NURS 212 Exam 3

A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should the nurse take first?

Inspect

A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the be on the right, placing them in the selected order of performance. Use all the steps.)

Inspection Auscultation Superficial palpation Deep palpating

A nurse in a clinic is caring for an older adult client who reports thirst, a dry mouth, and flaky skin on her upper back. Which of the foll appropriate next step?

Pinch up a fold of skin to check for turgor.

A nurse is preparing to inspect the umbilicus of a client's abdomen. Which of the following findings should the nurse identify as an unexpectec finding?

Swelling

A nurse is caring for a client who reports abdominal pain. The nurse asks the client to describe what the pain feels like. The nurse is using the following components of the PQRST mnemonic?

Quality

A nurse is preparing to perform an assessment on a client's abdomen. Which of the following pieces of equipment should the nurse use? (Selec

Stethoscope Watch Tape measure

A nurse is performing a cardiac assessment on a client and auscultates an S, sound. The nurse should recognize that this sound represents which of the following heart conditions?

Ventricular gallop

A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nurse's priority?

Blood pressure 92/50 mm Hg

A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?

Perform a Romberg's test.

When auscultating breath sounds, what is an appropriate term for softly coarse, blowing breaths sounds typically heard throughout most of the

Vesicular

A nurse asks a client how he is feeling. The client states, "I'm feeling a bit nervous today." Which of the following responses should the nurse

"Please explain what you mean by the word 'nervous.'

A nurse is performing range-of-motion exercises on a client's feet. The nurse should provide which of the following instructions to assess plantar flexion of the feet?

"Point your toes toward the floor."

A nurse is assessing the range of motion of a client's hands. The nurse should provide which of the following instructions to assess abduction and adduction of the client's fingers?

"Spread the fingers apart and then move them back together."

A nurse is assessing flexion of a client's elbows. The nurse should provide which of the following instructions to the client?

"Start with your arms straight out in front of you then bend your elbows up and bring your fingers toward your shoulders."

A nurse is providing dietary teaching to a client about the purpose of incorporating fiber in their diet. Which of the following inforn the nurse include?

Fiber allows larger stool to soften and pass easier.

During a health assessment interview, a client identifies smoking cigarettes. Below, identify the priority follow-up questions. (Select all apply.)

"How many packs of cigarettes do you smoke in a day?" "How many years have you smoked?" "Are you ready to consider quitting?"

A nurse is teaching a client about behaviors that promote cardiovascular health. Which of the following client statements indic understanding of the teaching? (Select all that apply.)

"I plan to join a support group to help me stop smoking." "I am going to start walking several times a week." "I will be sure to have my blood pressure checked at least every year."

During the assessment interview with a 26-year-old male client, he states "the world would be better off if I weren't around." Which of the following is the nurse's priority response?

"Are you having thoughts about harming yourself?"

A nurse is providing teaching to a client who has osteoporosis about the adequate intake of calcium. Which of the following intake amo should the nurse recommend?

1;000 to 1,200 mg daily

A nurse is assessing a client for pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. Which of the following notations should the nurse use to document the severity of the client's edema?

3+

nurse is assessing the anterior chest of a client. Which of the following findings should the nurse report to the provider?

A forceful chest movement at the midclavicular line in the fourth intercostal space

A nurse is assessing a client who has mitral valve stenosis. Which of the following findings should the nurse expect?

A heart murmur

A nurse is auscultating a client's abdomen for the presence of bowel sounds. Which of the following findings should the nurse e: hypoactive bowel sounds?

Bowel sounds heard after 2 min

A nurse has completed a cardiovascular assessment on a client. Which of the following findings should the nurse report to the provider?

Capillary refill of 3 seconds

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse ta cranial nerve Ill?

Checking the pupillary response to light

A nurse is interviewing an older adult who is being admitted to an assistive living facility, and conducting a general survey of the client's emotional state. What is a subjective unexpected finding?

Client reports he feels sad and lonely most of the time

A client involved in a car accident has sustained a serious injury to their left forearm. They are noted to be sweating profusely, holding and protecting the left forearm (guarding). Heart rate is 125/min, and blood pressure is 160/90. They are moaning and crying. During a pain assessment, they describe the pain as 5 on a 0-10 scale. Which of the following is the most reliable indicator of the intensity of the client's pain?

Client's reported pain rating of 5 on a 0-10 scale

A nurse is caring for a client who has hypovolemic shock and associated poor distal tissue perfusion. Which of the following should the nurse recognize as an expected finding?

Confusion or other mental status change

A nurse is providing teaching to a client about screening prevention for colorectal cancer. Which of the following tests should the nurse in (Select all that apply.)

Fecal occult test Flex sigmoidoscopy Barium enema with contrast Colonoscopy

A nurse is preparing to inspect a client's abdomen who has liver disease. Which of the following manifestations should the nurse expect

Dilated veins

A nurse is assessing a client who reports an increase in their stress level related to the demands of their job. Which of the f should the nurse recommend for the client to reduce their stress?

Discuss the benefits of meditation with the client.

A nurse is preparing a community program about injury prevention for a group of adults. Which of the following information should the ni include? (Select all that apply.)

Do not text and drive. Maintain spinal alignment when working at a desk. Remove loose rugs from the home. Wear a helmet when riding a bicycle.

Anurse is assessing a client who has a left lower arm fracture . Which of the affected arm ?

Increasing edema

A nurse is performing a neurological assessment for a client has head trauma. Which of the following assessments will give the nurse info about the function of cranial nerve III?

Instruct the client to look up and down without moving his head

A nurse is caring for a client who has a peripheral venous ulcer. Which of the following actions should the nurse take? (Select all that apply

Instruct the client to sit with their legs uncrossed. Encourage the client to avoid tobacco products. Instruct the client to sit with their legs uncrossed. Instruct the client to cleanse the area with mild soap. Instruct the client to wear shoes when ambulating.

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status?

Instruct the client to wiggle his toes.

A nurse is preparing to assess a client's abdomen. Upon palpation, which of the following findings should the nurse report to the provider

Involuntary rigidity

A nurse is preparing to palpate a client's abdomen. Which of the following findings should the nurse expect?

Nontender

An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?

Plantar flexion of the legs

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

Prior to percussing the abdomen

A nurse is teaching a client about the purpose of probiotics and incorporating them in their diet. Which of the following information should the nurse include?

Probiotics promote the growth of good bacteria in the client's intestinal tract.

A nurse is assessing a client who has peritonitis (inflammation of the outer lining of abdominal organs). Which of the following findings should the nurse expect?

Rigid abdomen

A nurse is teaching a newly licensed nurse about heart sounds. Which of the following sounds is heard when the aortic and pulmonic valves close?

S2

A nurse is assessing a client who has a new skin lesion that has a wavy, S-shaped border. The nurse should document the lesion using which of the following descriptions?

Serpiginous

A nurse is completing a medical history on a client. Which of the following findings indicates the client has a family history of cardiovascular

Sibling who has hypertension

A nurse is preparing to inspect a client's abdomen. Which of the following variations should the nurse expect to find? (Select all that apply)

Silver striae Healed scar Mole

A nurse is assessing an older adult client while they walk. Which of the following findings should the nurse report to the provider?

The client walks with a shuffling gait.

A nurse is assessing a client's head and neck. Which of the following findings should the nurse report to the provider?

There is locking of the jaw joint.

A nurse is assessing the range of motion of a client's head and neck. The nurse should provide which of the following instructions to assess hyperextension?

Tilt the head back and look up at the ceiling.

A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

oral mucosa

A nurse is preparing to obtain information regarding a client's abdominal health history. Which of the following questions should the nurse (Select all that apply.)

"Are you experiencing abdominal pain?" "Do you take any medication?" "Have you noticed a change in your appetite?" "When was your last bowel movement?"

A nurse is providing teaching to a client about health promotion to prevent constipation. Which of the following instructions should the n include?

"Consume foods that are high in whole grains."

A nurse is taking a health history from a client. Which of the following statements by the client requires further questioning by the nurse?

"For some reason I have been experiencing falls."

A nurse is preparing to perform a cardiovascular assessment on a client. The client asks, "Why do you need to use a penlight?" Which of the following responses should the nurse make?

"The penlight will allow me to look at the pulses in your neck."

A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve I?

Ask the client to read a Snellen chart.

A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nui nerve XII?

Ask the client to stick out their tongue and observe if it is midline.

A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.)

Dyspnea Barrel chest Clubbing of the fingers

A nurse is planning care for a client who states he is anxious concerning abdominal surgery. Which of the following actions should the nurse take?

Encourage the client to express negative emotions.

A nurse is preparing to inspect a male client's abdomen. Which of the following findings should the nurse identify is an unexpected fin all that apply.)

Everted umbilicus Purple striae Rash

A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve I?

Have the client identify specific smells.

A nurse is assessing a client's jugular veins and carotid arteries. The nurse should assist the client into which of the following positions?

Have the client lay supine with the head of their bed at a 45° angle.

A nurse is preparing to auscultate a client's abdomen. Which of the following should the nurse expect if the client is experiencing borborygmus

Hyperactive bowel sounds

A nurse is assessing a client's spinal range of motion. Which of the following motions is the nurse assessing by asking the client to bend back. as far as they can go?

Hyperextension

A nurse is performing a musculoskeletal and neurological assessment. Which of the following actions should the nurse take?

Inspect for symmetry on both sides of the body.

A 24-year-old client has a blood pressure of 95/70, and asks the nurse whether this blood pressure is okay. Below, identify all assessment findings that are consistent with adequate tissue perfusion. (Select all that apply.)

Intact mental status without weakness Extremities show symmetrical warmth and color Brisk capillary refill

A nurse is recommending sources of food with high calcium content to a client. Which of the following foods should the nurse recommend? (Seler all that apply.)

Milk Mustard greens Legumes

During an assessment interview, a client tells the nurse that she is experiencing difficulty swallowing. In addition to a detailed HEEl other system assessment should the nurse anticipate performing?

Neurological

A nurse is caring for a client who has a foot ulcer. Which of the following findings should the nurse identify as consistent with peripheral venot disease?

Palpable dorsalis pedal pulse

A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge

Palpates the abdomen prior to performing auscultation.

A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?

Perform a Romberg's test

A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?

Place suction equipment at the client's bedside.

While conducting a HEENT assessment, a nurse shines a light into a client's pupils, noting a brisk reflexive constriction. In describing ti of this assessment to the client, which of the following is the correct statement by the nurse?

• "This tests the pupil muscles themselves, as well as the cranial nerves that control them."

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?

Agitation

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

Increased lower extremity edema Increased respiratory rate Crackles, or wet congested breath sounds

A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the client's affected arm?

Increasing edema

A nurse is preparing to teach a client who has a BMI of 32 about a heart-healthy diet. Which of the following dietary recommendations should nurse include?

Limit sodium intake to less than 3,000 mg/day.

The client reports abdominal pain for the last two days that is now moving to the right lower quadrant. The pain has started to increase over the last hour and is a 9 on a 0 to 10 scale. Bowel sounds positive × 4 quadrants. The client's tympanic temperature is 37.2 ° C (99.0° F). Respiratory rate 22/min Lung sounds clear bilaterally. (Oxygen saturation is 96% on room air. Heart rate 110/min Blood pressure 88/58 mm Hg while lying down. Casual capillary blood glucose is 145 mg/dL.

Nurses' Notes The client reports abdominal pain for the last two days that is now moving to the right lower quadrant. The pain has started to increase over the last hour and is a 9 on a 0 to 10 scale. Respiratory rate 22/min Heart rate 110/min Blood pressure 88/58 mm Hg while laying down

A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve VII?

Observe for facial symmetry while the client smiles.

A nurse is preparing to perform a cranial nerve examination for a client. Which of the following actions should the nurse take to check cranial nerve XI?

Observe for the ability of the client to turn their head side to side.

A nurse is providing teaching about adequate daily intake of vitamin D to a client. Which of the following intake amounts should the nurse recommend?

800 IU daily

A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following find expect? (Select all that apply.)

Flat neck veins Hypotension Poor skin turgor

This 43-year-old male has presented today described a 1 day history of nausea and vomiting. On exam, he is awake and alert, speaking in complete sentences. Skin is uniform in color, even texture, with no tenting. Heart sounds show a regular rate and rhythm. St and S2 are easily identifiable. No murmurs. S3 present. There is symmetrical chest rise and fall. No barrel chest noted. Lung sounds are clear to auscultation in anterior, posterior and lateral fields. Abdomen is distended, rigid. Bowel sounds are low pitched, with borborygmi. There is diffuse generalized tenderness and guarding. No CVA tenderness.

Abdomen is distended and rigid Bowel sounds are low pitched with borborygm There is diffuse generalized tenderness and guarding

A nurse is auscultating heart sounds in a group of clients. Which of the following should the nurse identify as an expected variation?

An adolescent who has an S3 heart sound

A nurse is caring for a client who has a traumatic injury to a lower extremity. Which of the following actions should the nurse take

Apply compression to the injured area of the extremity.

A nurse is preparing to conduct a cardiovascular assessment on a client. Which of the following actions should the nurse plan to take? (Select all

Auscultate the apical pulse. Ask the client if they experience shortness of breath. Check the color of the client's skin. Inspect the extremities for the presence of edema.

A nurse is performing range-of-motion exercises on a client's hips. The nurse is assessing which of the following motions by instructing the clie to bend the knee and bring it up toward the chest?

Flexion of the hip

A nurse is inspecting and palpating the neck vessels of a client. Which of the following findings should the nurse report to the pri that apply.)

Full, bounding pulse noted bilaterally in the carotid arteries upon palpation Distention of the jugular vein on one side of the neck The left carotid artery pulse is weak.

A nurse is providing care for a surgeon on a medical-surgical unit. A nurse from another unit asks the nurse about the surgeon's medical diagnosis. The nurse responds that he is unable to provide the information requested. The nurse is displaying which of the following ethical principles?

Justice

A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse's priority?

Move any clients in the immediate vicinity.

A nurse is assessing a client's wrist and hands. Which of the following findings indicates the client might have arthritis? (Select all that apply)

Nodules on the joints Fingers deviate toward the ulnar

A nurse is preparing to auscultate a client's abdomen for the presence of bowel sounds. Which of the following quadrants should the nurse lis to first?

Right lower quadrant