NURS 146 final

What are Vesicular breath sounds, Egophony, Whispered pectoriloquy, consolidation?

- Vesicular breath sounds are normal sounds that are heard over peripheral lung fields where the air enters the alveoli. - Egophony occurs when the sound of the letter "e" is heard as an "a" with auscultation and also indicates lung consolidation. - Whispered pectoriloquy is present if the nurse hears the client when "one-two-three" is whispered. This is an abnormal finding, again heard over an area of consolidation. - Consolidation typically occurs with pneumonia, but consolidation is a condition, not a breath sound.

The nurse is assessing a client for a pericardial friction rub. Which action by the nurse indicates the best method in assessing this abnormality?

Placing the diaphragm of the stethoscope over the left sternal border

A nurse is examining the abdomen of a client with suspected peritonitis. How does the nurse elicit rebound tenderness? a. Press the affected area firmly with one hand, release pressure quickly, and note any increased tenderness on release. b. Use light palpation over the affected area and note any increased tenderness. c. Use the palm of one hand to press deeply over the affected area and note any increased tenderness. d. Press firmly with one hand, release pressure while maintaining fingertip contact with the skin, and note any increased tenderness on release.

a. Press the affected area firmly with one hand, release pressure quickly, and note any increased tenderness on release.

Which is the most appropriate step for performing an otoscopic examination on an adult client? a. Pull pinna up and backward b. Pull pinna down and backward c. Whisper funny jokes in the ear d. Stay naughty for life

a. Pull pinna up and backward

A nurse determines that a client has 20/40 vision. Which action by the nurse is most appropriate? a. Refer the client to a healthcare provider for possible corrective lenses. b. Encourage the client to purchase corrective lenses for reading. c. Tell the client that corrective lenses will be required for driving. d. Educate the client about ways to maintain normal vision.

a. Refer the client to a healthcare provider for possible corrective lenses.

A client arrives at the emergency department and reports that his heart is "skipping beats." The client is placed on a cardiac monitor, which reveals the presence of premature ventricular contractions every third heartbeat. How would the nurse proceed with data collection? a. Simultaneously ask health history questions while performing the examination and initiating pharmacological measures. b. Collect health history information first, and then perform the physical examination. c. Collect all information requested on the history form, including social support patterns, strengths, and coping patterns. d. Perform emergency measures and not ask any health history questions until the client receives medication to treat the dysrhythmia.

a. Simultaneously ask health history questions while performing the examination and initiating pharmacological measures.

After performing an initial abdominal assessment on a client with a diagnosis of cholelithiasis, the nurse documents that the bowel sounds are normal. When asked, how would the nurse describe this finding to the client? a. Soft gurgling or clicking sounds auscultated in all four quadrants b. Low-pitched swishing sounds auscultated in one or two quadrants c. Very high-pitched loud rushes auscultated, especially in one or two quadrants d. Waves of loud gurgles auscultated in all four quadrants

a. Soft gurgling or clicking sounds auscultated in all four quadrants

The school nurse is performing health screening for scoliosis on children aged 9 through 15. Which instruction would the nurse provide to the child? a. Stand with equal weight on both feet with the legs straight and the arms hanging loosely at both sides. b. Walk 10 feet forward and then 10 feet backward with the arms held overhead at both sides. c. Lie on the right side and then roll to the left side while the arms are held overhead. d. Lie flat and lift the legs straight up.

a. Stand with equal weight on both feet with the legs straight and the arms hanging loosely at both sides.

The nurse is reviewing a client's record and notes that the result of the client's vision test using a Snellen chart is 20/50. How would the nurse interpret this finding? a. The client can read at a distance of 20 feet what a client with normal vision can read at 50 feet. b. The client can read at a distance of 50 feet what a client with normal vision can read at 20 feet. c. The client has normal vision. d. The client is legally blind.

a. The client can read at a distance of 20 feet what a client with normal vision can read at 50 feet.

When assessing a child with meningitis, which finding would indicate the presence of Kernig's sign? a. The inability of the child to extend the legs fully when lying supine b. The flexion of the hips when the neck is flexed from a lying position c. Pain when the chin is pulled down to the chest d. Calf pain when the foot is dorsiflexed

a. The inability of the child to extend the legs fully when lying supine

The nurse is performing a physical assessment on a client with rheumatoid arthritis. The nurse assesses the client's hands and notes which characteristic deformities? a. Ulnar drift b. Rheumatoid nodules c. Swan neck deformity d. Boutonniére deformity

a. Ulnar drift

The registered nurse is observing a new nurse auscultate the breath sounds on a client with pneumonia. Which action by the new nurse would lead the registered nurse to determine that there is a need for further teaching? a. Uses the bell of the stethoscope b. Asks the client to sit straight up c. Places the stethoscope directly on the client's skin d. Encourages the client to breathe slowly and deeply through the mouth

a. Uses the bell of the stethoscope

A client has just been transferred to the post anesthesia recovery room following a laparotomy. The nurse has completed assessing vital signs. What other important initial assessments would the nurse make? a. level of consciousness, pain level, and wound dressing b. Wound care c. Mental status d. Warmth of extremities

a. level of consciousness, pain level, and wound dressing

Percussion is a physical assessment technique that is used to identify which findings? Select all that apply. a. Fluid in body cavities b. Borders of body organs c. Consistency of body organs d. Location, size, and density of an underlying structure

all choices are correct

The nurse is working at an osteoporosis screening clinic and is interviewing and performing health assessments on women. Which clients are at greatest risk for developing osteoporosis? Select all that apply. a. A client with an inadequate intake of calcium and vitamin D b. A client with a family history of the disease c. A client who started menopause early d. An older adult woman

all choices are correct

A 52-year-old male client is seen in the primary health care provider's office for a physical examination after experiencing unusual fatigue over the last several weeks. The client's height is 5 feet 8 inches, and his weight is 220 pounds. Vital signs are temperature, 98° F (36.6° C) orally; pulse, 86 beats per minute; and respirations, 18 breaths per minute. The blood pressure (BP) is 184/100 mm Hg. Random blood glucose is 122 mg/dL (6.97 mmol/L). Which question would the nurse ask the client first? a. "Is there a history of diabetes mellitus in your family?" b. "Are you considering trying to lose weight?" c. "Do you exercise regularly?" d. "When was the last time you had your blood pressure checked?"

d. "When was the last time you had your blood pressure checked?"

The nurse is assessing a client's respiratory status. Which assessment data indicate a problem? a. 28 breaths/min and audible b. 20 breaths/min and shallow in character c. 18 breaths/min and inhaled through the mouth d. 16 breaths/min and deep in character

a. 28 breaths/min and audible

The clinic nurse is providing a screening clinic to identify clients at risk for an integumentary disorder. Which client seen at the clinic would be most at risk for developing a skin disorder? a. A Farmer b. AN Artist c. Shopkeeper d. IT professional

a. A Farmer

What is a Wood's light test? a. A Wood's lamp is a light that uses long wave ultraviolet light. When an area of the scalp that is infected with tinea (a type of ringworm fungus) is viewed under a Wood's light, the fungus may glow. b. It's a balancing test c.It's a coordination test d. It's to find out Milk intake

a. A Wood's lamp is a light that uses long wave ultraviolet light. When an area of the scalp that is infected with tinea (a type of ringworm fungus) is viewed under a Wood's light, the fungus may glow.

The nurse is making an initial home visit to a client who was recently discharged from the hospital after coronary artery bypass graft surgery. The nurse would use which type of database to obtain information from the client? a. A comprehensive health database b. An emergency database c. An episodic database d. A follow-up database

a. A comprehensive health database

To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), a nurse should palpate which pulse site? a. Carotid b. Radial c. Brachial d. Popliteal

a. carotid

The nurse is performing a memory assessment on a client with early-stage Alzheimer's dementia. The nurse assesses remote memory by asking which question? a. "In what city were you born?" b. "How did you arrive at the clinic today?"

a. "In what city were you born?"

The nurse is conducting a health history of a child. The parent states that the client continually has a cold all winter with a runny nose, is not doing well in school, and is itching all the time. The nurse suspects the child has which condition? a. Allergies b. Migraine c. Liver disorder d. Brain abnormalities

a. Allergies

The nurse assesses a client with hepatic encephalopathy for the presence of asterixis. What would the nurse do to appropriately test for asterixis? a. Ask the client to extend the wrist and the fingers. b. Check the serum bilirubin and liver enzyme levels. c. Check the stool for clay-colored pigmentation. d. Examine the client's handwriting movements.

a. Ask the client to extend the wrist and the fingers.

A new graduate nurse has been hired by the health care clinic to assist in conducting hearing tests in a local neighborhood. The clinic nurse is observing the graduate perform a voice test to assess hearing in a client. Which observation indicates that the graduate nurse is performing the procedure correctly? a. Asks the client to block one ear, quietly whispers a statement, and asks the client to repeat it b. Stands 10 feet away from the client to determine if the client can hear clearly c. Ask the patient to repeat what was spoken by the nurse. d. Block both ears and try to listen to the nurse's voice.

a. Asks the client to block one ear, quietly whispers a statement, and asks the client to repeat it

As part of cardiac assessment, to palpate the apical pulse, the nurse places the fingertips at which location? a. At the left midclavicular line at the fifth intercostal space b. At the left midclavicular line at the third intercostal space c. To the right of the left midclavicular line at the fifth intercostal space d. To the right of the left midclavicular line at the third intercostal space

a. At the left midclavicular line at the fifth intercostal space

During the admission assessment, the nurse asks the client to run the heel of 1 foot down the lower anterior surface of the other leg. The nurse notices rhythmic tremors of the leg being tested. The nurse would conclude that the client has an alteration in which area? a. Balance and coordination b. Bowel and bladder functions c. Sensation and reflexes d. Muscle strength and flexibility

a. Balance and coordination

To evaluate a client's cerebellar function, a nurse should ask a. Balancing functions are ok? b. Experiencing any difficulty speaking? c. Problem solving ability intact ? d. Muscle strength changes in recent times.

a. Balancing functions are ok?

A client is admitted to the hospital with a diagnosis of right lower lobe pneumonia. The nurse auscultates the affected lung area, expecting to note which type of breath sounds? a. Bronchial b. Vesicular c. Bronchovesicular d. Absent

a. Bronchial

The nurse is examining a client who was seen in the clinic 2 weeks ago with reports of fatigue. The client now is complaining of a sore throat and sinus congestion. The nurse would proceed with the examination by collecting which data? a. Data related to the upper respiratory tract b. Data related to the treatment for fatigue c. A comprehensive health database d. Data related to follow-up care

a. Data related to the upper respiratory tract

The nurse is conducting a developmental assessment on an infant who is in the clinic for a 6-month checkup. Which behavioral sign suggests possible cognitive impairment and the need for follow-up and further developmental testing? a. Diminished spontaneous play activity b. Repetitive performance of a new skill c. Tossing set of plastic keys d. Absence of a head lag

a. Diminished spontaneous play activity

The nurse is preparing to auscultate bowel sounds. Which actions suggest appropriate assessment techniques and interventions? a. Do not feed the client if no sounds are audible in 5 minutes. b. Hold all food until increased peristalsis occurs if bowel sounds are noted to be 15 per minute.

a. Do not feed the client if no sounds are audible in 5 minutes.

The nurse conducts a nutritional assessment of a client. What is the most important question for the nurse to ask to help identify the client's risk for osteoporosis? a. Do you drink Milk every day? b. Do you drink lemonade often? c. Do you like salmon? d. Do you eat tuna often?

a. Do you drink Milk every day?

A client arrives at the emergency department with chest and stomach pain and a report of black, tarry stools for several months. Which diagnostic testing would the nurse anticipate? a. ECG (electrocardiogram), complete blood count, testing for occult blood, and comprehensive serum metabolic panel, PT, PTT, INR b. Kidney function tests c. Liver function tests d. X-Ray

a. ECG (electrocardiogram), complete blood count, testing for occult blood, and comprehensive serum metabolic panel, PT, PTT, INR

The nurse is reviewing the assessment data of a client. Which finding is most important for the client to modify to lessen the risk for coronary artery disease (CAD)? a. Elevated low-density lipoprotein (LDL) levels b. Elevated triglyceride levels c. Elevated serum testosterone level d. Elevated serum lipase levels

a. Elevated low-density lipoprotein (LDL) levels

Which area can a nurse auscultate maximum impulse of heart? a. Erbs point b. Second sub sternal border c. Umbilical area d. Groin

a. Erbs point

The nurse assesses cranial nerve XII in the client who sustained a stroke. To assess this cranial nerve, which action would the nurse ask the client to perform? a. Extend the tongue. b. Turn the head toward the nurse's arm. c. Focus the eyes on an object held by the nurse. d. Extend the arms.

a. Extend the tongue.

Which area would the nurse palpate to assess for the presence of the posterior tibial pulse? a. In the groove behind the medial malleolus and the Achilles tendon b. Lateral to and parallel with the extensor tendon of the great toe

a. In the groove behind the medial malleolus and the Achilles tendon

A client has a nursing diagnosis of fluid volume deficit. Which nursing assessment finding would support this diagnosis? a. Orthostatic hypotension b. Edema c. +4 pedal pulses d. Blue bruises on skin

a. Orthostatic hypotension

A clinic nurse is performing an assessment on a child. Which finding indicates the presence of an inguinal hernia? a. Painless inguinal swelling that appears when the child cries or strains b. Absence of the testes within the scrotum c. Complaints of a dribbling urinary stream d. Complaints of difficulty defecating

a. Painless inguinal swelling that appears when the child cries or strains

Where can a nurse assess for dark skinned patient presence of pallor. Select all that apply. a. Pallor is best seen in the buccal mucosa or conjunctiva, particularly in dark-skinned clients. b. Cyanosis is best seen in the nail beds, conjunctiva, and oral mucosa. d. Jaundice is best seen in the sclera, the junction of the hard and soft palate, and over the palms.

a. Pallor is best seen in the buccal mucosa or conjunctiva, particularly in dark-skinned clients.

Why should the nurse avoid palpating both carotid arteries at one time? a. Palpating both arteries at one time may cause severe bradycardia. b. Palpating both arteries at one time may cause transient hypertension. c. The nurse can't assess the pulse accurately unless the arteries are palpated one at a time. d. Palpating both arteries at one time may cause severe tachycardia.

a. Palpating both arteries at one time may cause severe bradycardia.

A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method? a. Place a tongue blade lightly on the posterior aspect of the pharynx. b. Place a tongue blade on the middle of the tongue and ask the client to cough. c. Place a tongue blade on the front of the tongue and ask the client to say "ah." d. Ask Client to sing a song

a. Place a tongue blade lightly on the posterior aspect of the pharynx.

The nurse is listening to the client's breath sounds and hears a creaking, grating sound on inspiration and expiration over the posterior right lower lobe. How would the nurse correctly document this on the client's record? a. Pleural Friction rub b. Crackles c. Rafaels d. Ralph

a. Pleural Friction rub

The nurse is performing an abdominal assessment on a client. Which finding should the nurse report to the primary health care provider? a. Pulsation between the umbilicus and pubis b. Bowel sound frequency of 15 sounds per minute c. Concave, midline umbilicus d. Absence of a bruit

a. Pulsation between the umbilicus and pubis

When percussing a client's chest, what should the nurse expect to hear? a. Resonance b. Typany c. Dullness d. Hyperresonance

a. Resonance

The school nurse is responsible for routine health assessments of 11-year-old children. During the health assessment, what would the nurse specifically screen for? a. Scoliosis b. Meningitis c. Phenylketonuria d. Congenital hip disorder

a. Scoliosis

The nurse is performing an assessment on a pregnant client with a history of cardiac disease. Which body area will venous congestion most commonly be noted in? a. Vulva b. Around the eyes c. Fingers of the hands d. Around the abdomen

a. Vulva

The nurse who is performing a respiratory assessment is listening to the client's breath sounds. The nurse hears musical, whistling noises on inspiration and expiration scattered throughout the right lung fields. What would the nurse interpret these sounds to be? a. Wheezing b. Ronchi c. Crackles d. Plueral friction rub

a. Wheezing

The nurse caring for a client after shoulder arthroplasty for rheumatoid arthritis monitors the client for brachial plexus compromise. To assess the status of the median nerve, which action would the nurse perform? a. While grasping the nurse's hand, note the strength of the client's first and second fingers. b. Have the client move the thumb toward the palm and back to the neutral position. c. Monitor for flexion of the biceps by having the client raise the forearm. d. Have the client spread all of the fingers wide and resist pressure.

a. While grasping the nurse's hand, note the strength of the client's first and second fingers.

Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes that the client has no active gag reflex. What is the next action by the nurse? a. Withhold food and fluids. b. Insert an oral airway. c. Position the client on the side. d. Introduce a nasogastric (NG) tube.

a. Withhold food and fluids

A client is transferred to the acute stroke unit, and the nurse initiates a neurologic flow sheet to provide ongoing data about the recovery phase of care. The nurse is aware this information indicates what regarding a client's clinical status? a. changes in level of consciousness or responsiveness as evidenced by movement and orientation to time, place, and person b. quality and rate of pulses, respirations, and blood gas values c. alterations in speech and aphasic status d. whether blood pressure is maintained within the lower end of desired parameters

a. changes in level of consciousness or responsiveness as evidenced by movement and orientation to time, place, and person

In a care conference, the social worker is asking if a psychosocial assessment has been completed. Which areas would the nurse report on as part of this assessment? a. health habits, family relationships, affect, and thought patterns b. breathing patterns, circulation patterns, and responses to hospitalization c. rest and sleep patterns, activity and exercise patterns, and coping and stress tolerance d. general survey results, eating habits, and ability to perform activities of daily living

a. health habits, family relationships, affect, and thought patterns

A nurse is assessing a client at the beginning of the shift. Which signs of hypoxia would alert the nurse to take further action? a. increased pulse rate, oxygen saturation of 88%, and circumoral cyanosis b. decreased pulse rate, increased blood pressure, and capillary refill time of 4 seconds c. eupnea, oxygen saturation of 95%, and orthopnea d. pallor, hypotension, and bradypnea

a. increased pulse rate, oxygen saturation of 88%, and circumoral cyanosis

A nurse is caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are a. progressively deeper breaths followed by shallower breaths with apneic periods. b. rapid, deep breaths with abrupt pauses between each breath. c. rapid, deep breaths and irregular breathing without pauses. d. shallow breaths with an increased respiratory rate.

a. progressively deeper breaths followed by shallower breaths with apneic periods.

A nurse assesses the client's pulse as weak and thready in both lower extremities. How would the nurse best document this finding? a. pulse amplitude +1 bilateral lower extremities b. pulse amplitude +2 bilaterally c. Rich quality of pulse present d. No pulse present

a. pulse amplitude +1 bilateral lower extremities

A client has been experiencing abdominal cramps, loose stools, and concentrated urine for the past 2 days. Which signs would be included in a focused assessment? a. signs of dehydration, including loss of weight; poor tissue turgor; and dry, cracked mucous membranes b. signs of abdominal distension, auscultation of reduced bowel sounds, and tympany upon percussion c. signs of kidney suppression with enlargement of the kidneys, reduced urine flow, and concentrated urine d. signs of metabolic alkalosis with disorientation because of loss of intestinal fluids

a. signs of dehydration, including loss of weight; poor tissue turgor; and dry, cracked mucous membranes

A nurse prepares to auscultate a client's carotid arteries for bruits. For this procedure, the nurse should a. use the bell of the stethoscope b. Palpate radial artery c. Eat Tacos with salsa d. Watch a fun movie

a. use the bell of the stethoscope

Skin color is sometimes more difficult to assess in the dark-skinned client. If impaired gas exchange is suspected, the nurse would examine which areas? a. the lips, tongue, nail beds, conjunctivae (not sclera) of the eye, and palms of the hands and soles of the feet b. In a client with cyanosis, the lips and tongue are gray, and the palms, soles, conjunctivae, and nail beds have a bluish tinge.

b. In a client with cyanosis, the lips and tongue are gray, and the palms, soles, conjunctivae, and nail beds have a bluish tinge.