FHA Questions
The nurse is assessing the muscle strength in the patient's left hand and notes active motion against some resistance. How would the nurse document this finding? A. 2 B. 3 C. 5 D. 4
4
During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as "absent" bowel sounds the nurse should listen in each quadrant for at least how long? A. 1 minute B. 10 minutes C. 2 minutes D. 5 minutes
5 minutes
A 40 year old male patient states that his physician told him he has a hernia and asks the nurse to explain what a hernia is. Which of the following responses is most appropriate? A. A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles B. The hernia is a result of prenatal growth abnormalities that are just now causing problems C. No need to worry, most men your age develop hernias D. I'll have to have your physician explain this to you
A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles
Which person would be considered at highest risk for development of a deep vein thrombosis? A. A person who is taking an anticoagulant medication B. A women in her 2nd month of pregnancy C. A person with a 20 pack-year smoking history D. A person who has been on bedrest for 5 days
A person who has been on bedrest for 5 days
The nurse is assessing a young women who has sprained her left ankle. What is the definition of a sprain? A. A stretched or torn muscle B. A stretched or torn ligament C. A stretched or torn fascial membrane D. A stretched or torn tendon
A stretched or torn ligament
Which abdominal assessment finding is expected? A. The presence of a bruit in the femoral area B. A palpable spleen between the ninth and eleventh ribs in the left midaxillary line C. A tympanic percussion note in the umbilical region D. A tympanic percussion note in the right upper quadrant at the midclavicular line
A tympanic percussion note in the umbilical region
What type of ROM is used to assess muscle strength? A. Active B. Active-assisted C. Active-resisted D. Physiologic
Active-resisted
A client who hit his head after falling from his roof has a Glasgow Come Scale score of 15. Based on this information, the nurse expects the client to be: A. Comatose B. Unable to close his eyes C. Confused D. Alert and oriented
Alert and oriented
Although a full mental status examination may not be required during a neuro assessment, you must be aware of the four main categories of the assessment while performing the health history interview and general survey. Which of the following contains the names of the four categories? A. Memory, attention, thought content, and perceptions B. Language, orientation, attention, and abstract reasoning C. Mood, affect, consciousness, and orientation D. Appearance, behavior, cognition, and thought processes
Appearance, behavior, cognition, and thought processes
During a routine office visit, a patient takes off his shoes and shows the nurse a lesion on his foot that has been there for four weeks. On inspection, the nurse notes a 3 cm round ulcer on the left medial malleolus. It has a pale, ischemic base, well-defined edges, and no drainage. What is likely to be the problem? A. Arterial Ulcer B. Venous Insufficiency C. Raynaud's disease D. Impetigo
Arterial Ulcer
During the abdominal assessment, the nurse tests for a fluid wave. Which condition is the most common cause of an abdominal wave? A. Distended bladder B. Ascites C. Splenomegaly D. Hepatoma
Ascites
During auscultation of a patient's breath sounds, the nurse hears an unfamiliar sound. What should the nurse do next? A. Describe the findings in the patient's record and report them to the oncoming shift B. Ask another nurse to listen to validate the findings C. Wait 30 minutes and auscultate again D. Report the observations to the physician immediately
Ask another nurse to listen to validate the findings
A nurse is obtaining a patient's radial pulse and identifies that its rhythm is irregular. What should the nurse do next? A. Take the pulse in the opposite arm B. Assess the apical pulse C. Notify the patient's primary care provider D. Obtain the patient's blood pressure
Assess the apical pulse
The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding? A. Graphesthesia B. Astereignosis C. Tactile discrimination D. Extinction
Astereignosis
The nurse is assessing a patient's gait. Which factors should the nurse observe as the patient ambulates in the room? Select all that apply Base of support Stride Posture Arm Swing Breathing
Base of support Stride Posture Arm Swing Breathing
You note that an adolescent has uneven shoulder height. To differentiate functional from structural scoliosis, you ask the patient to A. Shrug both shoulders while you provide resistance B. Bend forward at the waist while you palpate the spine C. Flex the elbow and pull against your resistance D. Stand up straight while you check the height of the iliac crest
Bend forward at the waist while you palpate the spine
The nurse is assessing flexion in Mr. Russell's hip. What instructions would the nurse give to Mr. Russell to complete the assessment? A. Bend your knee to your chest, and then put it against your abdomen B. Lie flat, and then bend your knee and move your lower leg toward the midline C. Lie face down, and then bend your knee and lift it up D. Lie flat, and then move your lower leg away from the midline
Bend your knee to your chest, and then put it against your abdomen
During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a bruit with the bell of the stethoscope over the left carotid artery. Which of the following is most likely the cause of this sound? A. A valvular disorder B. Blood flow turbulence C. Fluid volume overload D. Ventricular hypertrophy
Blood flow turbulence
While the nurse performs formal patient assessment, assistive personnel often observe changes when obtaining vital signs or assisting patients with ADLs. When discussing care for a patient with low back pain, the nurse should particularly alert the assistant to watch for: A. Dizziness B. Difficulty swallowing C. Arm weakness D. Bowel or bladder incontinence
Bowel or bladder incontinence
Asthma is associated with a wheezing lung sound. Which of the following is the cause of wheezing? A. Decreased mucus production B. Pneumothorax C. Pleural effusion D. Bronchoconstriction
Bronchoconstriction
Which of the following would be an unexpected clinical finding in a patient with bronchitis due to infectious agents or allergies? A. Clubbing of the fingers B. Dyspnea C. Bronchospasm D. Crackles
Clubbing of the fingers
The nurse is assessing an early adult aged man who complains of instability in his right knee. What structure is the most likely cause of knee instability if it becomes injured or diseased? A. Patellar tendon B. Medial and lateral mensci of the knee C. Cruciate ligaments within the knee D. Articular cartilage of the knee
Cruciate ligaments within the knee
A nurse is assessing an adult who is comatose after a head injury. In response to stimulus he has spastic muscle tone with flexion of the upper limbs and extension of the lower body. How would this be described? A. Decorticate posturing B. Decerebrate posturing C. Flaccid quadriplegia D. Flaccid paraplegia
Decorticate posturing
Which finding is normal when assessing the respiratory system of an elderly adult? A. Bronchovesicular breath sounds throughout the lungs B. Decreased mobility of the thorax C. Increased thoracic expansion D. Decreased anteroposterior diameter
Decreased mobility of the thorax
Which of the following describes Parkinson's Disease? A. Deficit of dopamine and degeneration of the basal ganglia B. Degeneration of motor fibers is the spinothalamic tracts C. Deficiency of acetylcholine in the neuromuscular junctions D. Excess secretion of stimulatory neurotransmitters in the sympathetic nervous system
Deficit of dopamine and degeneration of the basal ganglia
What are the predominant symptoms of right-sided heart failure? A. Dependent edema and fluid weight gain B. Pulmonary edema, cyanosis, and tachypnea C. Polyuria and polydipsia D. Venous stasis and deep vein thrombosis
Dependent edema and fluid weight gain
The nurse is caring for a patient newly admitted with a spinal cord injury. What is the primary goal the nurse will focus on after the patient has been physically stabilized? A. Prepare for the management of neurogenic shock B. Reduce the amount of cellular injury and death C. Achieve spinal mobilization D. Detemine the extent of paralysis
Detemine the extent of paralysis
The nurse is educating a patient on the effects of prolonged immobility. What physiologic change(s) would the nurse describe to Mr. Russell? Select all that apply Development of deep vein thrombosis Decreased muscle mass Increased inspiratory effort Decreased muscle protein synthesis Bone demineralization Increased muscle catabolism
Development of deep vein thrombosis Decreased muscle mass Increased inspiratory effort Decreased muscle protein synthesis Bone demineralization
The nurse is completing passive range of motion exercises and bends the patient's foot so that the toes point upward. Which joint movement has the nurse performed? A. Dorsiflexion B. Abduction C. Adduction D. Plantar flexion
Dorsiflexion
The nurse is percussing over the lungs of a patient with pneumonia. Which of the following percussion sounds would be expected over an area of atelectasis in the lungs? A. Hyperresonance B. Tympany C. Resonance D. Dullness
Dullness
The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound would you expect to hear? A. Resonance B. Hyperresonance C. Dullness D. Tympany
Dullness
Which of the percussion findings would the nurse expect to find in a patient with a large amount of ascites? A. Tympany in the right and left lower quadrants B. Hyperresonance in the left upper quadrant C. Dullness across the abdomen D. Flatness in the right upper quadrant
Dullness across the abdomen
Which term would the nurse use to document that a patient is having difficulty swallowing medications and food? A. Anorexia B. Dysphasia C. Aphasia D. Dysphagia
Dysphagia
A client is admitted completely immobilized by an acute exacerbation of multiple sclerosis. Two days after admission, the client cries frequently and refuses to see family members. For this client, the nurse identifies a nursing diagnosis of Hopelessness. To address this diagnosis, which intervention should the nurse include in the patient's care plan? A. Reinforce the client's responsibility to the family B. Encourage the client to verbalize his feelings C. Obtain an order for a sedative D. Limit visitors to 15 minutes/day
Encourage the client to verbalize his feelings
The nurse is preparing to assess a newly-hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment? A. Have the patient lie down to obtain an accurate cardiac, respiratory, and abdominal assessment B. Perform a complete history and physical assessment immediately to obtain baseline information C. Obtain through history and physical assessment information from the patient's family member D. Examine body areas appropriate to the problem and then complete the assessment after the symptoms have resolved
Examine body areas appropriate to the problem and then complete the assessment after the symptoms have resolved
When performing a respiratory assessment on a patient, the nurse observes that the patient's costal angle is 100 degrees. Which of the following is true about the finding? A. Expected in patients who have a pleural effusion B. Expected in patients who have emphysema C. Expected in patients who have enlarged hearts D. Expected in health adults
Expected in patients who have emphysema
A nurse is caring for a client with a recent diagnosis of amyotrophic lateral sclerosis. Which of the following psychosocial issues should the nurse encourage the client to discuss when appropriate? Select all that apply. Fears about losing mobility Anger about his diagnosis Information regarding advance directives Possibility about losing mobility
Fears about losing mobility Information regarding advance directives Possibility about losing mobility
A patient complains of feeling "full" has a distended abdomen, and has not had a bowel movement "for several days." The performs a digital examination of the rectum and notes that the patient has hard feces in the rectum. Which condition does the patient most likely have? A. Rectal abscess B. Rectal prolapse C. Fecal impaction D. Rectal polyp
Fecal impaction
The nurse is completing passive range of motion on a stoke victim. What movements would the nurse expect to complete at the elbow joint? A. Flexion, extension, supination, pronation B. Abduction, adduction, circumduction, rotation C. Flexion, hyperextension, rotation D. Flexion, extension, abduction, adduction
Flexion, extension, supination, pronation
Which of the following is the usual cause of melena? A. Overuse of laxatives B. Gastrointestinal bleeding C. Bleeding hemorrhoids D. Gallbladder
Gastrointestinal bleeding
The nurse is assessing a patient's range of motion and notes a limitation in the movement of the elbow joint. Which tool would the nurse use to measure the degree of movement in the joint? A. Reflex hammer B. Metric ruler C. Tape measure D. Goinometer
Goinometer
A nurse is caring for an older adult and suspects that the patient is experiencing hypovolemia caused by dehydration. What finding supports this? A. Grade 1 Pulse B. Distended Neck Veins C. Bradycardia D. An S4 heart sound
Grade 1 Pulse
A patient has had a spinal cord injury that resulted in permanent paralysis of his lower body (paraplegia). This condition causes immobility and places him at risk for which of the following complications? Select all that apply Hallucinations Pressure Ulcers Contractures Bowel and bladder incontinence
Hallucinations Pressure Ulcers Contractures Bowel and bladder incontinence
The nurse is describing a weak, thready pulse on the documentation flow sheet. Which statement is correct? A. Greater than normal force, then collapses suddenly B. Rhythm is regular but force varies C. Easily palpable, pounding under the fingertips D. Hard to palpate, easily obliterated by pressure
Hard to palpate, easily obliterated by pressure
What is the purpose of the blood brain barrier? A. Active and passive ROM B. Muscle strength C. History of current complaint D. Height, weight, and vital signs
Height, weight, and vital signs
A patient diagnosed with a cerebrovascular accident has CAT scan results that showed a burst aneurysm present in the middle cerebral artery. What type of CVA did this patient have? A. Hemorrhagic B. Vasogenic C. Ischemic D. Septic
Hemorrhagic
The nurse performs BP screening at the local community center. As part of the health promotion intervention, the nurse also discuss the following risk factors for stroke: A. Low BP, lack of exercise, and diet high in fat B. Diet high in fat, smoking and walking five times weekly C. High BP, diet high in fat, and smoking D. Obesity, swimming five times weekly, high BP
High BP, diet high in fat, and smoking
A patient has been admitted to the emergency department for a suspected drug overdose. His respirations are shallow and irregular at a rate of 8 per minute. The nurse interprets this respiratory pattern as which of the following/ A. Cheyne-Stokes B. Kussmaul's pattern C. Tachypnea D. Hypoventilation
Hypoventilation
The nurse is educating a patient on how to prevent falls. Which statement, if made by the patient, indicates that he understood the teaching? A. It is okay if I walk barefoot as long as I am in my room B. I should keep my walker by the door so it is easily accessible C. I only have to use my walker if I am feeling unsteady D. I should press my call light when I want to get out of bed
I should press my call light when I want to get out of bed
When performing an assessment, a nurse indentifies the following signs and symptoms: impaired coordination, decreased muscle strength, limited range of motion, and the clients reluctance to more. Which nursing diagnosis do these signs and symptoms indicate? A. Disturbed sensory perception B. Impaired physical mobility C. Deficient knowledge D. Health-seeking behaviors
Impaired physical mobility
Which topics will the nurse include when preparing education for a patient who has experienced a complete spinal cord separation injury at the T8 level? Select all that apply Incontinence of bowel and bladder Acute hypotension Risk of deep vein thrombosis Increased risk of urinary tract infections Risk of pressure ulcers Respiratory distress Increased pain sensations in the legs
Incontinence of bowel and bladder Acute hypotension Risk of deep vein thrombosis Increased risk of urinary tract infections Risk of pressure ulcers Respiratory distress
What is the most likely cause of a dull note when percussing over the lungs? A. Increased density of lung tissue B. Decreased adipose tissue C. Normal lung tissue D. Shallow breathing
Increased density of lung tissue
A 65-year-old patient experienced pain in his left calf after up ten steps to his apartment. When he sits down and rests, the pain disappears. Which of the following is most likely to be the cause? A. Ischemia caused by partial blockage of an artery supplying the left leg B. Ischemia caused by complete blockage of an artery supplying the left leg C. Claudication due to a varicose vein in his left leg D. Claudication due to a deep vein thrombosis in his left leg
Ischemia caused by partial blockage of an artery supplying the left leg
Which statement describes a correct understanding of the reason auscultation of the abdomen should be done before percussion and palpation? A. It allows better determination of ares of tenderness B. It will prevent distortion of bowel sounds that might be stimulated by percussion and palpation C. It allows the patient time to relax and be more comfortable during the physical examination D. It prevents distortion of vascular sounds such as an aortic bruit that might occur after percussion and palpation
It will prevent distortion of bowel sounds that might be stimulated by percussion and palpation
The nurse is assessing a patient's point of maximal impulse of PMI. What is true regarding the PMT? A. It should normally be palpable in the anterior axillary line B. It is palpable in all adults C. It occurs with the onset of diastole D. Its location is indicative of heart size
Its location is indicative of heart size
A patient is complaining of severe, sharp pain at the left costovertebral angle. For which condition is this symptom commonly seen? A. Liver enlargement B. Peptic ulcer disease C. Pleural effusion D. Kidney inflammation
Kidney inflammation
The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation? A. In the groove behind behind the medial malleolus B. Above the lateral malleolus C. Lateral to the extensor tendon of the great toe D. Behind the knee
Lateral to the extensor tendon of the great toe
A 26-year old man was in a motor vehicle accident and suffered a complete spinal cord injury to L3. The nurse assesses the patient for loss of motor function in the: A. Arms B. Legs C. Abdomen D. Chest
Legs
The nurse will identify both active range of motion (ROM) and physical exercise as an important part of the continuous treatment for a paraplegia patient. What is the primary goal for these interventions? A. Preserving a healthy sense of self-esteem B. Maintaining as much movement and upper body strength as possible C. Providing a health outlet for the management of physical stress D. Creating a social outlet that support emotional well-being
Maintaining as much movement and upper body strength as possible
The nurse is assessing a patient for fall risk. Which factors would place the patient at a higher risk for falls? Select all that apply Use of more than 4 prescription medicines Male gender Gait or balance impairment Depression Age 60 or over
Male gender Gait or balance impairment Depression Age 60 or over
When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the apex of the heart are: A. Mitral and pulmonic B. Mitral and tricuspid C. Aortic and pulmonic D. Tricuspid and aortic
Mitral and tricuspid
A patient who suffers from Amyotrophic lateral sclerosis (ALS) is learning information about it. What statement by the patient would indicate he needs more teaching? A. Cognitive function remains normal even in advanced stages B. Upper motor neurons of the spinal cord and brain are destroyed C. Neuromuscular junctions are destroyed D. It is also know as Lou Gehrig's disease
Neuromuscular junctions are destroyed
The nurse is performing a general survey. Which actions are components of the general survey? A. Observing specific body systems while performing the physical assessment B. Observing the patient's body stature and nutrition C. Measuring the patient's temperature, pulse, respirations, and blood pressure D. Interpreting the subjective information the patient has reported
Observing specific body systems while performing the physical assessment
A patient has a respiratory rate of 24 with mildly labored breathing. The nurse raises the head of the patient's bed, but the patient's breathing does not improve. What should the nurse do next? A. Call the patient's primary health-care provider B. Perform postural drainage C. Administer 100% oxygen D. Obtain vital signs and pulse oximetry
Obtain vital signs and pulse oximetry
Which finding is the most likely cause of unequal chest expansion in inspiration? A. The patient is morbidly obese B. Fluid accumulation from pulmonary edema C. Accessory muscles are being used to improve respirations D. Part of the lung is obstructed or collapsed
Part of the lung is obstructed or collapsed
A patient who has had a stroke causing right side hemiplegia asks the nurse. "What is the purpose of these passive range of motion (ROM) exercises? I can move my own arms and legs? What is the best response by the nurse? A. Range of motion exercises help prevent skin breakdown on your heels and elbows B. You need to exercise your muscles in the bed because you are not allowed to ambulate C. These exercises are necessary to prevent clots from forming in your extremities D. Passive range of motion exercises will help you maintain mobility in your joints
Passive range of motion exercises will help you maintain mobility in your joints
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. Auscultation and percuss in the inguinal region C. Inspect and palpate in the epigastric region D. Percuss and palpate the midline area above the suprapubic bone
Percuss and palpate the midline area above the suprapubic bone
What is the expected response when testing the Achilles Tendon reflex? A. Flexion of the knee joint B. Dorsal flexion of the ankle joint C. Extension of the knee joint D. Plantar flexion of the ankle joint
Plantar flexion of the ankle joint
During an assessment of muscle strength, the patient is unable ti effectively move the legs individually against the resistance provided by the nurse. Which instruction will the nurse provide to continue to evaluate the patient's muscle strength? A. Push against my hands with both your legs at the same time B. I'm going to move your leg through its range of motion (ROM) C. Please lift you leg up off the exam table D. Let's retest you leg strength at the end of the examination
Please lift you leg up off the exam table
If the great toe extends upward upward and the other toes fan out in response to stroking the lateral aspect of the sole of the foot, this is documented as which of the following? A. Cushing response B. Hyporeflexia C. Positive Babinski sign D. Normal plantar reflex (negative babinski)
Positive Babinski sign
When the nurse asks a 58-year-old patient to stand with feet together, arms at his side, and his eyes closed, he starts to sway and moves his feet further apart. How is this finding documented? A. Positive Huntington's Chorea sign B. Positive Murphy's sign C. Positive Romberg Sign D. Positive Clonus
Positive Romberg Sign
The nurse is educating Ms. Johnson's mother on how to effectively provide passive range of motion (ROM) exercises. Which instruction will have the greatest impact on the patient's potential risk for injury? A. Place the patient in a supine position B. Wear gloves when engaging in the exercise routine C. Provide the affect joint with support during exercise D. Keep the bed's side rails up as the individual joints are exercised
Provide the affect joint with support during exercise
The nurse observes that a patient is coughing up frothy, pink sputum. Which condition is this usually associate with? A. Pneumothorax B. Pulmonary edema C. Tuberculosis D. Croup
Pulmonary edema
The patient with a deep vein thrombosis (DVT) in the left thigh is being assisted back to bed after using the bathroom. She starts complaining of a sudden, sharp chest pain and shortness of breath. Her vital signs demonstrate hypoxia with a low oxygen saturation. Which of the following is the severe, life-threatening condition that can originate from a DVT? A. Pulmonary embolism B. Pulmonary edema C. Pulmonary hypertension D. Congestive heart failure
Pulmonary embolism
Which term describes the loss of motor function from a transection injury to the cervical region of the spinal cord? A. Hemiplegia B. Spastic Paralysis C. Quadriplegia D. Paraplegia
Quadriplegia
The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? A. Murphy's sign and Blumberg's sign B. Iliopsoas muscle test and check for fluid wave C. Rebound tenderness and iliopsoas muscle test D. Murphy's sign and fluid wave
Rebound tenderness and iliopsoas muscle test
A mom brings her 3-month-old child to the clinic for evaluation of a cold. She tells the nurse that the baby has had a runny nose for a week. The nurse notes nasal flaring and sternal and intercostal retractions. What is the next thing that needs to be done? (Hint: Think Maslow's, ABCs, Priority level) A. Recognize that these are serious signs and contact the physician B. Assure the mother that these are normal symptoms of a cold C. Perform a complete cardiac assessment because these may be signs of a cardiac abnormality D. Ask the mother if the infant has had trouble with feedings
Recognize that these are serious signs and contact the physician
A patient with a spinal cord injury and paraplegia requires intermittent bladder catheterization every 4 hours, Which nursing intervention is needed for the management of a commonly associated complication? A. Record the amount and color of urine emptied from the bladder at each catheterization B. Turn and position every 2 hours C. Assess temperature every 8 hours D. Perform passive rang of motion at least twice daily
Record the amount and color of urine emptied from the bladder at each catheterization
A nurse is caring for a patient with active tuberculosis. What color of sputum should the nurse anticipate the patient to expectorate (cough up)? A. Red, Rusty B. White C. Yellow-Green D. Pink, frothy
Red, Rusty
For a client with a compound fracture, which nursing diagnosis should the nurse give the highest priority? A. Imbalanced nutrition: less than body requirements B. Risk for infection C. Impaired physical mobility D. Activity intolerance
Risk for infection
A patient in a nursing home is admitted with a diagnosis of dementia. He started a fire because he was cooking at home and forgot that he left a pan on the stove. The nursing diagnosis that is highest priority is: A. Risk for injury B. Ineffective brain tissue perfusion C. Acute confusion D. Impaired memory
Risk for injury
When listening to heart sounds, which of the following is correct about S1? A. S1 coincides with the carotid artery pulse B. S1 is louder than S2 at the base of the heart C. S1 indicated the beginning of diastole D. S1 is caused by the closure of the semilunar valves
S1 coincides with the carotid artery pulse
A client, gravida 1, para 0, is 9 weeks pregnant. She states,"I can't believe I'm pregnant. I just started a new job!" What is the most accurate evaluation of the statement? A. She desires an abortion B. She may have difficulty bonding with the neonate C. She is depressed about the pregnancy D. She is expressing ambivalence
She is expressing ambivalence
When assessing a patient's major risk factors for heart disease, which of the following series of factors would the nurse include? A. Family History, hypertension, stress, age, hyperlipidemia B. Personality type, hypercholesterolemia, diabetes, smoking C. Smoking, hypertension, obesity, diabetes, hypercholesterolemia D. Alcohol consumption, obesity, diabetes, stress, hyperlipidemia
Smoking, Hypertension, Obesity, Diabetes, Hypercholesterolemia
A nurse is assessing a patient's muscle tone. The patient was asked to relax his muscles as much as possible. The nurse palpates the bodies of the muscles being tested, following with passive range of motion. Which result would the nurse expect to find? A. Flaccidity with no resistance to movement B. Soft muscles, with mild, even resistance to movement C. Resistance and pain with movement D. Hypertonic muscles and firm resistance to movement
Soft muscles, with mild, even resistance to movement
The patient's muscle tone is hypertonic so the muscles are stiff and the movements are awkward. The nurse documents these findings as: A. Spasicity B. Fasciculation C. Atony D. Tremors
Spasicity
When a nurse uses deep palpation for assessing the left upper quadrant, which structure is most likely to be involved if tenderness is present in the area? A. Cecum B. Sigmoid colon C. Spleen D. Gallbladder
Spleen
A nurse is caring for a patient who is experiencing a laryngeal spasm. Which clinical finding would the nurse expect with this patient? A. Rhonchi B. Wheeze C. Crackles D. Stridor
Stridor
A 47-year-old women states she is having vertigo and some difficulty with balance. The nurse should assess: A. Shoulder strength B. The whisper test C. Accomodation D. Soft touch
The whisper test
When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes with inspiration being longer than expiration. Which statement is true about these findings? A. These are bronchovesicular breath sounds and are normal in that location B. These sounds are normally auscultated over the trachea C. These are bronchi breath sounds and are normal in that location D. These are vesicular breath sounds and are normal in that location
These are vesicular breath sounds and are normal in that location
Which statement about bronchial breath sounds is true? A. They are expected over the trachea B. They are expected over the bronchi C. They are always pathological D. They are expected over the small airways and alveoli
They are expected over the trachea
The nurse is performing an assessment on an adult who has venous insufficiency of the legs and feet. Vital signs are normal, and the capillary refill time of the toes is 2 seconds. Which of the following is correct? A. The capillary refill time is not significant in a patient with venous disease B. This is an abnormal capillary refill time for someone with venous disease C. This is a normal capillary refill time that requires so further assessment D. This is a delayed capillary refill and should be investigated further
This is a normal capillary refill time that requires so further assessment
The nurse is preparing a modified Allen test. What is an appropriate reason for this test? A. To evaluate the adequacy of capillary patency before venous blood draws B. To evaluate the adequacy of lymphatic drainage from the hand and forearm C. To evaluate the adequacy of collateral circulation before using the radial artery for arterial BP monitoring D. To evaluate the venous refill rate that occurs after the ulnar and radial arterial are temporarily occluded
To evaluate the adequacy of collateral circulation before using the radial artery for arterial BP monitoring
Which procedure is used to assess the carotid arteries of an elderly patient? A. Palpate both arteries simultaneously to compare amplitude B. Instruct the patient to take slow deep breaths during auscultation C. Palpate the artery in the upper one third of the neck D. Use the stethoscope bell to auscultate the carotid arteries
Use the stethoscope bell to auscultate the carotid arteries
Use of the Glasgow Coma Scale (GCS) provides relatively objective of the Level of Consciousness (LOC). The three functions assessed are: A. Eye opening, motor response, and sensation B. Verbal response, eye opening, and motor response C. Verbal response, pupil retraction, and motor response D. Pupil reaction, orientation, and sensation
Verbal response, eye opening, and motor response
The chart states that a 62-year-old woman has had a stroke in the right parietal area of the brain. The nurse expects to note which of the following? A. Tremors on the left side of the face B. Tremors on the right side of the face C. Weakness in the left arm D. Weakness in the right arm
Weakness in the left arm
The nurse is completing a health history on a patient reporting musculoskeletal pain. Which questions would be appropriate for the nurse to include in the interview? Select all that apply. What type of job do you have? Do you exercise regularly? Have you experienced any previous injuried to you joints? What medications are you currently taking? Have you had any recent weight gain?
What type of job do you have? Do you exercise regularly? Have you experienced any previous injuried to you joints? What medications are you currently taking? Have you had any recent weight gain?
A patient with diabetes is admitted to the hospital with the concurrent diagnosis of peripheral vascular disease. Which assessment finding indicates that the vascular impairment is VENOUS rather than arterial? Select all that apply A. An ulceration is present on the right heel and is bright pink, moist and oozing B. 3+ pitting edema is present C. The skin of the lower extremities is erythematous D. An ulceration is present on the left preorbital region that is dry with a pale wound bed
n ulceration is present on the right heel and is bright pink, moist and oozing 3+ pitting edema is present The skin of the lower extremities is erythematous An ulceration is present on the left preorbital region that is dry with a pale wound bed