exam 2 scenario examples

a nurse has completed the general survey of a client who has been transferred to the unit. the information gathered during the general survey primarily provides the nurse with which of the following?

1. clues about the overall health of the client 2. an indication of the level of physical distress experienced by the client 3. indications about normal variations in the status of body systems

a nurse is providing a client with instructions on how to perform self-examination of the skin. the nurse would encourage the client to perform this examination at which frequency?

monthly

the nurse is assessing a newborn infant who currently has nasal congestion and rhinorrhea. what would the nurse consider when analyzing these data?

nasal congestion can impair oxygenation because infants are nose breathers

during a health history, a 62-year-old client reveals that he occasionally sees spots before his eyes. the nurse interprets this finding as the result of which if the following?

normal findings for client's age

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

a nurse palpates a client's ear and finds that the tragus is exquisitely tender. the nurse should suspect what health problem?

otitis externa

the nurse is assessing the sinuses of a client who exhibits many of the clinical characteristics of sinusitis. when assessing the client's sinuses, what assessment finding would most strongly suggest sinusitis?

pain on palpation

what would be most appropriate for the nurse to do when assessing motor function of a client's trigeminal nerve?

palpate temporal and masseter muscles while the client clenches the teeth

the nurse has completed a focused assessment of a client's mouth, nose, and throat. which finding would the nurse interpret as being normal?

pinkish, spongey soft palate

a 66-year-old client states that he has increasing difficulty hearing high-pitched sounds. the patient's statement most likely suggests that he has what diagnosis?

presbycusis

the nurse is performing an otoscopic examination of an infant's ears. what action would the nurse do?

pull the pinna down and back

an older adult client is concerned because her skin is very dry, she asks the nurse why she has dry skin now when she never had dry skin before. the nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what?

sebum production

a nurse is preparing a program on osteoporosis for a local women's group. what would the nurse cite as a risk factor?

smoking

an adult client has asked the nurse about actions that she can take to reduce her future risk of stroke. what health promotion activity should the nurse prioritize?

smoking cessation

a nurse is assessing an older adult client's risk for pressure ulcers using the braden scale for predicting pressure sore risk. which aspect of the client's current health status would be reflected in her score on this scale?

the client is consistently incontinent of urine

the nurse is assessing the characteristics and positioning of the client's uvula, which deviates asymmetrically when the nurse has the client say "ahh." this finding should prompt the nurse to focus on what during subsequent assessment?

the client's neurologic status

the nurse is assessing a 2-day-old infant prior to discharge home from the hospital with his mother. when assessing the infant's eyes, what finding would the nurse consider to be abnormal?

the infant's sclera have a yellowish tint

a patient's vision is recorded as 20/30 when the snellen eye chart is used. the nurse interprets these results to indicate that

the patient can read at 20 feet what a person with normal vision can read at 30 feet

a nurse is preparing a teaching session for a group of new parents about ear infections and measures to prevent them. the nurse is planning to address the reasons why children are more susceptible to these infections than adults. what information would the nurse describe?

the size and shape of children's eustachian tubes makes them vulnerable

during a prenatal visit, the nurse inspects the skin of the client's abdomen. what would the nurse identify as an abnormal finding?

urticaria

an older adult client reports that he is experiencing severe trunk pain and is concerned that he might have shingles. what type of lesion would the nurse most likely assess?

vesicle

the nurse is assessing a dark-skinned client whose forearms and hands have distinct regions of depigmentation. the nurse should document the presence of what health problem?

vitiligo

a client who works in a manufacturing plant is attending a teaching session on plant safety/ what would be an important risk prevention measure to teach regarding hearing?

wearing ear protection when in the work environment

the nurse assesses brisker than average reflexes in a client during a neurologic assessment. how would the nurse document this finding?

3+

The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an "itching rash." Which question would be most important for the nurse to ask?

"are you allergic to foods, medications, or other substances?"

a client describes her frequent headaches as being severe and lasting for days. the client's positive response to what question would most clearly suggest to the nurse that these headaches are migraines?

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

assessment reveals that a client has slight weakness with active range of motion agaisnt some resistance. how would the nurse document this finding?

4/5

a nurse is assessing the head and neck of an adult client. which vertebra should the nurse identify as a landmark in order to locate the client's other vertebrae?

C7

the nurse completes the inital newborn assessment and notes the presence of fine, downy hair on the infant's shoulders and back. how would the nurse document this finding?

lanugo

a nurse is having difficulty eliciting a patellar reflex during a client's neurologic assessment. what would be most appropriate for the nurse to have the client do?

lock the fingers together and pull against each other

a nurse has performed the corneal light reflex test during a client's eye examination during this test, the nurse appraised the client's eye alignment in which way?

by comparing the reflection of the light on the client's eye surface

a nurse is collecting subjective data during a client's eye and vision assessment. when asking the question, "do you wear sunglasses during exposure to the sun?" the nurse is addressing a known risk factor for what health problem?

cataracts

during the health interview, the nurse notes that a client is a mouth breather. the client denies nasal congestion and has a healthy body mass index. what objective assessment should the nurse perform first?

checking for a deviated nasal septum

On inspection, the nurse observes a line across the tip of an 8-year-old client's nose. The nurse should consequently focus on which area of assessment?

chronic allergies

a nurse observes the posture of a client who appears to breathe more comfortably when he is leaning forward with his arms resting on his knees. what would the nurse most likely suspect?

chronic obstructive pulmonary disease

after having a client perform a Romberg test, what finding would indicate to the nurse that the test is negative?

client maintains the position during the test

a patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. when assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding?

color variation

the nurse is assessing the eyes of a client who has a lesion of the sympathetic nervous system. what finding should the nurse anticipate?

constricted pupils, unresponsive to light

the nurse is conducting a focused musculoskeletal assessment of an older adult client. when analyzing assessment data, the nurse should be aware of what age related physiological changes?

decreased joint flexibility joint capsule calcification reduced muscle strength joint degeneration

an elderly client's history reveals the use of antihistamines. when inspecting the client's mouth, what would the nurse expect to find?

decreased saliva production

a client complains of temporomandibular joint pain. what would the nurse most likely assess?

difficulty chewing

a pregnant client asks the clinic nurse what she can use to relieve her nasal "stuffiness." the nurse bases the answer on the most likely cause of the congestion, which is attribute to which hormone?

estrogen

a nurse is preparing a presentation for a local community group about preventing traumatic brain injury. the nurse would discuss which measure as prevention of the leading cause?

falls prevention

the nurse is assessing the anterior fontanelle of a 4-month-old infant brought to the clinic for a well-child examination. what would the nurse expect to find?

flat fontanelles

when assessing the knee join of a client, a nurse also explains about the typical motions associated with that joint. what would the nurse include?

flexion

a nurse is preparing to assess a client's cerebellar function. what aspect of neurologic function should the nurse address?

balance

the nurse is assessing the skin condition and color of an African American client. what would the nurse document as an abnormal finding?

ashen gray skin color

the nurse's assessment of a child's hair reveals that it is clean and neatly trimmed but exceptionally dry and brittle. what is the nurse's best response to this finding?

assess the child for signs and symptoms of impaired nutrition

the nurse is performing an assessment of a client's musculoskeletal system. what would the nurse examine first?

gait

When talking to a client before starting the physical exam, the nurse notes that the client consistently tilts her head to one side. What would the nurse examine first?

hearing acuity

a client presents with a cluster of upper airway complaints that include rhinorrhea. which area of assessment would yield the most pertinent information to the etiology of rhinorrhea?

history of allergies

when assessing a newborn, the nurse observes that the infant's hands and feet are bluish in color. how would the nurse interpret this finding?

ineffective temperature regulation

a nurse is assessing a 49-year-old client who questions the nurse's need to know about sunburns he experienced as a child. how should the nurse best explain the rationale for this subjective assessment?

"having bad sunburns when you're a child puts you at risk for skin cancer later in life."