245 final

Which radiographic test would be used to view the entire skeleton ? A. Bone scan b. Gallium and thallium scan c. Computed tomography ( CT ) d. Magnetic resonance imaging ( MRI ) scan

A

Which type of surgery involves opening the skull with a drill ? A. Burr hole : b. Craniotomy c, Craniectomy d. Cranioplasty

A

Which part of the brain is primarily associated with life support and basic functions of the body ? A. Cerebrum b. Brainstem c. Cerebellum d. Cerebral cortex

B

A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has: a) Aphasia b) Dysphasia c) Dysphagia d) Anorexia

c

A patient is visiting the clinic for an evaluation of a swollen, painful knuckle. The nurse notices that the knuckle above his ring on the left hand is swollen and that he is unable to remove his wedding ring. This joint is called the _____ joint. a) Interphalangeal b) Tarsometatarsal c) Metacarpophalangeal d) Tibiotalar

c

The nurse is taking a family history. Important diseases or problems to ask the patient about specifically include: a) Emphysema b) Head trauma c) Mental illness d) Fractured bones

c

During an examination, a patient has just successfully completed the finger-to-nose and the rapid-alternating-movements tests and is able to run each heel down the opposite shin. The nurse will conclude that the patient9s ____ function is intact. A) occipital B) cerebral C) temporal D) cerebellar

d

The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is: a) Increased salivation b) Increased liver size c) Increased esophageal emptying d) Decreased gastric acid secretion

d

When the nurse performs the confrontation test, the nurse has assessed: A) extraocular eye muscles (EOMs). B) pupils (PERRLA). C) near vision. D) visual fields.

d

. The nurse is obtaining a health history for a client during an annual physical examination . When evaluating the client for menopausal symptoms , which finding indicates the client is perimenopausal ? A. Drenching night sweats . B. Excessive vaginal moisture . C. Increase in sexual desire . D. Cessation of menstruation .

A

. The nurse prepares to begin a systematic assessment of a client's heart sounds . Upon positioning the stethoscope, what should the nurse do first ? A. Identify S1 and S2 heart sounds . B. Change to the bell of the stethoscope . C. Move the stethoscope to the apical site . D. Listen for abnormal sounds .

A

Which client is suspected to have sustained injury to the cranial nerve III ? Client Eye finding Client A Drooping eyelids Client B Nearsightedness Client C Cross - eyes Client D Protruding eyes

A

Which education would the nurse provide the parents of an infant with bilateral cryptorchidism about the infant's prognosis if the problem is not corrected ? A. Sterility upon maturity . B. Inflammation in the epididymis . C. The development of a hydrocele d. The development of a varicocele

A

Which education would the nurse provide the parents of an infant with bilateral cryptorchidism about the infant's prognosis if the problem is not corrected ? A. Sterility upon maturity b. Inflammation in the epididymis c. The development of a hydrocele d. The development of a varicocele

A

Which statements are true regarding adolescent sexual health and wellness ? Select all that apply . One , some , or all responses may be correct . A. Papanicolaou ( Pap ) testing should start at age 21 b. Females should have Papanicolaou ( Pap ) tests when they become sexually active c. A sexually active teen who does not use contraception has a 50 % chance of pregnancy within 1 year d. Pregnant teenagers don't often know to avoid teratogens e. The human papiloma virus vaccine is often the point of entry to care for adolescent sexual health and wellness .

A d e

Which hormone is responsible for altered serum calcium concentrations ? Select all that apply . One , some , or all responses may be correct . A. Calcitonin b. Thyroxine c. Glucocorticoids d. Growth hormone e. Parathyroid hormone

A e

A 29 year old male client informs the nurse that he came to the clinic to see if , " Maybe I have lung cancer or something , " and wants to get checked out since , " I can't seem to get rid of this body - wracking dry cough that has been hanging around for the last six weeks . " Which computer documentation of this client's concerns should the nurse enter ? A. Presents with a hacking non - productive cough of 6 weeks duration . B. Describe having a " body - wracking dry cough " of 6 weeks duration . C. Expresses concern of " lung cancer " symptoms for last 6 weeks . D. Young adult male presents with fears that he has " lung cancer "

B

An adolescent reports scrotal pain , redness , dysuria , and fever . Which condition is the client most likely experiencing ? A. Varicocele b. Epididymitis c. Testicular torsion d. Testicular cancer

B

Which client's prescribed test for reproductive system assessment would a nurse recognize as needing revision ? A Lymphatic enlargement Computed tomography due to metastasis . B Uterine bleeding Hysterosalpingography C Varicoceles Ultrasonography D Cervical cancer Colposcopy

B

Which individual's activities increase the risk of developing carpal tunnel syndrome ? A. Housekeeper b. Software engineer c. Health care worker . D. Professional athlete .

B

Which screening report will help the nurse determine skeletal growth in a child ? A. Electroencephalogram reports b. Radiographs of the hand and wrist c. Magnetic resonance imaging ( MRI ) d. Denver Developmental Screening Test

B

The nurse begins a client's musculoskeletal assessment . While using the technique of inspection , the nurse assesses for which possible findings ? ( Select all that apply ) A. Osteopenia . B. Kyphosis . C. Atrophy . D. Contracture . E. Crepitus .

B c d

Which cranial nerves assist with both sensory and motor function ? Select all that apply . One , some , or all responses may be correct . A. Optic b, Facial c. Trochlear d. Accessory e. Trigeminal

B e

The nurse is performing a cranial nerve exam on an 87 - year - old client . The nurse notes that the client has a reduced upward gaze , a decreased corneal reflex , a high frequency hearing loss , and a reduced gag reflex . What action should the nurse take next ? A. Review past history for any episodes of a cerebral cortex lesion . B. Implement neuro vital signs every 2 hours to detect Cushing's Triad . C. Continue the assessment to the next pairs of cranial nerves . D. Assess the spinal reflexes for demyelination symptoms .

C

Which organ can be affected by Candida albicans ? Select all that apply . One , some , or all responses may be correct . A. Ears b. Lungs c. Vagina d. Mouth e. Intestines

C d e

Which cranial nerve would the nurse assess further if the client cannot close the right eye ? A. Tenth b. Fourth c. Second d. Seventh

D

During an interview the patient states, <I can feel this bump on the top of both of my shoulders4it doesn9t hurt but I am curious about what it might be.= The nurse should tell the patient: a) <That is your subacromial bursa.= b) <That is your acromion process.= c) <That is your glenohumeral joint.= d) <That is the greater tubercle of your humerus.=

b

The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination? a) When the infant is sleeping b) At the end of the examination c) Before auscultation of the thorax d) Halfway through the examination

b

A male client returns to the clinic for a follow - up visit after infection . While examining the client , which finding indicated an expected response to the being treated for a bladder treatment ? A Orange sized prostate gland . B. Post - voided residual volume of 50 mL . C. Pain score of 1 out of 10 with urination . D. Decreasing sperm cell count

C

A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first when beginning the examination? a) Auscultate the lungs and heart while the infant is still sleeping. b) Examine the infant9s hips because this procedure is uncomfortable. c) Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach

a

Which question by the nurse is likely to elicit the most information regarding a client's use of medications to treat a chronic cough ? A. What medications are you currently taking ? B. Have you tried any generic brands of cough syrup ? C. Have you been prescribed any medications for your cough ? D. What medications have you used for your cough ?

A

Which statement describes varicocele ? A. Varicocele occurs most often on the left side b. . The left testicle is larger when associated varicocele is present . C. Testicular size increases with increasing duration of a varicocele . D. Dihydrotestosterone increases with the duration of a varicocele .

A

Damage to which nerve explains why a client recovering from a head injury is unable to move the tongue ? A. Facial b. Trigeminal c. Hypoglossal d. Glossopharyngeal

C

passage , which finding suggests to the nurse A client is being evaluated for environmental allergies . While examining the client's nasal that the client is experiencing allergic rhinitis ? A. Purulent secretions from eyes and nares . B. Eye tearing and thick yellow nasal drainage . C. Snoring and bilateral , pale gray nodules . D. Intranasal edema and swelling of turbinates .

D

At which joint would the nurse be able to palpate spongy swelling caused by excess synovial fluid ? A. Biaxial joint b. Pivotal joint c. Synovial joint d. Temporomandibular joint

D

Using the muscle strength scale , which rating would the nurse record for a client who can complete range of motion with some resistance ? 01 02 03 4

4

A client diagnosed with Bell palsy has many questions about the course of the disorder . Which information would the nurse share with the client ? A. Cool compresses decrease facial involvement . B. Pain occurs with transient ischemic attacks ( TIAs ) . C. Most clients recover from the effects in several weeks . D. Body changes should be expected with residual effects .

C

A client reports enlargement of the hands and feet , thickened lips , and joint pains . The client's blood glucose is 250 mg / dL ( 13.89 mmol / L ) , and x - ray examinations reveal increased size of the lungs . Which hormone would the nurse suspect is being affected in the client ? A. Prolactin b. Thyrotropin c. Growth hormone d. Adrenocorticotropic hormone

C

A client with streptococcus pharyngitis reports high fever , difficulty swallowing and a muffled voice . Which complication should the nurse suspect ? A. Foreign body obstruction . B. Laryngeal polyps . C. Peritonsillar abscess . D. Nasal polyps .

C

. A client reports to the healthcare provider's office for a routine post - surgical evaluation six weeks after a hysterectomy . Which history - taking approach should the nurse use to gather the needed information ? A. Conduct a comprehensive review of systems . B. Perform a head - to - toe physical assessment . C. Prepare to collect a vaginal specimen for Papanicolaou smear . D. Collect information about the client's activities since surgery .

D

A client asks the nurse what causes the sudden loss of vision common in persons with multiple sclerosis . Which factor would the nurse include in the explanation ? A. Virus - induced iritis b. Intracranial pressure c. Closed - angle glaucoma d. Optic nerve inflammation

D

Which eye muscle is controlled by cranial nerve VI ? Levator Lateral rectus Medial rectus Superior oblique

Lacteral rectus

Which type of nerve helps the client's pupil constrict ? Motor Sensory Sympathetic Parasympathetic - motor

Parasympathetic motor

A 5-year old child is in the clinic for a checkup. The nurse would expect him to: A) have to be held on his mother9s lap. B) be able to sit on the examination table. C) be able to stand on the floor for the examination. D) be able to remain alone in the examination room

a

After the health history has been obtained, and before beginning the physical examination, the nurse should ask the patient to first: A) empty the bladder. B) completely disrobe. C) lie on the examination table. D) walk around the room

a

Which condition is characterized by infection of a client's bone or bone marrow ? A. Osteomalacia b. Osteomyelitis c.bHerniated disc d. Spinal stenosis

B

Which finding would the nurse expect to identify in a client who has osteoarthritis that would not be present in clients with rheumatoid arthritis ? A. Ulnar drift b. Heberden nodes c. Swan - neck deformity d. Boutonnière deformity

B

Which phase of a woman's sexual response is characterized elevation of the uterus ? A. Plateau phase b. Orgasmic phase .c. Excitation phase d. Resolution phase

A

A male client who is admitted for an acute brain attack reports sensation in his hands and legs . Which action should the nurse implement to identify additional the onset of a burning findings that are consistent with the client's paresthesia ? A. Evaluate client's muscle strength and hand grips . B. Observe skin for erythema , edema , and warmth . C. Review the client's serum electrolytes . D. Check distal phalanges capillary refill

A

Q17 . When performing a neurologic assessment on an alert client , the nurse observes that the client's pupils are both round , 3 mm in size , and respond briskly to light . Which notation should the nurse use when documenting the assessment ? A. PERRL . B. GCS of 15 . C. PERLA . D. Neuro status intact .

A

Which condition causes impaired speech coordination ? A. Cranial nerve lesion b. Occipital lobe lesion c. Parietal cortex lesion d. Limbic lobe lesion

A

Which cranial nerve would the nurse assess further for a client whose mouth is drooping over to the left ? A. Left facial nerve b. Right facial nerve c. Left abducens nerve d. Right abducens nerve

A

Which glands help in lubricating the female urinary meatus ? A. Skene glands b. Prostate glands c. Cowper glands d. Bartholin glands

A

Which age - related change would the nurse expect to find when assessing the reproductive health of an older female client ? Select all that apply . One , some , or all responses may be correct . A. Smaller clitoris b. Shrunken vulva c. Dimpled breasts d. Narrowed vaginal opening e. Green vaginal discharge

A b d

Which client activity warrants the highest priority for education about health promotion to prevent head and neck cancer ? Select all that apply . One , some , or all responses may be correct a, Chews tobacco . B. Multiple sex partners c. Uses condoms when having sex d. History of alcohol abuse for 5 years e. Brushes with a soft - bristle toothbrush

A b d

Which clinical indicators would the nurse consider evidence of increasing intracranial pressure ? Select all that apply . One , some , or all responses may be correct . A. Vomiting b. Irritability c. Hypotension d, Increased respirations e. Decreased level of consciousness

A b e

Which hormones are involved in building and maintaining healthy bone tissue ? Select all that apply . One , some , or all responses may be correct . Insulin Thyroxine Glucocorticoids Growth hormone Parathyroid hormone

A c d

Which client assessment data would correspond to a muscle - strength rating of 3 ? A. No evidence of muscle contractility b. Can complete range of motion ( ROM ) against gravity c. No joint motion and slight evidence of muscle contractility d. Can complete ROM against gravity with some resistance

B

A client states that he is legally blind . Which assessment techniques should the nurse use to obtain data to support the client's statement ? A. Observe the client's optic disc through an ophthalmoscope . B. Assess the client's ability to read a Snellen chart from a distance of 20 feet . C. Observe the client's pupillary response to a penlight . D. Observe the client's eye movements through the cardinal fields of vision .

B

In assessing a client's sensory nerve function , the nurse prepares to assess the client's response to temperature . What action should the nurse include during this assessment A. Darken the client's room environment . B. Cover the client with a warmed blanket . C. Measure the client's body temperature . D. Instruct the client to close both eyes .

B

The nurse is assessing an ulcer on a client's lower extremity , which is likely the result of either venous or arterial insufficiency . Which assessment technique should the nurse use to differentiate the pathophysiology causing the ulcer ? A. Measure the degree of join range of motion in the extremity . B. Compare the skin turgor of the client's upper and lower leg . C. Observe the specific location and appearance of the ulceration , D. Note any change in the color of the ulcer when the leg is moved .

C

A male client reports the onset of a burning the nurse document this finding in the electronic medical record ? sensation in his hands and legs . How should A. Circulation impaired . B. Inflammation present . C. Reports feeling " on fire . " D. Paresthesia reported .

D

After placing a client in a supine position , the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud , high gurgling in two quadrants . What action should the nurse implement ? pitched almost continuous A. Use the bell of the stethoscope to auscultate again . B. Elevate the head of the client's bed immediately . C. Document the presence of borborygmi . D. Auscultate the remaining two quadrants .

D

Which assessment findings would the nurse identify in a client with clinical manifestations of rheumatoid arthritis ( RA ) ? Select all that apply . One , some , or all responses may be correct . A. Obesity and asymmetric joint disease b, Development of antinuclear antibodies c. Inflammatory disease pattern d. Bilateral involvement of metacarpophalangeal joints e. Disease process involving the distal interphalangeal joints f. Disease in the weight - bearing joints and hands

B c d

While assessing the legs of a female client reports aching tired legs that swell if she stands for long client , the nurse observes leathery - looking skin . The periods of time . To screen for venous insufficiency , the nurse should ask the client if she has experienced which subject finding ? A. Decreased pain when legs are elevated . B. Deep , continuous pain in the calf muscles . C. Cool , pale skin below the knees . D. Painful symptoms alleviated by warmth .

A

The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs would reveal: a) Dullness b) Tympany c) Resonance d) Hyperresonance

a

Which client joint would be palpated by the nurse to identify genu valgum ? A, Hip b. Knee c. Temporomandibular

B

Illness is seen as a part of life9s rhythmic course and as an outward sign of disharmony within. This statement most accurately reflects the views about illness from the _____ theory. a) Naturalistic b) Biomedical c) Reductionist d) Magicoreligious

a

An imaginary line connecting the highest point on each iliac crest would cross the _____ vertebra. a) First sacral b) Fourth lumbar c) Seventh cervical d) Twelfth thoracic

b

An older adult client is admitted generalized malaise . To analyze the client to the medical unit because of loss of appetite and medical condition , which laboratory value is most important for the nurse to review ? A. Hematocrit . B. Serum Calcium . C. Hemoglobin . D. Serum pre - albumin .

C

During assessment of a client's neck , the nurse prepares to assess for jugular vein distention ( JVD ) as seen in the picture . What should the nurse do next ? A. Listen to swishing sound during systole . B. Use the bell of the stethoscope to auscultate . C. Remove the stethoscope to observe the site . D. Palpate the site of erythema and tenderness .

C

After checking a client's pupillary that the client's pupils are constricted findings , which action should the nurse take ? response to light , the practical with minimal response to light . Before verifying the PN's nurse ( PN ) tells the nurse A Brighten the light in the client's room . B. Assess the client's visual fields . C. Review the client's medication list . D. Administer PRN saline eye solution .

B

The nurse prepares to assess a client's heart during a routine health checkup . In which position would the nurse place the client to assess murmurs the heart ? A. Supine b. Left lateral c. Sims

B

When auscultating a client's lung sounds , the nurse hears rhonchi in the upper lung fields anteriorly . Which action should the nurse take first ? A. Measure capiliary refill . B. Ask the client to cough . C. Monitor oxygen saturation . D. Document the finding .

B

Which focused assessment technique should the nurse use for a client admitted with possible dehydration ? A. Press skin over a bony prominence . B. Grasp skin fold of the posterior forearm . C. Check hands for parchment - like appearance . D. Measure the circumference of the calf

B

Which information from the client's history would the nurse identify as a risk factor for developing osteoporosis ? A. Takes estrogen therapy b. Receives long - term steroid therapy c. Has a history of hypoparathyroidism d. Engages in strenuous physical activity

B

objectively confirm the presence of fever , before taking the client's temperature , which action should the nurse take ? A. Ask the client to describe any other related symptoms . B. Use both hands to hold and palpate the client's hands . C. Lightly pinch a fold of skin over the client's sternum . D. Place the dorsum of the hand on the client's forehead .

B

Which adolescent behavior increases the risk of injury ? Select all that apply . One , some , or all responses may be correct .. a. Poor diet . B. Substance abuse c. Unprotected sex d. Sedentary lifestyle e. Increased screen time .

B c

In assessing a male client's level of consciousness , the nurse determines that the client does not open his eyes spontaneously . What should the nurse do next ? A. Notify the healthcare provider . B. Observe for eye opening to a painful stimulus . C. Check the pupillary response to light . D. Ask the client to open his eyes .

C

In observing a client's face , which assessment finding requires the most immediate intervention by the nurse ? A. Eyelids are matted and crusted . B. Cornea are jaundiced . C. Oral mucosa is cyanotic . D. Face is flushed and diaphoretic .

C

The nurse is assessing a client for goiter and is unable to observe the thyroid gland . Which action should the nurse take ? A. Defer the thyroid exam and observe the client for signs of myxedema . B. Document that thyroid gland size is normal with no visible goiter . C. Ask the client to swallow while palpating along the sides of the trachea . D. Palpate deeply and firmly over the location of the thyroid gland .

C

The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy . While interviewing the client , which assessment technique should the nurse use when asking about the client's use of illegal drugs and alcohol ? A. Obtain a drug using screen to verify legitimacy of client's stated history . B. Allow the client to decline answering social questions . C. Ask specifically about alcohol , marijuana , cocaine , heroin , and amounts . D. Use the term illegal or illicit to describe street drugs .

C

A 75 - year - old client with a recent history of a cerebrovascular accident ( CVA ) presents with right hemiparesis The nurse tests the deep tendon reflexes on the right side and elicits a brisk 4+ response . Which interpretation of this finding is accurate ? A. A normal reflex response . B. Absent or sluggish response consistent with a lower motor neuron lesion . C. Flaccid paralysis . D. Hyperactive response consistent with an upper motor neuron disorder .

D

A client comes to the clinic due to shoulder discomfort and intermittent pain while swimming today . To assist normal range of motion ( ROM ) of the client's shoulder , which assessment techniques should the nurse ask the client to perform ? A. Alternate both index fingers to tough the tip of nose accurately . B. Extend arms up to 180 degrees besides the ears . C. Extend arms straight out and hold without drifting . D. Hold arms up at 90 degree while arms are pushed downward .

D

A client is diagnosed with testicular cancer . Which treatment would be first ? A. Radiotherapy b. Chemotherapy c. Testicular biopsy d. Radical inguinal orchiectomy

D

A client reports neck stiffness , severe headache , and a decreased level of consciousness . Which condition would the nurse suspect ? A. Encephalitis b. Brain abscess c. Viral meningitis d. Bacterial meningitis

D

A client sustained a subconjunctival hemorrhage . The presence of which set of symptoms indicate that the client needs to be seen for further evaluation by an ophthalmologist ? A. Acute pain , change in visual acuity , and foreign body sensation . B. Frequent burning , irritation and tearing of the eyes . C. Bilateral itchy , red eyes with watery discharge / D. Diminished ability to focus on close work and excessive illumination required

D

Which explanation best describes what is known about the pathophysiology of dementia of the Alzheimer type ? A. There is a genetic predisposition and dysregulation of neurotransmitters . B. The dementia is transient and secondary to a physical imbalance or disorder . C. Hypoxia and decreased perfusion of select areas of the brain causes tissue damage . D. The presence of amyloid plaques is associated with brain tissue destruction .

D

Which hormone promotes bone resorption in a client and potentially leads to decreased bone densities ? A. Estrogen b. Calcitonin c. Growth hormone d. Parathyroid hormone ( PTH )

D

Which risk would the nurse monitor when providing care for a client with scoliosis of the thoracic spine and lumbar spine ? A. Osteoarthritis b. Muscle spasticity c. Intervertebral disc prolapse d. Cardiac function impairment

D

Which tissue connects the client's tibia to the femur at the knee joint ? A. Fascia b. Bursae c. Tendons d. Ligaments

D

Which type of synovial joint movement is involved in moving the client's first and fifth metacarpals anteriorly from the flattened palm ? A. Flexion b. Extension c. Abduction d. Opposition

D

While performing a physical assessment pulses . Which action should the nurse take ? , the nurse is unable to palpate the client's pedali A. Apply warm blankets to both feet . B. Palpate pulse points with legs dependent . C. Notify the healthcare provider . D. Use a doppler ultrasonic stethoscope .

D

trigeminal neuralgia that Which treatment would the nurse be referring to when explaining to a client with treatment is effective on a temporary ( 6- to 18 - month ) basis ? a. Weekly intravenous injections of cobra venom b. A lidocaine injection at the ventral root of the 11th spinal nerve c. Microvascular decompression of the blood vessels at the nerve root d. An alcohol injection at the peripheral branch of the fifth cranial nerve

D

A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient's speech is dysarthric and that she is lethargic. The nurse9s best approach regarding this examination is to: a) Plan to defer the rest of the mental status examination b) Skip the language portion of the examination and go on to assess mood and affect c) Do an in-depth speech evaluation and defer the mental status examination to another time d) Go ahead and assess for suicidal thoughts because dysarthria is often accompanied by severe depression

a

A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse9s best course of action? a) The nurse should plan to perform a complete mental status examination. b) The nurse should refer him to a psychometrician. c) The nurse should plan to integrate the mental status examination into the history and physical examination. d) The nurse should reassure his wife that memory loss after a physical shock is normal and will subside soon

a

Which assessment finding supports the client statement , " My feet swell all the time ? " A 2+ pitting edema of ankles bilaterally B. Capillary refill both feet > 3 seconds . C. Pedal pulses weak and thread . D. Positive Homan's sign bilaterally .

A

To assess a female client for hirsutism , which action should the nurse take ? A. Lightly palpate over the client's entire scalp . B. Apply and release light pressure to the skin . C. Assess the appearance of the client's face . D. Observe the hair shafts on the client's scalp .

C

Which assessment finding is associated with cranial nerve dysfunction after carotid endarterectomy ? A. Labored breathing b. Edema of the neck c. Difficulty in swallowing d. Alteration in blood pressure .

C

Which cranial nerve emerges from the client's medulla ? A. Trochlear b. Trigeminal c. Hypoglossal d. Oculomotor

C

Which cranial nerve is responsible for the client's equilibrium ? A. Vagus b. Trochlear c. Vestibulocochlear d. Glossopharyngeal

C

Which diagnostic study is used to detect deep vein thrombosis in the client's lower extremities ? A. Thermography b. Plethysmography c. Duplex venous Doppler d. Somatosensory evoked potential

C

Which would be included in the assessment of a school health promotional program for adolescents ? Select all that apply . One , some , or all responses may be correct a. Perform a school violence assessment . B. Assess the sleep pattern of the students . C. Identify individuals at risk for drug abuse .. d. Explain the need for fluoride supplements to prevent dental caries . E. Instruct the students about principles of gun safety .

A c e

Which findings are consistent with hypercalcemia after prolonged immobility ? Select all that apply . One , some , or all responses may be correct . A. Bone pain b. Convulsions c. Muscle spasms d. Tingling of extremities e. Depressed deep tendon reflexes

A e

While performing a physical assessment of a female client , the nurse positions the client in a left lateral recumbent position . Which body system would the nurse assess in this position ? Select all that apply . One , some , or all responses may be correct . A. Heart b. Vagina c. Rectum d. Female genitalia e. Musculoskeletal system

B c

The nurse observes an unlicensed assistive personal ( UAP ) begin to provide oral care to an unresponsive client who is at risk for aspiration instruction should the nurse provide the UAP ? ( Select all that apply ) . as seen in the picture . What A ) Flex the client neck forward . B ) Turn the clients head to the side . C ) Remove the gloved finger from the mouth D ) Elevate the head of the bed to semi fowlers . E ) Apply lubricant to the toothed .

B c d

Which musculoskeletal changes directly place pregnant clients at increased risk for falls ? Select all that apply . One , some , or all responses may be correct . A, Back pain b. Joint laxity c. Weight gain d. Impaired balance e. Shifting center of gravity

B d e

A women comes to the clinic history and the women begins to cry when for her first prenatal visit . The nurse is conducting a health asked about previous pregnancies . Which response is best for the nurse to provide ? A. " Why don't I come back in a few B. Offer a tissue and sit quietly until the crying subsides . minutes after you are more composed . " C. Allow the client to compose herself then D. " I'm so sorry that I made you cry . I didn't mean to upset you . " change the subject .

C

The school nurse is interviewing a 13 - year - old girl who wants to go home from school because of " back pain " . Which question should the nurse ask the adolescent first ? A. " Have you taken any medications to relieve the pain ? " B. " What were you doing when you first noticed the problem ? " C. " Do you remember ever having this type of pain in the past ? " D. " Does changing your position make the pain worse ? "

C

Which hormone acts with luteinizing hormone to stimulate the production of sperm during puberty ? A. Somatropin b. Testosterone . C. Follicle - stimulating hormone . D. Gonadotropin - releasing hormone

C

Which hormone aids in regulating intestinal calcium and phosphorous absorption ? A. Insulin b. Thyroxine c. Glucocorticoids d. Parathyroid hormone

C

Which mechanism of action is responsible for the therapeutic effects of mannitol precribed for a client with a head injury ? A. Decreasing the production of cerebrospinal fluid b, Limiting the metabolic requirements of the brain c. Drawing fluid from brain cells into the bloodstream d. Preventing uncontrolled electrical discharges in the brain

C

While assessing a client who experienced an accident , the nurse found the client was unable to move her eyes laterally . Damage to which nerve led to this condition in the client ? A. Optic nerve b. Facial nerve c. Abducens nerve d. Oculomotor nerve

C

A client who sustained head injuries is admitted to the hospital . During assessment of cranial nerves , the nurse notices that the client lost the perception of taste , especially in the anterior portion of the tongue . Which cranial nerve might have been injured in this client ? A. Cranial nerve X b. Cranial nerve IX c. Cranial nerve XIII d. Cranial nerve VIII

D

During a health assessment for a young adult female client's gynecological annual screening , the client reports amenorrhea . The nurse calculates the client body mass index ( BMI as 16. Which finding should the nurse document in the electronic medical record that indicates an expected rationale for this condition ? A. Increased calcium intake with 3 glasses if non - fat milk daily . B. Reports a history of chronic urinary tract infections . C. Trains for competition and runs 12 miles every day . D. Received an implanted intrauterine device ( IUD ) last month .

D

Which condition is consistent with a client's report of posterior leg pain while walking that worsens upon rest ? A. Crepitus b. Ankylosis c. Contracture d. Tendonitis

D

A 45-year-old man is in the clinic for a routine physical. During the history the patient states that he9s been having difficulty sleeping. <I9ll be sleeping great and then I wake up and feel like I can9t get my breath.= The nurse9s best response to this would be: a) <When was your last electrocardiogram?= b) <It9s probably because it9s been so hot at night.= c) <Do you have any history of problems with your heart?= d) <Have you had a recent sinus infection or upper respiratory infection?=

c

A client with hemiparesis needs assistance transferring from the bed to the wheelchair. The nurse assists the clients to a sitting position on the side of the bed. Which action should the nurse implement next? A) Flex the hips and knee and align the knees with the client9s knees for safety B) Allow the client to sit on the side of the bed for a few minutes before transferring C) Place the client9s weight-bearing or strong leg forward and the weak foot back D) Grasp the transfer belt at the client9s sides to provide movement of the client.

c

In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 and slightly irregular; split S2. Which of these findings can be explained by expected hemodynamic changes related to age? a) Increase in resting heart rate b) Increase in systolic blood pressure c) Decrease in diastolic blood pressure d) Increase in diastolic blood pressure

b

Which of these statements is true regarding the complete physical assessment? A) The male genitalia should be examined in the supine position. B) The patient should be in the sitting position for examination of the head and neck. C) The vital signs, height, and weight should be obtained at the end of the examination.

b

Which of these statements is true regarding the recording of data from the history and physical examination? A) Use long, descriptive sentences to document findings. B) Record the data as soon as possible after the interview and physical examination. C) If the information is not documented, then it can be assumed that it was done as a standard of care. D) The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing rapport with the patient.

b

The nurse is performing an initial assessment of a client who has an expressionless facial affect , slurred speech , and red conjunctivae . What question should the nurse ask first ? " Have you A. Been depressed lately ? " B. Had everything to eat in the last 24 hours ? " C. Ever had problems with you blood sugar ? " D. Been sleeping well ?

D

Which cranial nerve would the nurse suspect is affected when a client reports buzzing in the ear for the past 5 days and a decreased ability to hear sounds while receiving long - term aminoglycoside therapy ? A. CN III b. CN V c. CN VII d. CN VIII

D

Which early indicator of potential damage to the motor branch of the facial nerve would the nurse assess in a client recovering from ear surgery ? A. Pain behind the ear b. Bitter , metallic taste c. Dryness of the mouth d. Inability to wrinkle the forehead

D

A client reports joint pain with deformities . Based on assessment findings , the nurse suspects that the client has acromegaly . The client will most likely receive a prescription for which medication ? A. Octreotide b. Carbamazepine c. Chlorpropamide d. Cyclophosphamide

A

A homeless male client ( CVA ) 10 years ago that resulted in left with a history of alcohol abuse had a cerebrovascular accident hemiparesis . Today he is complaining of pain in his left leg , is afebrile , has 4+ pitting Which action should the nurse implement first ? edema in the lower left leg , and minimal swelling of the right leg . A. Inspect legs for infection of trauma . B. Obtain a blood alcohol level . C. Complete a mental status exam . D. Inquire about dietary salt intake .

A

Q23 . Which skill should the nurse have an older client demonstrate to evaluate performance of daily living activities ? A. Opening a bar soap package . B. Sorting a collection of socks . C. Reading a short paragraph . D. Telephoning a family member .

A

Q34 . While completing an admission nurse inspects the perineal area and assessment for a client with gastrointestinal bleeding , the anus . Which findings indicates a normal appearance of the anus ? A. Increased pigmentation and coarse skin . B. Flap of tissue at sphincter C. Hypotonic tone of the anal sphincter . D. Dimpled area above anus .

A

The nurse finds a client at 33 weeks gestation in cardiac arrest . What adaptation to cardiopulmonary resuscitation ( CPR ) should the nurse implement ? A ) Position a firm wedge to support pelvis and thorax at 30 degree tilt . B ) Apply oxygen by mask after opening the airway C ) Apply less compression force to reduce aspiration . D ) Give continuous compression with a ventilation ration at 20 : 3 .

A

The nurse has just completed palpitation maneuvers for lymph female client . Which findings are considered normal for this elderly client ? nodes on a 75 - year - old A. Nodes are non - palpable . B. Axillary nodes feel soft and fatty C. Nodes feel ropey and rubbery . D. Inguinal nodes are enlarged and warm to the touch .

A

A client with positive family history of testicular cancer arrives at the hospital and reports testicular pain . The primary health care provider reviews the laboratory reports and makes a diagnosis of testicular cancer . After surgery , the client will undergo chemotherapy . Which condition might occur in this client after chemotherapy ? Select all that apply . One , some , or all responses may be correct . A, Infertility b. Varicocele . C. Heart disease d. Penile carcinoma e. Metabolic syndrome

A c e

During a health assessment , the client reports being examines a client's hands and finds Heberden's nodes . Which finding should the nurse treated for osteoarthritis . The nurse document in the client's medical record ? A. Proximal intertarsal join swelling of big toe B. Non - painful enlarged interphalangeal joints . C. Distal interphalangeal joint nodules that deviate . D. Frozen , non - movable phalangeal joints .

C

While obtaining a health history , a male client tells the nurse that he sometimes experiences shortness of breath . The nurse determines that the client's respirators are regular and deep , and his respiratory rate is 14 breaths / minutes . What is the best nursing action ? A. Ask the client to perform light exercise and observe the respiratory effect . B. Document " dyspnea on exertion " in the client's medical record . C. Ask the client to describe the episodes of dyspnea in more detail . D. Explain to the client the possible causes of dyspnea or " shortness of breath . "

C

Which statement is inaccurate regarding the developmental needs of toddlers ? Select all that apply . A. They need fewer calories . B. " They have a decreased appetite . C. " They are easy to please with food . D. " They are growing at an increased rate e. . " They need calcium for healthy bone growth . "

C d

Which diagnostic exam would be used to detect muscle weakness ? A. Arthroscopy b. Radiography c. Myelography d. Electromyography

D

In assessing a patient9s major risk factors for heart disease, which would the nurse want to include when taking a history? a) Family history, hypertension, stress, age b) Personality type, high cholesterol, diabetes, smoking c) Smoking, hypertension, obesity, diabetes, high cholesterol d) Alcohol consumption, obesity, diabetes, stress, high cholesterol

c

A male patient is admitted for observation after being hit on the head with a baseball bat. Six hours after admission the client attempts to crawl out of bed and asks the nurse why there are so many bugs in his bed. His vital signs are stable and the pulse oximeter reading is 98% on room air. Which intervention should the nurse perform first? A) Administer oxygen per nasal cannula at 2L/min B) Plan to check his vitals signs again in 30 mins C) Notify the healthcare provider of the change in mental status D) Ask the client why he thinks there are bugs in the bed

c

A patient has been in the intensive care unit for 10 days. He has just been moved to the medicalsurgical unit, and the admitting nurse is planning to perform a mental status examination on him. During the tests of cognitive function the nurse would expect that he: a) May display some disruption in thought content b) Will state, <I am so relieved to be out of intensive care= c) Will be oriented to place and person but may not be certain of the date d) May show evidence of some clouding of his level of consciousness

c

The nurse completes inspection of the abdomen on an adult client . Which finding is considered normal for this client ? A. Masses . 8 . Peristaltic waves - C. Heterogeneous color , D. Homogeneous color .

D

The nurse completes palpitation of the abdomen on an older adult client . Which finding is considered normal for the client ? A. Non - tender . B. Gallop . C. Thrill . D. Peristaltic waves .

D

The nurse examines a client's abdomen . Which finding indicates an abnormal response when palpating the spleen ? A. Pain notes when palpating McBurney's point . B. Tip of spleen palpable when client is asked to forcefully exhale . C. Rebound tenderness with compression over right upper quadrant . D. Firm mass palpated at bottom of left rib cage

D

The nurse is conducting a physical assessment of a young adult . Which information provides the best indication of the individual's nutritional status ? A. Status of current appetite . B. A 24 - hour diet history . C. History of a recent weight loss . D. Condition of hair , nails , and skin . reflection

D

During which situation would the nurse expect the client who has rheumatoid arthritis to experience the most joint pain and stiffness ? A. After assistive exercise b. When the room is cool c. During the evening hours . D. In the morning on awakening

D

When assessing a male client's respiratory status , which technique should the nurse use to assess his anterior- posterior ( AP ) chest diameter ? A. Auscultation . B. Percussion . C. Palpation . D. Observation .

D

The nurse is assessing a healthy adult male during an annual auscultates the client's abdomen and hears gurgling sound every ten seconds . What action physical examination . The nurse should the nurse take in response to this finding ? A. Document this normal bowel sound activity in the record . 8. Encourage increased consumption of fiber in the diet . C. Observe the next bowel movement for signs of bleeding . D. Report the hyperactivity to the healthcare provider

A

The nurse reviews the diagnostic reports of a client and discovers that the client has an injury to cranial nerve VII . Which condition would the nurse observe upon assessment ? A. Inhibition of tear production b. Inhibition of peripheral vision c. Impairment of eye movement d. Impairment of pupil constriction

A

During an abdominal assessment , a client with a temperature of 103 F ( 39.4 C ) experiences pain and abruptly stops inhaling during deep palpation . Which prescription is most important for the nurse to implement ? A. Electrocardiogram . B. Complete bed rest . C. Monitor urinary output . D. Nothing by mouth .

D

The nurse is auscultating the chest in an adult. Which technique is correct? a) Instruct the patient to take deep, rapid breaths. b) Instruct the patient to breathe in and out through his or her nose. c) Use the diaphragm of the stethoscope held firmly against the chest. d) Use the bell of the stethoscope held lightly against the chest to avoid friction

c

The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to: a) Administer the FACT test. b) Ask him to describe his first job. c) Give him the Four Unrelated Words test. d) Ask him to describe what television show he was watching before coming to the clinic.

c

A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data? a) <Mr. Y., at your age, surely you have been hospitalized before!= b) <Mr. Y., I just need permission to get your medical records from County Medical.= c) <Mr. Y., you mentioned that you have been hospitalized on several occasions. Would you tell me more about that?= d) <Mr. Y., I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain?=

c

Which change in the joint may result in joint pain for older adults ? A. Dehydration of discs b. Loss of muscle mass c. Decreased elasticity in the ligaments d. Increased cartilage erosion

D

To confirm the presence which action should the nurse take ? of a barrel chest documented in the client's medical record , A. Observe the appearance of the thorax . B. Auscultate the client's breath sounds . C. Percuss diaphragmatic excursion . D. Palpate tactile fremitus on the posterior chest .

A

The nurse asks a 50 - year - old female client what her natural hair color is . The client replies , " I've been dying my hair for so long , I'm not even sure ,,,, I just know that this month it's ravishing red . " Based on this information , the nurse expects to obtain which finding when palpating this client's scalp hair ? A. Excess vellus hair . B. Receding front hairline . C. Fine , thin , limp texture . D. Coarse , dry , brittle texture .

D

The nurse assesses a client and observes the condition of postaricular ecchymosis . How would the nurse chart this finding ? Otorrhea present Halo sign present Rhinorrhea present Battle's sign present

D

When assessing a child who complains of fever , chills , and a headache after returning from a camping trip , which is most important for the nurse to assess ? A. Exposure to chickenpox b. Sports played on the trip c. Developmental screening d. Duration of clinical findings

D

Q19 . The nurse is assessing a female client who states that her hemorrhoids are inflamed and hurt constantly . Which intervention is best for the nurse to complete a focused assessment ? A Ask the client how long she has experienced discomfort related to hemorrhoids . B. Place the client in a standing position , leaning over the exam bed for inspection . C. Determine if the client uses any over - the - counter preparation for hemorrhoids . D. Position client in left lateral position to inspect perianal area for fissures or sacs .

D

The nurse applies pressure over an area of the lower abdomen where the client reports pain . The client denies pain upon palpation , but reports pain when the pressure is released . What action should the nurse implement ? A. Offer to administer a laxative prescribed for PRN use . B. Obtain a prescription to catheterize the client's bladder . C. Instruct the client in distraction and relation techniques . D. Notify the healthcare provider of the rebound tenderness

D

The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? a) <Tactile fremitus is caused by moisture in the alveoli.= b) <Tactile fremitus indicates that there is air in the subcutaneous tissues.= c) <Tactile fremitus is caused by sounds generated from the larynx.= d) <Tactile fremitus reflects the blood flow through the pulmonary arteries.=

c

When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse interprets that these are: a) Sounds normally auscultated over the trachea b) Bronchial breath sounds and are normal in that location c) Vesicular breath sounds and are normal in that location d) Bronchovesicular breath sounds and are normal in that location

c

A woman has just entered the emergency department after being battered by her husband. The nurse needs to get some information from her to begin treatment. What is the best choice for an opening with this patient? a) <Hello, Nancy, my name is Mrs. C.= b) <Hello, Mrs. H., my name is Mrs. C. It sure is cold today!= c) <Mrs. H., my name is Mrs. C. How are you?= d) <Mrs. H., my name is Mrs. C. I9ll need to ask you a few questions about what happened.=

d

An examiner is using an ophthalmoscope to examine a patient9s eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would indicate that the examination is being performed correctly? a) Using the large full circle of light when assessing pupils that are not dilated b) Rotating the lens selector dial to the black numbers to compensate for astigmatism c) Using the grid on the lens aperture dial to visualize the external structures of the eye d) Rotating the lens selector dial to bring the object into focus

d

Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should: a) Warm the end piece of the stethoscope by placing it in warm water b) Leave the gown on so that the patient does not get chilled during the examination c) Make sure that the bell side of the stethoscope is turned to the <on= position d) Check the temperature of the room and offer blankets to the patient if he or she feels cold

d

The mother of a 3-month-old infant states that her baby has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short amount of time, hungry again. What other information would the nurse want to have? a) The infant9s sleeping position b) Sibling history of eating disorders c) Amount of background noise when eating d) Presence of dyspnea or diaphoresis when sucking

d

The nurse asks, <I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here.= This question is found at the _____ phase of the interview process. a) Summary b) Closing c) Body d) Opening or introduction

d

The nurse has just completed an examination of a patient9s extraocular muscles. When documenting the findings, the nurse should document the assessment of which cranial nerves? A) II, III, VI B) II, IV, V C) III, IV, V D) III, IV, V

d

The nurse is explaining to a patient that there are <shock absorbers= in his back to cushion the spine and to help it move. The nurse is referring to his: a) Vertebral column b) Nucleus pulposus c) Vertebral foramen d) Intervertebral disks

d

The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? a) The nurse performs the examination from the left side of the bed. b) The nurse examines tender or painful areas first to help relieve the patient9s anxiety. c) The nurse follows the same examination sequence regardless of the patient9s age or condition. d) The nurse organizes the assessment so that the patient does not change positions too often

d

The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? a) The otoscope is often used to direct light onto the sinuses. b) The otoscope uses a short, broad speculum to help visualize the ear. c) The otoscope is used to examine the structures of the internal ear. d) The otoscope directs light into the ear canal and onto the tympanic membrane.

d

The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? a) Percuss and palpate in the lumbar region. b) Inspect and palpate in the epigastric region. c) Auscultate and percuss in the inguinal region. d) Percuss and palpate the midline area above the suprapubic bone

d

The review of systems provides the nurse with: a) Physical findings related to each system b) Information regarding health promotion practices c) An opportunity to teach the patient medical terms d) Information necessary for the nurse to diagnose the patient9s medical problem

d

Which structure is located in the left lower quadrant of the abdomen? a) Liver b) Duodenum c) Gallbladder d) Sigmoid colon

d