NUR306 EAQ Final Review

Which points will be part of the nurse preceptors lecture on caring for the lesbian gay bisexual transgender queer questioning older adult population? Select all that apply. This group should be forced to answer any questions May have sexual organs that conflict with their gender identity Are at an elevated risk for disability from chronic disease and mental distress Older adult client are commonly heterosexual May I add their gender identities and sexual orientations from the nurse and other healthcare providers?

Conflict, elevated risk, hide their gender identities

Which client is at risk for heart disease? Client one - red, face, area of trauma, sacrum, shoulders Client two - bluish, nail beds, lips, mouth, skin Client three - pallor, face, conjunctivae, nail beds, palms of hands Client four - yellow, orange, sclera, mucous membranes, skin

Client two Rationale: These symptoms may be due to an increased amount of deoxygenated, hemoglobin, which may be due to heart or lung disease. Client one would indicate fever or trauma. Client three would indicate anemia. Client number four would indicate jaundice or liver disease.

A client weighs 150 pounds and is 5 foot seven. Which numerical value reflects the clients body mass index.

23.53 Rationale: BMI can be calculated by dividing the clients weight in kilograms by the height in meters squared. 1 pound equals 0.45 kg.

The nurse is caring for a client with a fractured hip. Which is the nurse trying to prevent by placing pillows around the injured area? Abduction Adduction Traction Elevation

Abduction

What are performing a visual system assessment, the nurse observes that the client has a misalignment of the right eye. The client reports to the nurse, I am having double vision. Which condition may be the cause of the double vision? Myasthenia gravis Peri orbital tumors Conjunctival blood vessels rupture Abnormalities of extraocular muscle actions

Abnormalities of extraocular muscle actions Rational: Myasthenia gravis may cause drooping of the upper lid margin, ptosis. Periorbital tumors may result in exophthalmos, which is manifested as protrusion of the globe be on its normal position within the bony orbit. If conjunctival blood vessels, rupture, blood spots may appear on the sclera as a sub, conjunctival hemorrhage.

Which action would the nurse take for a client whose right radio pulse is weak and thready? select all the apply Assessing all peripheral pulses Assessing and comparing both radial pulses Asking a second nurse to assess the client pulses Assessing for edema or other issues that may be restricting peripheral blood flow Observing for pallor or skin, temperature, differences distal to the weak pulse

All responses are correct

Which population would the nurse include in a community education session unsexually, transmitted infections? Select all the reply. Adolescence Homosexual men Transgender clients Multiple sex partners Intravenous drug users

All responses listed are correct

When accessing a client, reporting shortness of breath, which activity best interest the nurse, obtains, accurate and complete data to prevent a nursing diagnostic error? Assess the client lungs Assess the client for pain Obtain details of smoking habits Ask about the onset of shortness of breath

Assess the clients lungs

Which step of the nursing process involves the nurse interviewing a client about current health problem and obtaining the clients vital signs? Planning Diagnosis Assessment Implementation

Assessment

Which behavioral finding corresponds to intimate partner, violence and young adults? Select all that apply. Attempting suicide Sexually acting out Pattern of substance abuse Fear of certain people or places Preoccupation with others or ones on genitals

Attempting suicide, pattern of substance abuse Rational: The behavioral findings and children undergoing sexual abuse, includes actually acting out, fear of certain people are places, and preoccupation with genitalia

Which statement describes gynecomastia? Select all that apply. Information of epididymis of testes Suspended testes from its vascular structures Bilateral or unilateral, enlargement of breast and adolescent boys Elongation and dilation of the vans of the spermatic cord superior to the testicle Any unusual physical change during the growth and development of sexual organs

Bilateral or unilateral, enlargement of breast and adolescent boys, and unusual physical change during the growth and development of sexual organs

For a client diagnosed with acquired immunodeficiency syndrome, aids, the nurse identifies white patchy plaques on the mucosa of the clients oral cavity. The nurse recognizes this finding most likely represents which opportunistic infection? Cytomegalovirus Histoplasmosis Candida albicans Human papillomavirus

Candida albicans Rationale: Cytomegalovirus causes a serious viral infection in clients with HIV, resulting in retinal, gastrointestinal, and pulmonary manifestations Histoplasmosis is an infection caused by inhalation of fungi, spores, histoplasma cup post Sultan, and is characterized by fever, mouse, cough, and lymphadenopathy HPV manifest as warts on hands and feet, as well as mucous membrane, lesions of the oral, anal and general cavities, and may be transmitted without the presence of warts throughout Bodily fluids, with some forms associated with cancerous and precancerous conditions

Well, assessing an older adult during a regular health, check up, the nurse find signs of elder abuse. Which physical finding will confirm the nurses suspicion? Select all that apply. Pressure of hyoid bone damage Presence of cognitive impairment Presence of burns from cigarettes Presence of bedsores Presence of unexplained bruises on the wrist

Cigarettes, bedsores, bruises Rationale: Presence of hyoid bone damage is an indication of intimate partner violence. The presence of cognitive impairment is a behavioral finding an older adult abuse.

Which client is at a higher risk for a rice and blood pressure based on the given data? Client A- 20 years, 70 bpm, normal stroke, volume Client, B- 30 years old, 90 bpm, decreased stroke, volume Client C- 40 years, 40 bpm, increased stroke, volume Client D- 50 years, 100 bpm, normal stroke, volume

Client C Rationale: The blood pressure rises when the heart rate is decreased, and the stroke volume is increased. In adults, the pulse rate should be between 60 and 100 bpm. Client C heart rate is 40 bpm, which is less than normal, and the stroke volume is increased.

When is Ossing a pediatric client common optimhal just notices the client is unable to focus on an object with both I simultaneously. Which other finding would confirm the diagnosis as strabismus? Select all the reply. Impaired near vision Crossed appearance of the eyes Elevated intraocular pressure Impaired extraocular muscles Degeneration of the central retina

Crossed appearance of the eyes, impaired extraocular muscles

Which observation by the nurse indicates a clients decrease in hearing acuity? Select all that apply. Frequent use of the words such as what Postural changes while listening to the speaker Tending toward the other person while talking Mismatch between the questions asked in response given Startled expression to any unexpected sound in the environment

Everything but the last one

Which question with the nurse asked the client on obtaining their health history? Select all that apply. Tell me about your food habits Do you use alcohol or tobacco? Have you sustained any personal loss recently? Have you ever experienced any allergic reactions? Does any family member have a long-term illness?

Food, habits, alcohol or tobacco, allergic reactions

The nurse is completing the health history of a client admitted to the hospital with osteoarthritis. Which joint with the nurse expect the client to report as having been involved first? Hips Knees Ankles Shoulders Metacarpals

Hips and knees Rationale: Osteoarthritis affects the weight-bearing joints, example given to hips and knees, first, because they bear the most bodyweight. The resulting joint damage causes a series of physiological responses like the release of cytokines and proteolytic enzymes, that lead to more damage. Although the ankles are weight-bearing joints, and eventually are affected, the motion in the ankles is not as great as in the hips and knees; thus there is less degeneration. Although the distal interphalangeal joints are commonly affected, the remaining interphalangeal joints and metacarpals are not.

When performing an assessment of a client trigeminal nerve function, how would the nurse identify the function of this nerve? Observing a pupil constriction Identifying corneal sensation Determining the ability to smell Determining the ability to shrug the shoulders

Identifying the corneal sensation Rationale: The afferent sensory branch of the trigeminal nerve, cranial nerve five, innervates the cornea. When observing pupil, constriction, the nurse test, the function of cranial nerve three. Cranial nerve one and tails, using test to determine the clients ability to smell. The test a function of cranial nerve 11 the nurse asked the client to shrug the shoulders.

Moro Babinski Stepping Cremasteric

If Bivinski reflex is present an adults, it may indicate a lesion of the Pyramidal tract and disappears after one year in infants. The Moro, startle, reflects, is also expected a newborns and disappears between third and fourth months and is present after four months indicates neurological disease. The stepping reflects is also expected in newborns and disappears about 3 to 4 weeks after birth, and is replaced by more delivered action. The cremasteric is a superficial, reflects the test, the lumbar segment one and two stimulating this reflects is useful, initiating reflex, emptying of this Bastic bladder after a spinal cord, disruption about the second, third, or fourth sacral segment.

Which client joint would be palpated by the nurse to identify genu valgum? Hip Knee Temporomandibular Metacarpophalangeal

Knee Rationale: The identifying condition is also known as knock knees

When Oscal Tating, the heart, a healthcare provider notices S3 heart sounds and four clients. Which client has the highest risk for heart failure? Child Pregnant Older adult Young adult

Older adult Rationale: S3 is indicative of congestive heart failure in adults over 30 years old. And young, pregnant, and under 30 year old clients, the third heart sound is often considered to be a normal parameter.

Which site with the nurse prefer to assess for determining the turgor of an older adult select all that apply Back of the neck Back of the hand Palm of the hand On the sternal area Back of the forearm

On the sternal area, and back of the forearm Rationale: The rest of the sites are not reliable or ideal sites for turgor assessment

When teaching a client about their disease process, which term with the nurse use to describe boneless greater than normal, but less than that caused by osteoporosis? Osteopenia Osteomyelitis Osteomalacia Osteoarthritis

Osteopenia Rationale: Osteomyelitis is infection of the bone or bone marrow. Osteomalacia is softening of bones due to calcium or vitamin D deficiency. Osteoarthritis is cartilage deterioration in the joints.

The nurse is performing a health, history and physical assessment of a client with colalysis and obstructive jaundice which clinical findings with the nurse expect the client to exhibit? Hematuria Bloody stools Straw colored urine Pain in the right upper quadrant

Pain in the right upper quadrant Rationale: This is where the gallbladder is located. Pain occurs after fatty meals and they radiate to the right back or shoulder. Hematuria occurs with nephrolithiasis not cholelitheasis. The store will be clay colored, not bloody because of the lack of bile. When the level of bile and blood increases by, will be present in urine, causing it to have a dark color.

Which statement is an accurate description of dysmenorrhea Pain with menses Endometrial hyperplasia Bleeding between menses Heavy, bleeding with menses

Pain with menses Rational: Endometrial hyperplasia results from anovulation and persistent estrogen stimulation. Bleeding between menses is metrorrhagia. Heavy bleeding with the menses is menorrhagia

A client is admitted with an acute onset of right lower quadrant pain at McBurney point, and appendicitis is suspected. For which clinical indicator with the nurse assess the client to determine if the pain is secondary to appendicitis? Urinary retention Gastric hyperacidity Rebound tenderness Increased lower bowel motility

Rebound tenderness Rationale: Urinary retention does not cause acute lower, right quadrant pain. Hyperacidity causes epigastric, not lower, right quadrant pain. They're generally is decreased Bauer motility distal to an inflamed appendix.

A nurse is caring for a client with a bowel obstruction. Which assessment findings indicate that possible onset of peritonitis? Select all that apply. Diarrhea Bradycardia Rebound tenderness Diminished bowel sounds Richard, bored like abdomen

Rebound tenderness, diminished, bowel, sounds, rigid, bored, like abdomen Rationale: The client, experience, constipation, not diarrhea. The heart rate will be tachycardic, not bradycardic.

Which instruction would the nurse give me a client when assessing for damage to the glossopharyngeal and Vegas nerves? Smile Shrug Smell Swallow

Swallow Rationale: Shrugging test the accessory nerve. The sense of smell test the olfactory nerve. Smiling test the facial nerve.

The nursing student, under the supervision of the registered nurse, plans to perform a post assessment. While preparing to assess the client, the RN asked the student to check the apical pulse after assessing the radio poles. Which rationale supports the RNs request? The client may have a dysrhythmia The client may have physiologic shock The client underwent surgery earlier in the day The client may have peripheral artery disease

The client may have a dysrhythmia Rationale: A client with dysrhythmia may have an intermittent or abnormal radial pulse. If the client is in shock, then assessing the carotid or femoral pulse would be appropriate. If the client had peripheral artery disease, you would assess using the femoral pulse.

During a newborn assessment, the nurse identifies with the temperature, pulse, respirations, and other physical characteristics are within the expected range. The nurse record these findings on the electronic health record. How are the nurses action be interpreted? The nurse perform the actions correctly This is a medical procedure, and the nurse overstep scope of practice Nursing assessments are not equivalent to a primary healthcare providers assessments The initial assessment with infants, physical status is the responsibility of the clients primary healthcare provider

The nurse performed the actions correctly

Which statement describes scoliosis? The concave lumbar curvature is exaggerated There are pathological changes in the vertebrae There is a rotary deformity of the lateral curvature of the spine The curvature of the thoracic spine has an increased convex angulation

There is a rotary deformity of the lateral curvature of the spine (The last one is describing kyphosis)

Which statement describes varicocele? Occurs most often on the left side Left testicle is larger one associated varicocele is present Testicular size increases with increasing duration of a varicocele Dihydrotestosterone level increases with the duration of a varicocele

Varicocele Occurs most often on the left side Rationale: Varicocele occurs most often on the west side. The left testicle is smaller, one associated with varicocele. Testicular size decreases with increased duration of varicocele. Dihydrotestosterone levels increase with increasing duration of varicocele.

Which action will be included in the assessment process by a nurse working in a school health promotion program for adolescence? Select all that apply. Conduct a school violence assessment Access to sleep pattern of the students Try identifying individuals at risk for substance abuse Identify the need for fluoride supplements to prevent dental caries Inquire about the presence of guns in the home to reduce the incidence of homicide

Violence, assessment, substance abuse, incidence of homicide

Which individuals activities increase the risk of developing carpal tunnel syndrome? Housekeeper Software engineer Healthcare worker Professional athlete

Software engineer - because it is a computer related job that involves repetitive movement of the fingers and hand predisposing the individual

Which client is most at risk for osteoporosis? A non-smoking 60 year old woman, BMI of 27.1. A 66 year old, white woman, BMI 18, who is a paralegal Hey 68 year old, black woman, BMI 23.3, who is a retired receptionist A 62 year old woman, BMI 23.2, who takes calcium carbonate daily.

66 year old, white woman Rational: A post menopausal woman who is small boned, underweight, parentheses BMI, 18 parentheses, and relatively sedentary as a paralegal. Is it rich for osteoporosis; other's factors are family, history and white or Asian ethnicity. A woman who is relatively heavy, BMI, 27.1, and does not smoke is it less words for osteoporosis then is a thin postmenopausal woman. Postmenopausal women who are black or lower risk for osteoporosis then or white and Asian woman.

What time will the nurse use to describe noticeable difference in the people sizes? Mydriasis Hyperopia Aniscoria Arcus Senilis

Aniscoria Rationale: It is also a normal condition in about 5% of people. Normal diameter of the peoples between three and 5 mm. Hyper Opia clients have smaller pupils with a diameter of less than 3 mm. My GASIS is the process of pupillary dilation. Archeson Ellis is an opaque, bluish white ring within the outer edge of the cornea caused by the presence of fat deposits.

Which condition with the nurse suspect when an older adult as a thin white ring around the margin of her Iris? Cataract Arcus Senilis Conjunctivitis Macular degeneration

Arcus Senilis Rational: An older adults, the Irish becomes faded, and a thin, white ring known as arcus. Synovus appears around the margin of the iris. A cataract as a condition involving increased opacity of the ones that blocks light rays from emerging the eye. The presence of redness indicates allergic or infectious conjunctivitis. Macular degeneration is March, by blurring of central vision, caused by progressive degeneration of the center of the retina.

For which client with the nurse assess the carotid pulse? select all that apply Client with cardiac arrest Client indicated for Alan test Client under physiological shock Client with impaired circulation to foot Client with impaired circulation to hand

Cardiac arrest and physiological shock Rationale: Carotid pulse is indicated in clients with this physiological shock or cardiac arrest, when other sides are not palpable Ulnar pulse is indicated in clients requiring an Allen test Posterior tibial and dorsalis pedis pulse is indicated in clients with impaired circulation to feet Ulnar and radial pulse is indicated in clients with impaired circulation to hands

A client reports excessive tearing. Which disorders with the nurse suspect could be responsible for the clients condition? Select all that apply. Chalazion Entropion Hordeolum Conjunctivitis Keratoconjunctivitis sicca

Chalazion, entropion, conjunctivitis Rationale: Chalazion is an inflammation of a sebaceous gland in the eyelid, manifested by excessive, tearing and light sensitivity. Entropion is disorder of the eye that causes pain and excessive tearing. Conjunctivitis also causes excessive, tearing, a blood, draw appearance, and itching. A hordeolum is an infection of the eyelid. Sweat glands that causes red, swollen and painful eyes. Keratoconjunctivitis sicca is a dry eye syndrome; this disorder causes decreased tear production.

A older client was usually cheerful and cooperative, demonstrates irritability and restlessness during morning hygiene. Which assessment with the nurse perform first? Level of stress and ability to cope Changes in mental status and cognition Deviations from baseline mood and affect Feelings related to loss of independence

Changes a mental status and cognition Rationale: Sudden changes and mental status and cognition our sister reported to healthcare provider because there are many physical causes such as delirium, Electra and balances, decrease oxygenation, sepsis, increased, intercranial, pressure, they must be immediately treated. Once physical causes a rolled out or identified and treated, the nurse process for stress mood, and affect as well as feelings.

Which characteristic of urine changes in the presence of a urinary tract infection? Clarity Viscosity Glucose level Specific gravity

Clarity Rationale: Specific gravity yields information related to fluid balance

A client reports right ear hearing loss. When performing a weber test with a tuning fork, the client hears the sound better with the right ear. Which condition would the nurse suspect from these results? Normal hearing Mixed hearing loss Conduction hearing loss Sensorineural hearing loss

Conduction hearing loss Rationale: During a weber test conduction hearing loss often causes a tuning fork to be heard better and more clearly in the impaired year. People with sensorineural hearing loss will hear the sound better in the normal year. Mixed hearing loss is a combination of both conduction and sensorineural hearing loss, and would not result in the findings observed within the Weber test. The client does not have normal hearing.

Which problems common for a client with a diagnosis of schizophrenia? Change your mental status Disordered thinking Rigid, personal boundaries Violence directed towards others

Disorder, thinking

The nurse notes, bruises on the pregnant, clients face and abdomen. There are no bruises on her legs and arms. Further assessment is required to confirm which condition? Domestic abuse Hydatidiform mole Excessive exercise Thrombocytopenic purpura

Domestic abuse Rationale: Hydatidiform mole manifest as an unusually enlarged uterus for gestational age, accompanied by hypertension, nausea and vomiting and vaginal bleeding. Not bruises on the face and abdomen. Excessive exercise may cause cardiovascular or pulmonary problems not bruising. Thrombocytopenic purpura another bleeding disorders manifest is bruises and petechiae, how many areas of the body surface, not just the face and abdomen

Which client's assessment playing correctly yield's effective results? Ulnar - ulnar side of forearm at the wrist - cardiac arrest one other sites are not palpable Carotid - along the medial edge of the sternocleidomastoid muscle in the neck - presence of owner blood flow Dorsalis pedis - along the top of the foot - status of circulation to the foot Posterior tibial - above the medial malleolus - status of circulation to the foot

Dorsalis pedis Rationale: Owner site is used to assess the status of circulation to the hand and to perform the Allen test. The carotid site is used to assess in times of physiological shock or cardiac arrest when other sites are not palpable. The posterior tibial site is found below, not above, the medial malleolus, and is used to assess the status of circulation in the foot.

What, assessing the eyes of a client, and healthcare provider notices there's an obstruction to the outflow of aqueous humor. Which additional finding with support a diagnosis of glaucoma? Blurred central vision Increased opacity of the lens Elevated intraocular pressure Changes in retinol blood vessels

Elevated intraocular pressure Rationale: Blurred, central vision is seen in macular degeneration. Increased opacity of the ones may be seen and cataracts. Retinopathy may result from changes and retinol blood vessels.

Which instruction will the nurse provide to adolescent males regarding the usual procedure to be followed and normal findings observed during testicular self examination? Select all that apply. A firm, smooth, egg shaped organ that can be palpated Each testicle is examined individually after relaxing the scrotal skin A hard mass can be palpated on anterior or lateral aspect of the testicle The salmon fingers of both hands can be used to apply for him and gentle pressure Erase swelling, they can be palpated on the superior aspect of the testicle is the epididymis

Everything, but the hard mass that can suspects testicular cancer

Which finding would the nurse expect to identify in a client who has osteoarthritis that would not be present in clients with rheumatoid arthritis? Ulnar drift Heberden nodes Swan neck deformity Boutonniere deformity

Heberden nodes Rationale: Heberden nodes are the bony or cartilaginous enlargement of the distal Interfit phalangeal joints that are associated with osteoarthritis. All other options occur with rheumatoid arthritis.

A client reports difficulty breathing, and the nurse auscultates bilateral wheezing in the anterior upper lobes. Which potential rationale would explain the sound? Inflammation of the pleura Muscular spasm in the larger airways Sudden reinstallation of groups of alveoli High velocity, air flow through an obstructed airway

High velocity airflow threw an obstructed airway Rationale: Wheezing equals an obstructed or narrowed airway Plural inflammation produces pleural friction rub Muscular spasm in larger airways, or any new growth equals turbulence that produces rhonchi, which are low and loud pitched sounds Sudden reinstallation of groups of alveoli equals crackling sounds

When obtaining a health history, from the newly admitted, client who has chronic pain in the right knee, which pain assessment data, would the nurse include? Select all that apply. Pain, history, including location, intensity, and quality of pain Clients purposeful body movement, and arranging the papers on the bedside table Pain pattern, including precipitating in alleviating factors Vital signs, such as increase blood pressure and heart rate The clients family statement about increases in pain with ambulation

Pain, history, including location, intensity, and quality of pain Pain pattern, including precipitating, and alleviating factors Rationale: The initial pain assessment should include information about the location, quality, intensity, onset, duration, and frequency of pain, as well as factors that relieve or exacerbate the pain. Vital signs are a secondary assessment related to the initial.

Which action would the nurse take to assess for ascites? Observe the client for signs of respiratory distress Percuss the clients abdomen and listen for dull sounds Palpate the lower extremities over the tibia and observe for pitting Auscultate for the absence of bowel sounds in the abdomen

Percuss the clients abdomen and listen for dull sounds Rationale: Percussing over the clients abdomen will produce a dull sound if excess fluid is present. Respiratory distress may occur with ascites, but is not evidence of ascites, and can be used for many other conditions. When I say, this is extensive, bowel sounds made diminish, but may still be heard when it is developing. .

Which client would experience impaired near vision? A client with myopia A client with presbyopia A client with hyperopia A client with retinopathy A client with macular degeneration

Presbyopia and hyperopia

Which, finding in the clients history will alert the nurse to the most likely cause of the sensorineural hearing loss? Prolonged exposure to noise Build up of cerumen in the ear Blockage of the ear from a foreign body Perforation of the tympanic membrane

Prolonged exposure to noise

A primary healthcare provider diagnosis the clients condition as Otitus media. Which assessment finding supports that diagnosis? Nodules on the pinna Redness of the eardrum Lesions in the external canal Excessive's room, and in the external canal

Redness of the eardrum Rational: Nodules may be an indication of rheumatoid arthritis, chronic out, or basil or squamous cell carcinoma. Lesions in external Kanell macaws decreasing hearing acuity, but not manifest, otitis media. Excessive soft Roman in the external Kanell a text to hearing acuity, but not manifestation of the tightest media.

Which sign with the nurse document is being positive after observing the client swaying with their eyes closed? Kernig Romberg Babinski Brudzinski

Rhomberg Rational: A positive Kernig sign and positive Brudzinski sign indicate meningitis. A positive Babinski sign indicates the presence of central nervous system disease.

During orientation, a registered nurse reviews Contant about the third heart sound S3 with recently employed nurses. Which participants statement indicates ineffective learning? S3 is heard in clients with heart failure S3 is a normal sound in pregnant women S3 is abnormal and adults over 31 years of age S3 is normal in children and young adults

S3 is normal in pregnant women Rationale: A third heart sound can be heard when the heart attempts to fill an already distended ventricle. This sound may be common and normal in the last stages of pregnancy, but not in all stages. The sound may be heard in heart failure clients. The S3 sound is abnormal in adults over the age of 31. The sound is normally heard in children and young adults .

The nurse assesses bilateral plus for peripheral edema well assessing a client with heart failure and peripheral vascular disease. Which is the pathophysiological reason for the excessive edema? Shift of fluid into the interstitial spaces Weakening of the cell wall Increased intravascular compliance Increased intracellular fluid volume

Shift of fluid into the interstitial spaces

For a client who arrived at the healthcare facility for an appointment, which nurses action would be beneficial during the assessment interview? Ask about the clients current concerns Ensure the interview follows a strict Ask questions that promote short responses by the client Tell the client what they should expect from the visit

Ask about the clients current concerns

Which test result will confirm the diagnosis of benign prostatic hyperplasia? Digital rectal examination Serum phosphatase level Biopsy of prostatic tissue Massage of prostatic fluid

Biopsy of prostatic tissue

When Osco tating the mid abdomen of a client with an intestinal obstruction in the descending:, which type of sound when the nurse expect to hear? Tympany Borborygmi Abdominal bruit Pleural friction rub

Borborygmi Rationale: These are rapid, high-pitched bowel sounds that are indicative of the hyper pair is Dallas that occurs by intestinal obstruction. Timpani is not auscultated, but per cost, and is described as a high pitched or musical because of the presence of gas. In aortic brew is auscultated above the umbilicus ; a renal bruit is heard laterally above the umbilicus. Neither type of bro he can be auscultated the mid abdomen, and neither type is related to an intestinal obstruction. April friction rub is heard in the chest; it and is associated with inflamed lung pleura..

The nurse assesses the length of a client, auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. Which term with the nurse use to document the sounds? Vesicular Bronchial Crackles Rhonchi

Crackles Rationale: Crackles are abnormal breath sounds described as soft, crackling, bubbling, sounds, produced by air, moving across fluid in the alveoli . Rhonchi or abnormal breath, sounds heard over the large airways of the lungs, and consist of a low pitch and are caused by the movement of secretions in the larger airways; they usually clear with coughing The secular breath sounds are normal they are quiet, soft, and inspiration sounds that are short and almost silent on expiration and heard over the long periphery. Bronchioles breath sounds are normal and consist of a full inspiration and expiratory phase with the expiratory phase, being louder, and are heard over the trachea and large bronchi of the lungs.

Which are general growth parameters for an adolescent client that the nurse will monitor during a health maintenance visit? Select all that apply. Height Weight Body mass Blood pressure Head circumference

Height, weight, body mass Rationale: head circumference is assessed until 36 months of age; therefore, this is not an appropriate growth, parameter for the nurse to include in the growth and development assessment

Which assessment finding with the nurse document in the clients how record is a positive Romberg test? Inability to stand with feet together when eyes are closed Fanning of toes when the soul of the foot is firmly stroked Dilation of pupils on focusing on an object in the distance Movement of the eyes towards the opposite side, when the head is turned

Inability to stand with me together, when eyes are closed

Which term refers to the exaggerative posterior curvature of a clients thoracic spine? Lordosis Scoliosis Kyphosis Osteoporosis

Kyphosis Rationale: Lordosis is the excess of N-word curvature of the lumbar part of the spine. Scoliosis is the abnormal lateral curvature of the spine.

Which guideline is useful for reducing disparity when caring for transgender clients? Learning about healthcare needs of homosexual clients I was referring to transgender clients using pronouns of the sex to watch the transition I was referring to transgender clients using pronouns of the sex with which they were born Learning about the treatment of options for transgender clients and requirements of follow up care

Learning about the treatment options

Which test with the nurse used to assess a clients cortical sensory function? Select all that apply. Stereognosis Romberg test Graphesthesia Finger to nose test Two points discrimination

Stereognosis, graphesthesia, two point discrimination Rationale: Stereognosis measures the ability to perceive the form and nature of objects, graphesthesia is the ability to feel writing on the skin, and two point discrimination is the ability to perceive a separation between fingers and toes commonly used to assess cortical sensory function. Romberg test measures proprioception, and the finger to nose test measures coordination, and cerebellar function.

Which action elicits the brachioradialis reflex? Striking the triceps tendon above the elbow Striking the radius 3-5 cm above the wrist Striking the patellar tendon just below the patella Striking the achilles tendon when the client's leg is flexed

Striking the radius, 3 to 5 cm above the wrist

The nurse documents auscultation of course rhonchi in the anterior upper lung fields bilaterally declares with coughing. Which condition would the nurse associate with the sounds? Parietal pleura, rubbing against visceral pleura Random sudden reinstallation of groups of alveoli Turbulence due to muscular spasm and fluid or mucus in the larger airways High velocity, air flow through a severely narrowed or obstructed airway

Turbulence due to muscular spasm and fluid or mucus in the larger airways Rationale: Loud, low pitched, rumbling course sounds heard over the trachea and bronchi = turbulence caused by muscular spasm when fluid or mucus is present in the larger airways. Pleural rub = sound of dry or grading quality, best heard in the lower portion of the anterior lateral long. Random and sudden reinflation of groups of alveoli = crackling sounds predominantly heard in the left and right lung bases. High velocity, air flow through severely narrowed or obstructed airway = wheezing sound heard all over the lung

Which question for a home care nurse ask him all the adult, dependent I care provided by their son, who recently has become very withdrawn and has multiple bruises in various stages of healing on their arms and torso? What can you tell me about how these bruises occurred? May I draw some blood to check your platelet levels? Has your son been hitting you are handling you roughly Have you had issues with depression, or bruising in the past?

What can you tell me about how these bruises occurred?