nursing 211 prep U

When the nurse is assessing a client's mental status as part of the screening neurological examination, which question would be most appropriate to ask?

"Can you tell me where you are right now?"

A client describes headaches as severe and lasting for days. Which question would be most appropriate to use to determine if these headaches are migraines?

"Do you have any visual changes before the headache?"

The nurse is providing teaching to a client with type 1 diabetes. When providing information about reducing the risk of diabetic neuropathy, the nurse should be sure to include which point?

"Effective blood glucose regulation can prevent this problem."

A client presents to the health care clinic with reports of a 3-day history of fever, sore throat, and trouble swallowing. The nurse notes that the client is febrile, with a temperature of 101.5°F, tonsils are 2+ and red, and transillumination of the sinuses is normal. Which nursing diagnosis should the nurse confirm based on this data?

Acute Pain

The nurse is interviewing an adult client in the context of a focused mouth, nose, sinus, and throat assessment. After asking the client about his history of environmental allergies, the client states, "I'm pretty sure that I'm allergic to something, but I'm not exactly sure what triggers my allergies." What would the nurse do next?

Ask the client about the timing of allergy symptoms.

A client reports, "There is something in my left eye that is causing me considerable discomfort." What initial step should the nurse take when everting the client's upper eyelid in order to search for the foreign body?

Ask the client to look down toward the left cheek.

A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCD" characteristic of malignant melanoma?

Asymmetrical shape

A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding?

At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet.

The husband of a 65-year-old female tells the nurse, "My wife is having trouble navigating the steps in our home and needs my help to step down off a curb." What part of the nervous system should the nurse assess for a potential source of the problem?

Cerebellum

A male college student presents to the student health clinic with reports of night-time headaches for the past two weeks. He denies nausea and photosensitivity but states he has noticed his eyes are tearing and his nose runs a lot. He is stressed because of final exams and confesses to drinking more alcohol than normal. The nurse recognizes these findings as indicative of what type of headache?

Cluster

The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin

D

The client has experienced a stroke and has dysphagia. The nurse knows this is what?

Difficulty swallowing

A nurse is educating a client about the function of the parts of the auditory system. Which is the function of the eustachian tube?

Equalizes the pressure in the middle ear with atmospheric pressure.

When performing the cover test, a nurse notices that the client's left eye turns outward. How should the nurse document this finding in the client's record?

Exotropia- With the cover test, the eyes of the client should remain fixed straight ahead. If the covered eye moves when uncovered to reestablish focus, it is abnormal. If the eye turns outward it is called exotropia. If the uncovered eye turns inward, it is called esotropia. Strabismus is constant malalignment of the eyes. Presbyopia is impaired near vision.

The nurse is preparing to perform a physical examination of a client who is an Orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client, based on his religious beliefs?

Have a nurse who is the same sex as the client examine him

The nurse is caring for a female client with hormone disorder producing excessive testosterone. Which of the following is an expected finding when assessing this client?

Hirsutism- a condition in women that results in excessive growth of dark or coarse hair in a male-like pattern — face, chest and back

A nurse has completed the assessment of a client's direct pupillary response and is now assessing consensual response. This aspect of assessment should include which action?

Observing the eye's reaction when a light is shone into the opposite eye

The nurse is preparing to perform the Rinne test on a client. The nurse should place the tuning fork at which location first?

On the client's mastoid process

When performing a client's ophthalmoscopic exam, the nurse observes a round shape with distinct margins. How would the nurse document this finding?

Optic disc

On a health history, a client reports no visual disturbances, last eye exam being 2 years ago, and not wearing glasses. The nurse notices that the client squints when signing the consent for treatment form and holds the paper close to the face. What should the nurse do next?

Perform both the distant and near visual acuity tests

The nurse would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following?

Pressure ulcer

A client reports severe pain in the posterior region of the neck and difficulty turning the head to the right. What additional information should the nurse collect?

Previous injuries to the head and neck

The results of a Rinne test show bone conduction is greater than air conduction. Which of the following would be most appropriate?

Refer the client for further evaluation- Bone conduction greater than air conduction suggest a conductive hearing loss. When data suggests signs and symptoms requiring diagnosis and treatment, the client should be referred to a physician for further evaluation.

A nurse is providing care at an inner-city shelter, and a man who frequents the shelter presents with a significant frontal growth that is located midline at the base of his neck. The nurse should recognize the need for what referral?

Referral for further assessment of thyroid function

A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. Client states he almost ran into a parked car yesterday because he misjudged the distance from the bumper of his own car. He works for a computer software company and has noticed he is experiencing difficulty reading the manuals that accompany the software he installs for companies. What nursing diagnosis can the nurse confirm based on this data?

Risk for Injury

What is the most important focus area for the integumentary system?

UV radiation exposure

The tongue is attached to the hyoid bone and styloid process of the temporal bone and is connected to the floor of the mouth by the

frenulum.

A client has conjunctivitis. The nurses understand that conjunctivitis differs from conjunctival hemorrhage in that conjunctivitis

has a watery, mucoid discharge. Pink eye (conjunctivitis) is an inflammation or infection of the transparent membrane (conjunctiva) that lines your eyelid and covers the white part of your eyeball.

The nurse is planning to assess a client's near vision. Which technique should be used?

have the client read newspaper print held 14 inches from the eyes

The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should

position the client 609.6 cm (20 ft) away from the chart.

The nurse is planning to conduct the Weber test on an adult male client. To perform this test, the nurse should plan to

strike a tuning fork and place it on the center of the client's head or forehead.

The nurse is preparing to assess the neck of an adult client. To inspect movement of the client's thyroid gland, the nurse should ask the client to

swallow a small sip of water.