document? A. Pediculosis in hair distribution B. Hypospadias on the glans C. Yellow discharge from the meatus D. Smegma under the foreskin
D. Smegma under the foreskin
The correct position in which to place a healthy adult male client to examine the rectum and prostate is A. The left lateral sims position with right knee flexed and left leg extended B. The supine position with hips and legs flexed and feet positioned on the examining table C. The modified knee-chest position with the patient prone and knees flexed under hips D. Standing and leaning over the examination table with chest and shoulders resting on the table
D. Standing and leaning over the examination table with chest and shoulders resting on the table
While conducting the physical examination, which of the following assessments would require the nurse to auscultate the abdomen? A. To identify the edges of abdominal organs B. To identify abdominal tenderness C. To identify the distribution of gas in the abdomen D. To identify bowel sounds
D. To identify bowel sounds
The nurse is assessing a client's abdomen as shown. Which technique is the nursing using? (Two hands pushing on the abdomen) A. Hooking B. Percussion C. Light palpation D. Two-handed deep palpation
D. Two-handed deep palpation
What percussion sound is heard over most of the abdomen? A. Resonance B. Hyperresonance C. Dullness D. Tympany
D. Tympany
The chart states that a 62-year-old woman has had a stroke in the right parietal area of the brain. The nurse expects to note which of the following? A. Tremors on the left side of the face B. Tremors on the right side of the face C. Weakness in the right arm D. Weakness in the left arm
D. Weakness in the left arm