pn NCLEX Health assessment/physical exam

upon palpation of the fontanelle of a three month old newborn, the nurse notes that the anterior fontanelle has not closed and is soft and flat. Which action should the nurse take

document the findings

the nurse notes documentation that a client has conductive hearing loss. The nurse understands that which is a cause of this type of hearing loss

a physical obstruction to the transmission of sound waves

while collecting data related to the cardiac system on a client diagnosed with an incompetent heart valve, the nurse auscultate say murmur. Which best describes the sound of a heart murmur

gentle, blowing or swishing noise

a nursing student enrolled in a physical assessment courses asked to describe the probable signs of pregnancy. Which are probable signs indicating possible pregnancy

hager's Chadwicks McDonald's

the nurse is preparing the client for eye testing, and the examiner is planning to test the eyes using the confrontational method. What should the nurse tell the client about the purpose of the test

examines visual fields or peripheral vision

the nurse is collecting medication information from a client, and the client states that she is taking garlic as an herbal supplement. The nurse understands that the client is most likely treating which condition

hyperlipidemia

to assess for the presence of the posterior tibialis pulse the nurse should palpate which area

in the groove behind the medial malleolus and the Achilles tendon

the nurse is preparing to collect data by examining the abdomen. The nurse should begin the assessment by performing which action first

inspection

the nurse is preparing to perform an abdominal examination. The initial step should be which

inspection

the nurse is preparing to perform an abdominal assessment on a client. The nurse places the client in which best position to perform the assessment

2

when collecting physical assessment data, the nurse understands that the spleen is located in which abdominal quadrant

2

the nurse is preparing to auscultate a client's abdomen for bowel sounds. The nurse listens for bowel sounds in which abdominal quadrant first

3

the nurse provides information to a client regarding breast self-examination. Which client statement indicates a need for further teaching

I don't need to do that, I'm too old for that

the nurse is reviewing the client's health record and notes that the client elicited a positive Romberg sign. The nurse understands that this indicates which finding

a significant sway when the client stands erect with feet together, arms at the side and eyes closed

the nurse is preparing to assist the healthcare provider to test the extraocular movements in a client for muscle weakness in the eyes. The nurse anticipates that which physical assessment technique will be done to assess for muscle weakness in the eye

testing the six cardinal positions of gaze

the nurse notes that the physical assessment findings for a client with mebingeal irritation indicate a positive Brudzinski sign. the nurse understands that which observation was made

the client passively flexes the hip and knee in response to Netflix Ian and reports pain in the vertebral column

the nurse is asked to test the visual Acuity of a client using a Snellen chart. The nurse prepares to perform the test, knowing that which identifies the accurate procedure for this visual Acuity test

the right eye is tested, followed by the left eye, and then both eyes are tested

a client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. how should the nurse interpret this result

they client can read at a distance of 20 feet with a clot with normal vision can read at 60 feet

the nurse is checking the apical heart rate of a client with a complaint of angina. The nurse places the stethoscope in which anatomical area

4

the nurse notes documentation that a client is exhibiting Cheyenne Stokes respirations. On data collection of the client, the nurse expects to note which finding

Rhythmic respirations with periods of apnea

the nurse is reinforcing instructions for a client and how to perform a testicular self-examination. The nurse explains that which is the best time to perform this exam

after a shower or bath

which observation indicates that the nurse is performing a whispered voice hearing assessment test procedure correctly

ask the client to block one ear at a time

they Clinic nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of data collection

auscultating lung sounds obtaining the client's temperature obtaining information about the client's respirations

the nurse is auscultating bowel sounds. Which are appropriate data collection methods

divide the abdomen into four quadrants at the umbilicus do not feed the client if no sounds are audible in 5 minutes listen and each quadrant for gurgling sounds indicating movement

a client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventititious lung sounds should the nurse expect to note documented in the health record when collecting data related to the respiratory system for this client

wheezes