HA hesi kahoot

The nurse notes documentation that a client is exhibiting shine, stokes respirations. On assessment of the client, the nurse should expect to note which finding? a) rhythmic, respirations with periods of apnea b) regular, rapid and deep, sustain respiration c) totally irregular, respirations with rhythm and depth d) irregular, respirations with pauses at the end of inspiration and expiration

a) rhythmic, respirations with periods of apnea

The nurse is preparing to check the breath sound of a client. When auscultating for bronchovesicular breath sounds, the nurse should plays the set the scope over which area? a) the major bronchi b) the trachea and larynx c) the peripheral lung fields d) the lower posterior thorax

a) the major bronchi

The community health nurse with instructing a group of young female clients about breast, self examination. The nurse instruct the client to perform the examination at which time? a) at the onset of menstruation b) every month during ovulation c) weekly at the same time of the day d) one week after menstruation begins

d) one week after menstruation begins

A home care. Nurse is assessing a client activities of daily living after a stroke. What should the nurse include in the clients focused assessment? a) ability to drive a car b) the normal every day routine in the home c) ability to do light or heavy house, work, and pay bills d) self-care, needs such as toileting, feeding an ambulating

d) self-care, needs such as toileting, feeding an ambulating

A client experiencing "skipped heartbeats" is diagnosed with a benign premature vesicular contractions and is placed on metoprolol tartrate. The client returns to the healthcare providers office one month later for a checkup. the nurse should implement which type of database when performing an assessment? b) emergency database c) complete health database d) problem centered database

a) follow up database

The nurse is testing a client for astereogenosis. The nurse should ask the client to close the eyes and perform which action? a) identify an object placed in the clients hands b) identify three numbers or letters trace on the client c) state weather, one or two pin pricks, are felt when the skin is pricked bilaterally in the same place d) identify the smallest distance between two detectable pin pricks, made with two pins held at various distances

a) identify an object placed in the clients hands

The nurse is instructing a client in breast, self examination. The nurse tells a client to lie down and examine the left breast. The nurse should instruct the client that while examining the left breast she should place a pillow under which area? a) left shoulder b) right scapula c) right shoulder d) small of the back

a) left shoulder

The nurse is preparing to measure the apical pulse on unassigned client. The nurse place is a diaphragm of the stethoscope over which cardiac site? a) mitral area b) right atrium c) right ventricule d) pulmonic valve

a) mitral area

The nurse is providing care to a client admitted for coronary artery, disease and history of tobacco use. What is the most important element of the nurses focused assessment of the client smoking history? a) number of packs per year b) desire to quit smoking c) brand of cigarette used d) number of pass attempts to quit smoking

a) number of packs per year

The nurse is preparing to interview a client to collect data about the clientele history. The nurse should take which action to make sure that the physical environment is ready? Select all that apply. a) provide sufficient lighting b) set the room temperature at a comfortable level c) ensure that the distance between the nurse in the client is no more than 2 feet (60 cm). d) arrange seating so that the nurse sits behind the desk across from the client e) make sure that the client will be seated comfortably at eye level with the nurse f) leave equipment needed for the physical exam on the desk so it is readily available

a) provide sufficient lighting b) set the room temperature at a comfortable level e) make sure that the client will be seated comfortably at eye level with the nurse

The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. using a flashlight, the nurse would perform which action to obtain the assessment data? a) turn the flashlight on directly in front of the eye and watch for a response b) ask the client to follow the flashlight through the six cardinal position of gaze c) instruct the client to look straightahead, and then shut the flashlight from the temporal area to the eye d) check, pupil size, and then ask the client to alternate, looking at the flashlight and then examiners finger

b) ask the client to follow the flashlight through the six cardinal position of gaze

The nurse is planning to test the sensory function of the olfactory nerve (I). The nurse would gather which item to perform a test? a) tuning fork and audio meter b) cloves, peppermint, and coffee grounds c) flashlight in pupil size chart d) safety pin, hot water, and a cotton wisp

b) cloves, peppermint, and coffee grounds

A client nurse is performing a cardiovascular assessment on a client and auscultates the chest over the apex of the heart. the nurse document this, finding as which sound? a) ventricular sound b) first heart sound, S1 c) third heart sound, S3 d) fourth heart sound, S4

b) first heart sound, S1

The nurse in a healthcare clinic is preparing to test a client for accommodation. Initially, the nurse should ask the client to take which action? a) raise 1 finger when the sound is heard b) focus on a distant object c) close 1 eye and read letter on a chart d) focus on a close object

b) focus on a distant object

The nurse is performing a physical assessment of a clients musculoskeletal system and notes that the client is right handed. The nurse with document which assessment finding as normal? Select all that apply. a) presence of fasciculation b) muscle strength graded 5/5 c) symmetrical movement bilaterally d) increased muscle size on the dominant arm e) A 1cm hypertrophy of the right upper arm

b) muscle strength graded 5/5 c) symmetrical movement bilaterally d) increased muscle size on the dominant arm e) A 1cm hypertrophy of the right upper arm

The nurse is preparing to performance auto scopic examination on an adult client. Which action should the nurse take to perform this examination? a) pull the earlobe down and back before inserting speculum b) pull the pinna I've been back before inserting speculum c) use the smallest speculum available to decrease exam discomfort d) tilt the clients head forward and down before inserting speculum

b) pull the pinna up and back before inserting speculum

The nurse is assessing for changes in skin color in a dark skin client. The nurse find which area helpful in assessing for pallor or cyanosis? Select all that apply. a) sclerae b) tongue c) nail beds d) elbows and heels e) mucous membranes

b) tongue c) nail beds d) elbows and heels

A nursing student is asked about the procedure used to elect Homans sign. Which response by the student indicates an understanding of this assessment technique? a) "I will ask the client to raise the legs up to the waist, and then lower the leg slowly" b) "I will ask the client to raise the legs and try to lower them against pressure for my hands" c) "I will ask the client to extend the legs flat on the bed, and I will gently dorsiflex the foot forward" d) "I will ask the client to extend the legs flat on the bed, and I will grass the foot and sharply extend it backwards"

c) "I will ask the client to extend the legs flat on the bed, and I will gently dorsiflex the foot forward"

The nurse is reviewing a client record and notes that the result of a vision test using a snow chart is 20/30. How should the nurse explain these results to the client? a) "you have normal vision" b) "you have some degree of blindness" c) "you can read at a distance of 20 feet what a person with normal vision can read at 30" d) "you can read at a distance of 30 feet would a person with normal vision can read at 20 feet"

c) "you can read at a distance of 20 feet what a person with normal vision can read at 30"

The nurse is preparing to perform an abdominal examination on a client. The nurse should place a client in which position for this examination? a) Sims position b) supine with head and feet flat c) Supine with the head of the bed, raised in the knees, slightly flexed d) semi Fowlers position with the head of bed raise 45° and knees flexed

c) Supine with the head of the bed, raised in the knees, slightly flexed

A client diagnosed with the conductive hearing loss. Ask the nurse to explain the cause of the hearing problem. The nurse plans to explained to the client that the condition is caused by which problem? a) a defect in the cochlea b) a defect in cranial nerve VII c) a physical obstruction to the transmission of sound waves d) a defect in the sensory fibers that lead to the cerebral cortex

c) a physical obstruction to the transmission of sound waves

The nurse is performing a neurological assessment on a client and Alexa positive Romberg sign. The nurse makes this determination based on which observation? a) and involuntary rhythmic, rapid, twitching of the eyeballs b) a dorsiflexion of the ankle and great toe with fanning of the other toes c) a significant sway when the client stand erect with feet together, arms at the side, and the eyes closed d) a lack of normal sense of position when the client is unable to return, extended fingers to a point of reference

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

which action will the nurse take to test cranial nerve XI, the spinal accessory nerve? a) ask the client to clench the teeth b) ask the client to read the letters in a line on the snell chart c) ask the client to shrugged his shoulders against the nurses resistance d) ask the client to close the eyes, occlude, one nostril, and identify specific odor such as coffee

c) ask the client to shrugged his shoulders against the nurses resistance

the nurse would perform which action to asses for a pulse deficit? a) count the carotid pulsations for one full minute b) measure the blood pressure in both the arm and the leg c) auscultate the apical HR while palpating the radial artery d) place the diaphragm of the stethoscope directly over the skin at the mitral area

c) auscultate the apical HR while palpating the radial artery

The nurse performs a physical assessment on a client and gathers both subjective and objective data. Which would the nurse document as subjective data? a) pedal pulses are present b) temp is 99.6 c) client reports difficulty sleeping at night d) client has an apical pulse rate of 56 BPM

c) client reports difficulty sleeping at night

A nursing student is performing a respiratory assessment on a female dog client, and is assessing for tactile fremitus. Which action by the nursing student indicates a need for further teaching? a) palpate over the lung apices in the sub clavicular area b) asking the client to repeat the word 99 during palpation c) palpating over the breast tissue to assess and compare vibrations from one side to the other d) comparing vibrations from one side to the other as a client repeats the word 99

c) palpating over the breast tissue to assess and compare vibrations from one side to the other

The nurse is assessing a client muscle strength, the nurse at the client to hold the arm up and supinated, and then ask the client to close the eyes. The clients left hand turns and moves downward slightly. The nurse interprets this to mean that the client has, which condition? a) ataxia b) nystagmus c) pronator drift d) hyperreflexia

c) pronator drift

The nurse is performing an abdominal assessment on a client. The nurse determines that which findings should be reported to the healthcare provider.? a) absence of bruit b) concave, midline umbilicus c) pulsation between the umbilicus and the pubis d) bowel sound frequency of 15 sounds per minute

c) pulsation between the umbilicus and the pubis

A client is diagnosed with external Otitis. Which finding would the nurse expect to note on assessment of the client? a) whiter than normal ear canal b) pearly gray tympanic membrane c) redness, and swelling in the ear canal d) an excessive amount of serum lodged in the ear canal

c) redness, and swelling in the ear canal

after performing an initial abdominal assessment on a client, the nurse documents at the bowel sounds are normal. Which description best describes normal bowel sound? a) waves of loud gurgles auscultated in all four quadrants b) low pitched swishing auscultated in one hour to quadrants c) relatively high pitched, clicks or gurgles auscultated in all four quadrants d) very high pitch loud rushes auscultated, especially in one or two quadrants

c) relatively high pitched, clicks or gurgles auscultated in all four quadrants

A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which method describes accurate procedure to perform this test? a) the client is asked to discriminate numbers from a chart composed of colored dots b) the room is darkened, and the client is asked to identify colored blocks and shapes when they appear in the visual field c) the examiner in client, cover their write eyes and stare at each other's left eyes, and a small object is brought into the visual field d) the examiner in client, cover the eyes directly opposite to one another, and stared each other's uncovered I, and a small object is brought to the visual field

d) the examiner in client, cover the eyes directly opposite to one another, and stared each other's uncovered I, and a small object is brought to the visual field