Health Assessment Final Exam

How can you remember the supination position?

"give me more soup"

Uses a rolling walker

+RW

1kg = ?gm

1000gm

1gm=?mg

1000mg

The spinal accessory is the ___ cranial nerve.

11th

1 tablespoon = ? cc

15 cc

1 Ib= ? oz

16 oz

1/2 gallon - ? L

2 L

1kg = ? lb

2.2 lb

8oz = ? cc

240

1 oz = ? cc

30

1 tsp = ? cc

5 cc

The Trigeminal nerve is the ___ cranial nerve.

5th

The facial nerve is the ____ cranial nerve

7

1 cup = ? oz

8 oz

A nurse is practicing her physical assessment examination skills and is trying to differentiate different types of breath sounds. Which of the following provides an accurate information regarding breath sounds? A. Bronchovesicular sounds have equal length of inspiration and expiration B. Vesicular sounds are the sounds heard over the trachea C. Bronchovesicular sounds are harsh, hollow, tubular sounds D. Bronchial sounds are those that are heard around the scapula and in the first and second intercostal space

A. Bronchovesicular sounds have equal length of inspiration and expiration

An adult who was involved in a sports injury has a fractured right radius. His right arm has been casted. While performing assessment of this client, which of the following findings should prompt the nurse to inform the physician immediately? A. Diminished capillary refill on the affected arm B. Pain on the right forearm C. Warm, dry fingers bilaterally D. Swollen fingers of the right hand

A. Diminished capillary refill on the affected arm

A patient with Parkinson disease has difficulty speaking because of the loss of muscular control that produces speech. The patient can still produce sounds nasally, and they speak with a slur. The patient no difficulty comprehending language. Which of the following refers the patients manifestation? Select one: A. Dysarthria B. Aphonia C. Broca aphasia D. Wernicke aphasia

A. Dysarthria

The nurse is assessing a newly admitted older client for risk for falls. What assessment data would be most concerning and alert the nurse that the client is at risk for falls? A. Increased nocturia and incontinence at night B. Slightly hard of hearing C. Blood pressure of 132/86 mm Hg D. Walks with a cane

A. Increased nocturia and incontinence at night

A nurse is doing a physical examination of the client. She asked the client who is lying supine on the examination table to mvoe the ankles, and turn the feet inwards and then outwards. Which of the following did the nurse make the client do? A. Inversion and eversion B. Pronation and supination C. Retraction and protraction D. Abduction and adduction

A. Inversion and eversion

The nurse wants to assess the abdomen of a client with splenomegaly. Which part of the abdomen will she particularly focus on? A. Lower left quadrant B. Midline C. Upper right quadrant D. Upper left quadrant

A. Lower left quadrant

A nurse is inspecting a patient's mouth and notices white cheesy substance sticking to the patient's mucosa. The patient's history reveals that the patient has taken several types of antibiotics for recurrent tonsillitis. Which of the following accurately describes the patient's symptoms? A. Oral candidiasis B. Tonsillitis C. Diabetic ketoacidosis D. HIV

A. Oral candidiasis

A community health nurse is doing her rounds in the neighborhood when she is summoned by a frantic mother whose young child appears to be in distress. The mother says her child is making strange noises as she breathes. Upon assessment, the nurse hears a loud, harsh, high-pitched sound during inspiration. This alerts the nurse to which finding? A. Stridor B. Ronchi C. Rales D. Wheeze

A. Stridor

Which of the following are important assessment aspects of the nose exam? Select all that apply. A. Testing for nasal patency B. Inspecting for septal symmetry C. Using the ophthalmoscope to assess internal structures D. Assessing olfactory nerve E. Assessing CN II

A. Testing for nasal patency B. Inspecting for septal symmetry D. Assessing olfactory nerve

Which of the following is not a drug that could cause ototoxicity? A. Warfarin B. Non steroidal anti-inflammatory drugs (NSAIDs) C. Loop diuretics D. Aminoglycoside antibiotics

A. Warfarin

A nurse is receiving report on a group of clients. Using the ABCDE priority framework, which of the following clients should the nurse see first? A. A client who has pneumonia and has developed wheezing B. A client who is scheduled for discharge and has 38.4 (101.1) temperature this morning C. A client who has early dementia and awoke confused to their location this morning D. A client who is postoperative and has a urine output of 50 mL for the past 3 hr

A. A client who has pneumonia and has developed wheezing

While auscultating a client's heart sounds, the nurse hears turbulence between S1 and S2 heart sounds. The nurse should document this as which of the following? A. A systolic murmur B. A third heart sound (S3) c. An expected heart sound D. A fourth heart sound (S4)

A. A systolic murmur

A nurse is teaching a client about the Rinne test. Which of the following client statements indicates an understanding of the teaching? A. A tuning fork is placed on my head B. Small electrodes are placed on my scalp C. I will wear earphones during this test D. A small prove is placed inside my ear

A. A tuning fork is placed on my head

A nurse on the medical-surgical unit is conducting a false risk assessment for four clients. The nurse should identify that which of the following clients is the greatest risk for a fall? A. An older adult client who is confused and has urinary frequency B. A client with diabetes mellitus who has a leg ulcer C. A client who is 1 day postoperative and has a nursing assistant helping him out of bed D. An adolescent client who has a leg fracture and has been using crutches for the past 2 days

A. An older adult client who is confused and has urinary frequency

A nurse is reviewing communication styles. Which of the following characteristics should the nurse identify as being exhibited by an aggressive communicator? A. Are often controlling during conversation B. Frequently interrupt others during conversation C. Tend to blame others for misunderstandings D. Seek to avoid expressing personal opinions E. Are often anxious about how their message will be received F. Advocate for their rights as well as the rights of others

A. Are often controlling during conversation B. Frequently interrupt others during conversation C. Tend to blame others for misunderstandings

When checking a client's capillary refill, the nurse finds that the color returns in 10 seconds. The nurse should understand that this finding indicates which of the following? A. Arterial insufficiency B. Venous insufficiency C. Within the expected range D. Thrombus formation in the vein

A. Arterial insufficiency

A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve II? A. Ask the client to read a Snellen Chart B. Listen to the client's speech C. Ask the client to identify scented aromas D. Ask the client to clench his teeth

A. Ask the client to read a Snellen Chart

A nurse is assessing a client who is 2 days post operative and auscultates bilateral breath sounds, but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications? A. Atelectasis B. Pneumonia C. Pulmonary embolism D. Arterial thrombus

A. Atelectasis

A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include the client's plan of care? A. Auscultate breath sounds at least every 2 hr B. Perform range-of-motion (ROM) exercises at least two or three times daily C. Make sure the client intake of 2,000 to 3,000 mL of fluid per day D. Apply anti embolic stockings

A. Auscultate breath sounds at least every 2 hr

Which cranial nerves are responding for eye movements? A. CN III, IV, VI B. CN I, II V C. CN VIII, X D. CN VII, XI

A. CN III, IV, VI

A nurse is caring for a client who ingested poison and is now experiencing a seizure. Which of the following is priority action the nurse should take? A. Check the patency of the client's airway B. Determine the poison that was ingested C. Identify the amount of poison that was ingested D. Position the client side-lying

A. Check the patency of the client's airway

A nurse is documenting in a client's health record using the subjective, objective, assessment, and plan (SOAP) charting model. Which of the following information should be included in the subjective component? A. Client reports chest pain after mowing lawn this morning. B. Client administered nitroglycerin 0.3 mg SL for chest pain C. Client's blood pressure is 182/98 mm Hg D. Client's skin is pale diaphoretic

A. Client reports chest pain after mowing lawn this morning.

A nurse is documenting assessment findings on a client. Which of the following entries should the nurse identify as subjective date? Note: Subjective data is what the patient tells you A. Client reports dull, aching pain in lower right calf B. Client's oral temperature is 38.4 C (101.2 F) C. Client has a vesicular rash on their upper back D. Client reports the rash on their back is itchy E. Client reports nausea following administration of pain medication

A. Client reports dull, aching pain in lower right calf D. Client reports the rash on their back is itchy E. Client reports nausea following administration of pain medication

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? A. Contractures of the extremities B. Polyuria C. Diarrhea D. Crackles in the lungs E. Pressure ulcers

A. Contractures of the extremities D. Crackles in the lungs E. Pressure ulcers

A patient with chronic back pain is seen I the pain clinic for follow-up. In order to evaluate whether the pain management is effective, which question is best for the nurse to ask for? A. Does the pain keep you from doing things you enjoy? B. How would you rate your pain on a 0 to 10 scale? C. Can you describe the quality of your pain? D. Has there been a change in pain location?

A. Does the pain keep you from doing things you enjoy?

A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse? A. Explain to the client what is about to happen B. Make sure the room temperature is cool C. Provide music an environmental distraction D. Inform the client that the provider will examine sensitive areas first

A. Explain to the client what is about to happen

A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect? A. Frothy sputum B. Dependent edema C. Nocturnal polyuria D. Jugular distention

A. Frothy sputum

A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client ambulate? A. Gait belt B. Jacket harness C. Four-wheel walker D. Cane

A. Gait belt

A nurse is teaching a client about how to use her new hearing aids. Which of the following statements should the nurse identify as an indication that the client needs further instruction? A. I will clean the hearing aids with alcohol wipes B. I will not use hairspray if I am wearing the hearing aids C. I will change the batteries once a week D. I will expect the hearing aids to whistle when I cup my hand over them2

A. I will clean the hearing aids with alcohol wipes

A nurse is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate? A. Incorporate nonverbal cues in the conversation B. Ask multiple choice questions as part of the conversation C. Use a higher-pitched tone of voice when speaking D. Use simple, child-like statements when speaking

A. Incorporate nonverbal cues in the conversation

A nurse is performing a neurological assessment for a client who has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III? A. Instruct the client to look up and down without moving his head B. Observe the client's ability to smile and frown C. Have the client stand with eyes his closed and touch his nose D. Ask the client to shrug his shoulders against passive resistance

A. Instruct the client to look up and down without moving his head

A nurse is discussing factors that influence communication with a group of newly licensed nurses. Which of the following information should the nurse include? A. Nurses might focus on a client's physiological needs over psychosocial needs when communicating during care B. Client's who have developmental deficits are less distracted by environmental noises than client who do not have these deficits C. Nurses caring for a clients experiencing a highly emotional situation report that communication is rarely affected D. Hearing loss is considered a development factor that has minimal effect on nurse-client communication

A. Nurses might focus on a client's physiological needs over psychosocial needs when communicating during care

A nurse is caring for a client who reports an area of redness, warmth, tenderness and pain in the right calf. The nurse anticipates which of following orders when notifying the provider of this finding? A. Obtain a venous duplex ultrasound B. Obtain impedance plethysmography C. Monitor Homan's sign D. Apply cold therapy to the affected leg

A. Obtain a venous duplex ultrasound

A nurse is caring for a client who has right -sided neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take? A. Place suction equipment at the client's bedside B. Apply an eye patch to the client's right eye C. Avoid the use of warm water to wash the client's face D. Provide range of motion exercises to the client's neck and shoulders

A. Place suction equipment at the client's bedside

A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply) A. Provide a suction setup at the bedside B. Elevate the side rails near the head when the client is in bed C. Place the bed in the lowest position D. Keep an oxygen setup at the bedside E. Furnish the restraints

A. Provide a suction setup at the bedside B. Elevate the side rails near the head when the client is in bed C. Place the bed in the lowest position D. Keep an oxygen setup at the bedside

A nurse is caring for a client who has dementia. Which of the following actions should the nurse take to reduce the client's risk of aspiration pneumonia? A. Provide the client with oral hygiene B. Instruct the client to tilt their head back while swallowing C. Elevate the head of the client's bed to 45 during meals D. Turn on the television

A. Provide the client with oral hygiene

A charge nurse is teaching a newly licensed nurse about fall prevention strategies when caring for clients. Which of the following information should the nurse include in the teaching? A. Provide under-bed lighting at night B. Lock the wheels C. Keep the bed in the high position D. Apply socks on clients when ambulating E. Place breaks on the clients' wheelchairs

A. Provide under-bed lighting at night B. Lock the wheels E. Place breaks on the clients' wheelchairs

A nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take? A. Repeat auscultation after asking the client to breathe deeply and cough B. Instruct the client to limit fluid intake to less than 2,000 mL/day C. Prepare to administer antibiotics D. Place the client on bed rest in semi-Fowler's position

A. Repeat auscultation after asking the client to breathe deeply and cough

You are interviewing a patient who is very anxious in order to complete the health history. The patient has been talking nonstop about topics unrelated to the question you asked. What therapeutic technique from the list below might be helpful to bring the interview back on track? Select the best answer. A. Silence B. interrupt and ask and open ended questions C. Ask for clarification D. Focusing

A. Silence

A nurse is caring for a client who has global aphasia. Which of the following actions should the nurse take? A. Speak to the client about one idea at a time B. Ask the client to multi-task C. Limit questions to yes and no answers. D. Focus on a single form of communication

A. Speak to the client about one idea at a time

A nurse enters an adult client's room and finds him unresponsive. After determining that the client is not breathing and does not have a pulse, which of the following actions should the nurse take first? A. Summon the code team B. Begin chest compressions C. Administer rescue breathing D. Open the client's airway

A. Summon the code team

A nurse is assessing a client who is receiving intermittent enteral nutrition through a nasogastric tube. Which of the following assessments is the nurse's priority? A. The client is regurgitating the enteral formula B. The client is experiencing abdominal cramping C. The client is reporting constipation D. The client reports being thirsty

A. The client is regurgitating the enteral formula

A nurse is assessing a client for manifestations of pain. Which of the following findings is a subjective indicator of pain? A. The client reports a burning sensation B. The client is grimacing C. The client's pupils are dilated D. The client is restless

A. The client reports a burning sensation

A charge nurse is reviewing the documentation completed by a newly licensed nurse. Which of the following entries should the charge nurse recommend for revision? A. The client seems to be more comfortable performing self-administration of insulin B. The client stated, I struggle to see those little lines on the syringe C. The client demonstrated proper technique when drawing up 8 units of insulin D. The client's FBS was 95 mg/dl

A. The client seems to be more comfortable performing self-administration of insulin

A nurse is caring for a client who is 3hr postoperative following abdominal surgery. Which of the following assessment data should the nurse report to the provider? A. The client urine output has been 50 mL since surgery B. The client's pain level has decreased since the administration of morphine C. Serosanguineous drainage noted on the abdominal dressing D. Postoperative lab results are Hgb 15% and Hit 40%

A. The client urine output has been 50 mL since surgery

A nurse is teaching a class about the epidermis. Which of the following information should the nurse include? A. The epidermis receives nutrition from the dermis B. The epidermis is composed of blood vessels C. The epidermis contains adipose tissue D. The epidermis is made up of nerves

A. The epidermis receives nutrition from the dermis

A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers? A. The left second intercostal space B. The right second intercostal space C. The left fifth intercostal space D. The left fifth intercostal space at the midclavicular line

A. The left second intercostal space

A nurse hears a heart murmur and says that the murmur is a Grade 6. Which of the following is the correct interpretation of the nurse's findings? A. The murmur is loud, with thrill, heard with a stethoscope entirely off the chest B. The murmur is moderately loud C. The murmur is loud with palpable thrill D. The murmur is loud, with thrill

A. The murmur is loud, with thrill, heard with a stethoscope entirely off the chest

A nurse is teaching a class about documenting blood pressure. The nurse should include to document which of the following information? A. The site where the blood pressure was obtained B. Intervention implemented in response to a client's blood pressure C. A client's position when the blood pressure was obtained D. The frequency in which a blood pressure is taken E. A client's response to interventions implemented

A. The site where the blood pressure was obtained C. A client's position when the blood pressure was obtained E. A client's response to interventions implemented

A nurse is reinforcing teaching with a client who has low health literacy. Which of the following actions should the nurse take? A. Use the teach-back method B. Encourage questions C. Speak slowly D. Use medical terminology E. Provide written materials

A. Use the teach-back method B. Encourage questions C. Speak slowly

A nurse is assessing a client who has acoustic neuroma. Which of the following client manifestations should the nurse expect? A. Vertigo B. Dysphagia C. Diplopia D. Apraxia

A. Vertigo

A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse use to promote this discussion? A. What brought you to the hospital? B. Would you tell me about all your medical issues? C. Do you want to talk about your health concerns? D. Would it help to discuss your feelings about hospitalization?

A. What brought you to the hospital?

A charge nurse is reviewing legal guidelines for documentation with a newly licensed nurse. Which of the following should the charge nurse include in the teaching? Select all that apply. A. a medical record can be used as evidence in a court of law B. a nurse should ensure the documentation is organized and completed in a timely fashion C. documentation should include the nurse's interpretation of the client situation D. data contained in a client's medical record can be shared with all employees within a health care facility E. information recorded in the client's medical record must be accurate and complete

A. a medical record can be used as evidence in a court of law B. a nurse should ensure the documentation is organized and completed in a timely fashion E. information recorded in the client's medical record must be accurate and complete

The nurse wants to locate the second intercostal space,. Which of the following landmark would be most useful for the nurse to locate first? A. angle of louis B. Nipple C. Midclavicular line D. Precordium

A. angle of louis

A nurse is teaching a class about teeth. The nurse should include that which of the following are functions of teeth? Select all that apply. A. chew food B. secrete mucus C. shape the face D. protect against pathogens E. assist with speech

A. chew food C. shape the face E. assist with speech

A nurse is caring for an older adult client. The nurse should recognize the client is at risk for which of the following physiological changes? Select all that apply. A. decreased gastric motility B. decreased skin elasticity C. increased pain threshold D. increased metabolic rate E. increased cardiac output

A. decreased gastric motility B. decreased skin elasticity C. increased pain threshold

You are documenting the objective findings of your admission assessment on a 67-year-old patient who was just admitted pre operatively for a surgical intervention. Which of the following objective statements from the list below would your write down? Select all that apply. A. denies chest pain B. skin is clean, dry and intact C. heart rate is 89 D. I think I have a blood pressure pill but dont have the bottle with me E. im very anxious about this procedure

A. denies chest pain B. skin is clean, dry and intact C. heart rate is 89

The nurse is performing a physical examination and is assessing the patient's skin temperature, numbness, tingling and pressure on their skin. The nurse's findings are aligned with which function of the integumentary system? A. it allows sensory perception B. it gives identity C. it allows repair of wounds D. it provides non verbal cues

A. it allows sensory perception

The nurse is assessing a 78-year-old male client. At the beginning of the mental status portion of the assessment, the nurse expects that this client: A. may take a little longer to respond, but his general knowledge and abilities should not have declined B. will have had a decrease in his response time because of language loss and a decrease in general knowledge C. will have no decrease in any of his abilities, including response times D. will have difficulty on tests of remote memory because this typically decreases with age

A. may take a little longer to respond, but his general knowledge and abilities should not have declined

A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination. During the cognitive function tests, the nurse would expect that he: A. might be oriented to place and person but not be certain of the date B. might state, I am so relieved to be out of intensive care C. might display some disruption in thought content D. might show evidence of some clouding of consciousness

A. might be oriented to place and person but not be certain of the date

Which of the following assessment findings of the patient's head and neck will the nurse prioritize to inform the physician? A. trachea that slightly leans to the left B. dry sparse hair C. enlarged tonsillar lymph nodes D. cold finger tips

A. trachea that slightly leans to the left

A nurse who is percussing the back of a patient with a large pneumothorax hears a drum-like sound. Which of the following correctly describes the nurses's findings? A. tympany on percussion B. resonance on percussion C. flatness on percussion D. dullness on percussion

A. tympany on percussion

The nurse is assessing the optic nerve of a client. Which of the following procedures tests CN II? A. using a snellen chart B. testing the corneal reflex C. observing the extraocular movements D. inspecting pupil's reaction to light

A. using a snellen chart

A nurse is auscultating the chest of a patient and hears crackles caused by chest hair. Which of the following can the nurse dot that will help in the auscultation ? A. wet the chest hairs B. ask the patient to hold their breath for a few seconds C. use the bell of the stethoscope instead D. ask the patient to lie down

A. wet the chest hairs

A nurse is assessing a client who has a score of 6 on the Glasgow coma Scale. The nurse should expect which of the following outcomes based on this source? A.The client needs total nursing care B. The client is alert and oriented C. The client is in a deep coma D. Indicate stable neurologic coma

A.The client needs total nursing care

My patient knows the date, the hospital's name and is able to tell me current events in the news. The best objective documentation would be...

AAO x 3

Before meals?

AC

Abbreviation for activities of daily living

ADL

VI

Abducens

When a patient raises both arms all the way up, what is this movement called?

Abduction

VIII

Acoustic

When a patient brings their arms down towards their body from the sky, what does that mean?

Adduction

Assist of one person.

Assist x1

A nurse is conducting an interview of a client and she wants to know if the client is experiencing dysphagia. Which of the following is most appropriate to ask to assess for dysphagia A. "Is there any pain when you swallow?" B. "Do you have difficulty swallowing?" C. "Do you have difficulty chewing your food?" D. "Is there any pain in your abdomen after eating?"

B. "Do you have difficulty swallowing?"

Using the OLD CART pneumonic in assessing client's headache, which of the following questions coincides with the "C"? A. How long has this been going on? B. Can you describe how it feels? C. What do you think triggers the headache? D. When did you first notice the headache?

B. Can you describe how it feels?

A nurse is assessing a patient and notices that the patient's nasal septum is perforated. The patient also has rhinorrhea and appears restless. Which of the following conditions most likely caused the patient's symptoms? A. Allergies B. Cocaine abuse C. Upper respiratory tract infection D. Epistaxis

B. Cocaine abuse

A patient who is a chronic smoker has been recently diagnosed with chronic obstructive pulmonary disease (COPD). Which of the following findings will the nurse most likely note of the patient's thorax? A. Protruding ribs B. Diameter is equal the length of anterior posterior C. Diameter is twice the length of anterior posterior D. Pigeon breast

B. Diameter is equal the length of anterior posterior

Where is the location of the Parotid glands? A. In the gingiva of the upper teeth B. In the buccal mucosa behind the top second molars C. In the floor of the mouth lateral to the frenulum D. Under the mandible

B. In the buccal mucosa behind the top second molars

A nurse is assessing the patient's neck, she notes two enlarged cervical lymph nodes that are fixed and immoveable. Which of the following is the priority nursing action? A. Message gently B. Inform the physician of your findings C. Document accordingly D. Put hot compresses on site

B. Inform the physician of your findings

A nurse wants to know if a patient has thrills. Which of the following is the best assessment to perform? A. Auscultation B. Palpation C. Inspection D. Percussion

B. Palpation

The nurse is caring for a client who is learning the English language but does not understand the language well. What approaches would the nurse use when communicating with this client? Select all that apply. A. Repeat a message once, and if needed, contact the family to repeat the message again. B. Use a caring tone of voice and facial expressions. C. Speak at the usual pace, and raise the voice when needed. D. Be alert to and use words that the client seems to understand, and use them frequently. E. Avoid using medical terms that the client may not understand. F. Avoid use of role play because this will make the client feel as if she or he is being treated like a child.

B. Use a caring tone of voice and facial expressions. D. Be alert to and use words that the client seems to understand, and use them frequently. E. Avoid using medical terms that the client may not understand.

Mental Status assessment documents: A. intelligence and educational level. B. emotional and cognitive functioning. C. schizophrenia and other mental health disorders. D. artistic and writing ability in a mentally ill person.

B. emotional and cognitive functioning.

A nurse in the outpatient department of neurology is examining a client's deep tendon reflexes. When the nurse strikes the patellar tendon, the nurse was able to elicit very minimal response. What is the most appropriate grade to assign to the client's deep tendon reflexes? A. 3+ B. 1+ C. 2+ D. 4+

B. 1+

A nurse is assessing a client for pitting edema and notes an indentation of 6mm (0.25) at the point of pressure. Which of the following notations should the nurse use to document the severity of the client's edema? A. 4+ B. 3+ C. 2+ D.1+

B. 3+

A nurse is caring for four clients who are all requesting assistance. Which of the following clients should the nurse assist first? A. A client who reports their IV pump is beeping B. A client who reports they have fallen while ambulating C. A client who is requesting a bedpan D. A client who is postoperative and is reporting nausea

B. A client who reports they have fallen while ambulating

A nurse has received a change-of shift report on a group of clients and is preparing her assignment. Which of the following clients should the nurse assess first? A. A client who had a blood glucose reading at 0650 of 70 mg/dL after reaching 50% dextrose for a hypoglycemic episode B. A client who was admitted for chest pain and is reporting a new onset indigestion C. A client who has pneumonia and was treated for a temperature of 38.9 (102 F) at 0400 D. A client who has pulled out the peripheral IV catheter and is schedules to receive a dose of famotidine at 0800

B. A client who was admitted for chest pain and is reporting a new onset indigestion

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having an increased risk of aspiration while eating? (Select all that apply.) A. A client who has lactose intolerance B. A client who's has had a cerebrovascular accident c. A client who is 4 hr postoperative following a leg amputation with general anesthesia D. A client who has had prolonged diarrhea E. A client who has had radiation therapy for head and neck cancer

B. A client who's has had a cerebrovascular accident E. A client who has had radiation therapy for head and neck cancer

A nurse is caring for a client of Chinese heritage. Which of the following actions should the nurse take to demonstrate cultural competence? A. Make sure the dietary department does not serve the client pork. B. Ask the client's permission to add ice to drinking water C. Maintain direct eye contact with the client D. Place a hand on the client's head

B. Ask the client's permission to add ice to drinking water

A nurse enters a client's room and finds him unresponsive. After notifying the rapid response team, which of the following actions should the nurse take first? A. Attach defibrillator pads to the client B. Check for carotid pulse C. Begin chest compressions D. Deliver two breaths

B. Check for carotid pulse

A charge nurse is teaching a newly licensed nurse the importance of client confidentiality. Which of the following professional standards should the charge nurse refer to in the teaching? A. American Nurses Association Position Statements B. Code of Ethics for Nurses C. Principles of Nursing Practice D. Nursing Scope and Standards of Practice

B. Code of Ethics for Nurses

A nurse is applying knowledge to analyze a clinical situation. Which of the following roles is the nurse taking? A. Advocate B. Critical thinker C. Educator D. Mentor

B. Critical thinker

A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect? A. Dependent rubor B. Edema C. Hair loss D. Thick, deformed toenails

B. Edema (swelling)

A nurse is planning care for a client who has decreased level consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is priority action by the nurse? A. Observe client's respiratory status B. Elevate the head of the client's bed 30 to 45 C. Monitor intake and output every 8 hr D. Check residual volume every 4 to 6 hr

B. Elevate the head of the client's bed 30 to 45

A nurses is assessing a client who is nonverbal for acute pain. Which of the following findings is a manifestation of pain? A. Constricted pupils B. Elevated blood pressure C. Reduced respiratory rate D. Decreased heart rate

B. Elevated blood pressure

A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect? A. Decreased brain natriuretic peptide (BNP) B. Elevated central venous pressure (CVP) C. Increased pulmonary artery wedge pressure (PAWP) D. Decreased specific gravity

B. Elevated central venous pressure (CVP)

A nurse is teaching a newly licensed nurse about professionalism. The nurse should include that which of the following demonstrates unprofessional behavior by a nurse ? A. Witnessing a client consent for a surgical procedure B. Explaining the steps of a surgical procedure to a client C. Confirming that a client appears competent to consent to a surgical procedure D. Verifying that a client voluntarily gave consent to a surgical procedure

B. Explaining the steps of a surgical procedure to a client

A nurse observes an adolescent client who has paraplegia sitting in a wheel chair crying. The client says, "Go away, no one can help me." Which of the following responses should the nurse make? A. Everything will be okay B. I will come back let and we can talk C. Why are you crying? D. Do you think crying will help?

B. I will come back let and we can talk

A nurse intercepts a messenger at the nurses's station who has a flower delivery for a client on the unit. As the nurse accepts the flowers, the messenger says, "I know Mrs. Welch from the neighborhood. What happened to her? Which of the following responses should the nurse provide? A. You know it's not appropriate for you to ask me that B. It's my responsibility to remind you that we have to respect our clients' privacy C. It's a minor injury. I'm sure you'll see her back in the neighborhood soon D. Oh, what lovely flowers. She will enjoy these

B. It's my responsibility to remind you that we have to respect our clients' privacy

Freckles are an example of what skin lesion? A. Vesicle B. Macule C. Papule D. Nodule

B. Macule

A nurse is using a medical interpreter to communicate with a client. Which of the following actions should the nurse take? A. Speak to the client in the third person B. Make eye contact with the client when speaking C. Use long sentenced when speaking to the client D. Have the interpreter sit in front of the client

B. Make eye contact with the client when speaking

A nurse is performing a medication reconciliation while admitting an older adult client transferred from a long-term care facility. Which of the following should the nurse identify as part of the medication reconciliation process? A. Medications for another pharmacy B. Medications from another facility C. Discontinuation of medications D. Recommendation for prescribed medications

B. Medications from another facility

A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate? A. observe the presence of Kernig's sign B. Perform a Romberg's test C. Check the function of cranial nerve V D. Inspect for the presence of clubbing

B. Perform a Romberg's test

A nurse is caring for a client who has not voided for 8 hr following the removal of an indwelling urinary catheter. Which of the following actions should be the nurse take first? A. increase fluids B. perform a bladder scan C. Insert a straight catheter D. Provide assistance to bathroom

B. Perform a bladder scan

A charge nurse is providing teaching a newly licensed nurse on the advantages of electronic documentation. Which of the following information should the nurse include in the teaching? A. Same day accessory to client record B. Portal that allows clients to interact with providers C. Decrease in coordination of client care D. Increase of duplicate tests performed client

B. Portal that allows clients to interact with providers

A nurse is assessing a client's bowel sounds. At which of the following in the assessment should the nurse auscultate the client's abdomen? A. After palpating the abdomen B. Prior to percussing the abdomen C. After assessing for kidney tenderness D. Prior to inspecting the abdomen

B. Prior to percussing the abdomen

A nurse is providing oral care for a client who had has impaired upper extremity strength. Which of the following actions should the nurse take? A. Provide the client with a spool of dental floss B. Provide the client with an electric toothbrush C. Give the client an alcohol-based mouth wash d. Give the client lemon-glycerin mouth swabs

B. Provide the client with an electric toothbrush

A nurse is teaching a newly licensed nurse about documenting vital signs. Which of the following documentations made by newly licensed nurse indicates an understanding of the teaching? A. BP 148/72 mmHg B. Radial pulse regular 68/min C. SpO2 95% D. Temp 36 C (96.8)

B. Radial pulse regular 68/min

A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan? A. Apply a heat lamp twice a day B. Reposition the client at least ever 2 hr C. Clean the wound with hydrogen peroxide solution D. Massage reddened areas with dressing changes

B. Reposition the client at least ever 2 hr

A nurse palpates a client's radial pulses bilaterally and notes the client's radial pulse is bounding, and the client's left radial pulse is as expected. The client's heart rate is 80/min. Which of the following documentations should the nurse make? A. Right radial pulse 2+, 80/min, palpated B. Right radial pulse 4+, 80/min, palpated C. Left radial pulse 1+, 80/min, palpated D. Left radial pulse 4+, 80/min, palpated

B. Right radial pulse 4+, 80/min, palpated

A nurse is teaching a newly license nurse about pain. Which of the following is an example of acute pain? A. Rheumatoid arthiritis B. Surgical incision C. Peripheral neuropathy D. Fibromyalgia

B. Surgical incision

A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? (Select all that apply) A. Keep the client's room dark at night B. Teach the client to use the call light C. Keep the client's bed in the lowest position D. Place a fall risk identification board on the client' wrist

B. Teach the client to use the call light C. Keep the client's bed in the lowest position D. Place a fall risk identification board on the client' wrist

A nurse is providing education on priority setting framework to a group of newly license nurses. Which of the following statements should the nurse make regarding the acute vs. chronic priority setting framework? A. This framework help clients to establish order in their individual environment B. This framework guides care by recognizing conditions that can worsen rapidly C. This framework follows a specific algorithm for prioritizing care D. This framework recognizes when client conditions have less time to adapt E. This framework will guide your care using a sequential process

B. This framework guides care by recognizing conditions that can worsen rapidly

What is the purpose of of the Rinne test? A. To test for unilateral hearing loss B. To test bone conduction vs air conduction C. To test for Cranial Nerve VII D. To assess the gag reflex

B. To test bone conduction vs air conduction

A nurse is performing a cardiac assessment on a client and auscultated and S3 sound. The nurse should recognize that this sound represents which of the following heart conditions? A. Atrial gallop B. Ventricular gallop C. Closure of the mitral valve D. Closure of the pulmonic valve

B. Ventricular gallop

A nurse administers the wrong medication to a client. After assessing the client, the nurse contacts the provider and completes an incident report. Which of the following components of professionalism is the nurse demonstrating? A. fairness B. accountability C. advocacy D. confidence

B. accountability

A nurse is documenting a client's medical record. Which of the following abbreviations is appropriate for the nurse to use? (Select all that apply). A. MSO4 B. bid C. 30 mL D. .2mg E. Q.D.

B. bid C. 30 mL

A nurse is assessing a patient suspected of having a complete intestinal obstruction. Which of the following signs and symptoms is unlikely to be manifested by this patient? A. colicky pain B. flatulence C. no passage of stool D. fever

B. flatulence

The nurse conducts an assessment of an older adult. Which of the following findings indicates the client is at risk for malnutrition? Select all that apply. A. receives monthly paychecks B. ill-fitting dentures C. lives at home with family D. difficulty ambulating E. confusion

B. ill-fitting dentures D. difficulty ambulating E. confusion

A nurse in a clinic is caring for a client who reports pain, crepitus, and a popping sound in his temporomandibular joint. Based on these findings, to which of the following providers should the nurse request a referral for the client? A. occupational therapist B. oral surgeon C. physical therapist D. ortohinolaryngologist

B. oral surgeon

The following are components of the comprehensive health history EXCEPT: A. health patterns B. ordered diagnostic exams C. review of systems D. chief complaint

B. ordered diagnostic exams

Which of the following findings is consistent with scoliosis? A. hairy patches B. pelvic tilt C. port wine stains on the back D. cafe au lait spots

B. pelvic tilt

A nurse is examining a patient diagnoses with a large pneumothorax. Which of the following will the nurse most likely observe of the patient's trachea? A. shifted towards the affected side B. shifted towards the unaffected side C. collapsed D. midline

B. shifted towards the unaffected side

A patient who has asthma is recovering from an acute attack. The patient asks the nurse why the sound of their breathing sound musical when they breath out? Which of the following is the best nursing response? A. the musical sound is produced by how hard the patient breaths B. the musical sound is produced by narrowed airways C. your body is trying to get more air into the lungs D. the air passages are filled with fluid that makes the musical sound

B. the musical sound is produced by narrowed airways

A nurse is assessing a patient who reports having difficulty hearing in one ear. Which of the following questions can the nurse ask the patient to know the onset of the hearing difficulty? A. did you also notice some hearing loss in the other ear? B. when did you start noticing that you had difficulty hearing in that ear? C. do you notice any other symptoms with your hearing difficulty? D. have you consulted any health provider for your hearing difficulty?

B. when did you start noticing that you had difficulty hearing in that ear?

A nurse is reviewing new prescriptions for a client. The nurse should identify that which of the following abbreviation used by the provide indicates, "to administer medications before meals"? A. Tx B.ac C. DNR D.NG

B.ac

Abbreviation for bilateral

BL

Bowel movement?

BM

Bowel sounds?

BS

Bronchovesicular?

BV

Define cyanosis.

Bluish color of skin

What does asymmetry mean?

Both halves do not look the same

The nurse is caring for a client whose entire family wants to be present in the room. The nurse would plan to make which best response? A. "You will need to follow the visitor's rules, or I will need to call security." B. "I'm sorry but our policy limits visitors to two at a time." C. "I will check with the admissions department to see whether a private room near a lounge is available." D. "I will talk to your primary health care provider to ask if you may all stay."

C. "I will check with the admissions department to see whether a private room near a lounge is available."

A patient had recently been involved in a car accident. He is recuperating in the hospital. The nurse notes a purplish discoloration of the skin with some tinge of yellow and green. The patient states the area is still painful. Which skin lesion is the client most likely exhibiting? A. Urticaria B. Petechiae C. Ecchymosis D. Purpura

C. Ecchymosis

The nurse is seen pinching the forearm of the patient and observing the skin to spring back. Which assessment is the nurse completing? A. Assessing for petechiae B. Presence of edema C. Mobility and turgor D. Skin blanching

C. Mobility and turgor

The nurse palpate an enlarged lymph node in the area deep in the angle formed by the clavicle and the sternocleidomastoid. Which of the following nodes did the nurse find enlarged? A. Posterior cervical node B. Tonsillar node C. Supraclavicular node D. Posterior auricular node

C. Supraclavicular node

The nurse is assessing a patient with pitting edema. The patient depresses the skin with one finger and notes 6mm pit. The nurse is sure to document the degree of pitting as: A. 1+ B. 2+ C. 3+ D. 4+

C. 3+

A client was admitted after a motor vehicle accident. The doctor finds him in a comatose state. Which Glasgow coma scale is indicative of coma? A. 0 B. 2 C. 6 D. 1O

C. 6

A nurse is caring for four clients. Which of the following clients should the nurse identify as having the highest risk of aspiration? A. A client who has a chest tube following a fall from a ladder B. A client who has a semi-colectomy and placement of a colostomy C. A client receiving continuous enteral feeding through NG tube D. A client who Crohn's disease and has an ileostomy

C. A client receiving continuous enteral feeding through NG tube

A nurse is assessing a client who reports feeling stress and anxiety. The client appears restless and is pacing in the room. The client is alert and oriented to person, place, and time. Which of the following findings is subjective? A. Pacing B. Restless C.Anxiety D. Alert

C. Anxiety

A nurse who is off duty finds a woman who has collapsed and has right-sided weakness and slurred speech. Which of the following actions should the nurse take? A. Obtain the telephone number of the client's provider B. Find a location for the client to sit C. Call emergency services D. Drive the client to the nearest emergency department

C. Call emergency services

The family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling. Which of the following factors should the nurse identifies a likely explanation for the client's behavior? A. He is hard of hearing B. Pain C. Confusion D. Language barrier

C. Confusion

A nurse is caring for a client who is a member of a marginalized sexual group. The nurse should recognize the client is at risk for which of the following conditions? A. Infectious diseases B. Rhinitis C. Depression D. Fractures

C. Depression

A nurse is the initial admission assessment and history for a client. Which of the following is the priority action for the nurse to take? A. Teach the client about his diagnosis B. Provide a schedule of visiting hours to the client's family C. Document the client's allergies in the electronic medical record D. Develop a plan of care for the client

C. Document the client's allergies in the electronic medical record

A nurse is teaching a client about positive signs of pregnancy. Which of the following findings should the nurse include? A. breast tenderness B. fatigue C. Fetal heart tones detected by ultrasound D. positive urine pregnancy test

C. Fetal heart tones detected by ultrasound

A nurse in a provider's office is assessing a client who reports dyspnea and fatigue. Physical assessment reveals and weak peripheral pulses. The nurse should recognize these findings as manifestations of which of the following condition? A. Asthma B. Aortic valve regurgitation C. Heart failure D. Aortic Stenosis

C. Heart failure

The nurse is doing a health teaching on a client with colon cancer. She is explaining the different types of bleeding manifestations. Of particular interest to her is the type of blood associated with colon cancer and that is passing of fresh blood or maroon colored stool. The client understands the teaching if he replies with which answer? A. Melena B. Steatorrhea C. Hematochezia D. Hematemesis

C. Hematochezia

A nurse is caring for a client 1 day postoperative who has developed atelectasis. Which of the following manifestations is an expected finding for this condition? A. Apnea B. Dysphagia C. Hypoxemia D. Pleural effusion

C. Hypoxemia

A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should the nurse take first? A. Auscultate B. Percuss C. Inspect D. Palpate

C. Inspect

A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take? A. Limit the client's fluid intake in the evening B. Obtain a bedside commode for the client's use C. Leave a nightlight on the client's room D. Put the side rails up and tell the client to call the nurse before voiding

C. Leave a nightlight on the client's room

A nurse is discussing the effect of low health literacy with a group of community members. Which of the following statements should the nurse make? A. Client's who have low health literacy have lower mortality rates than others B. Clients who have low health literacy tend to have greater availability of care C. Low health literacy leads to increased use of emergency services D. Low health literacy leads to an increase in preventative services

C. Low health literacy leads to increased use of emergency services

A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse take? A. Talk quickly when speaking to the client B. Speak to the client using a loud voice C. Make eye contact with the client when speaking D. Use high-pitched tones to speak to the client

C. Make eye contact with the client when speaking

A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take? A. Measure from the heel to the gluteal fold B. Measure the length of the feet C. Measure from the heel to the popliteal space D. Measure the ankle circumference

C. Measure from the heel to the popliteal space

A nurse is reviewing a client's medical record. Which of the following findings should the nurse identify as a fall risk? A. Hyperthyroidism B. Hyperlipidemia C. Multiple Sclerosis D. Inguinal Hernia

C. Multiple Sclerosis

A nurse is teaching a client the partner of a client who had a stroke about dysphagia. Which of the following statements by the client's partner should indicate to the nurse that the teaching was effective? A. My partner should cough while swallowing food B. My partner should place their food on the weaker side of their mouth when eating C. My partner should tilt their head forward when swallowing D. My partner should sit at a 30 degree angle while eating their meals

C. My partner should tilt their head forward when swallowing

A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech. Which of the following actions should the nurse take? A. Provide the client with water to test the gag reflex B. Perform carotid massage C. Notify emergency management services D. Drive the client to the nearest medical facility

C. Notify emergency management services

A nurse in a community health clinic is interviewing a couple who just lost their house in a fire. Use the priority framework of Maslow's hierarchy of needs, which category should the nurse identify for the client's situation? A. Self-actualization B. Safety physiological C. Physiological D. Esteem

C. Physiological

A nurse is discussing management strategies with another nurse. The nurse should include which of the following as an example of a time management strategy? A. Skip a meal break to catch up on charting B. Offer to complete another nurse's task C. Plan time for disruptions D. Complete the easiest tasks first

C. Plan time for disruptions

A nurse is developing a plan of care for a client who practices Islam. Which of the following actions should the nurse include the plan? A. Serve foods that have a hot/cold balance B. Serve milk products separately from meals C. Request a meal tray without a pork D. Remove tea and coffee from meal trays

C. Request a meal tray without a pork

A nurse is teaching a newly hired nurse about cell phone use in the workplace. Which of the following information should the nurse include in the teaching? A. Send a personal text to a co-worker B. Take a photo of a client's incision site for learning purposes C. Request for assistance from the client's room D. Call the client's family member per their request

C. Request for assistance from the client's room

A nurse checks a client to evaluate effectiveness of pain medication. Which of the following components of professionalism is the nurse demonstrating? A. Advocacy B. Fairness C. Responsibility D. Confidence

C. Responsibility

A nurse is receiving a shift report about a group of assigned clients. Which of the following actions should the nurse plan to take first? A. Ask the provider about advance a client's diet. B. Reinsert an intravenous catheter that was removed due to infiltration C. Suction the tracheostomy of a client who has copious secretions D. Check the laboratory findings of a preoperative client scheduled for surgery later in the shift

C. Suction the tracheostomy of a client who has copious secretions

A nurse caring for client is using active listening skills. Which of the following actions should the nurse take? A. Sit side-by-side with with client B. Have a pen and paper handy C. Use intermittent eye contact D. Lean back in the chair

C. Use intermittent eye contact

A nurse is preparing different samples for food with varying tastes. She then asked the client to taste each sample. She later instructed the client to frown, smile, close their eyes and move their lips and mouth. Which cranial nerve is the nurse assessing? A. V B. VI C. VII D. VIII

C. VII

A nurse on a medical unit is assessing four clients for urinary retention. Which of the following clients have manifestations of urinary retention? A. a client who has an evaluated BUN B. a client who reports painful urination C. a client who reports urinary frequency D. a client who has glucose in his urine

C. a client who reports urinary frequency

A nurse is caring for a client who is experiencing stress. Which of the following actions should the nurse take first? A. establish short and long term goals for the client B. develop a statement about the client's health alteration C. conduct a mental status exam for the client D. review the client's condition to determine if the plan was effective

C. conduct a mental status exam for the client

The nurse is measuring jugular vein pressure. To start the assessment, how should the nurse position the patient? A. supine, flay B. supine, HOB 60 degrees C. supine, HOB 30 degrees D. side-lying

C. supine, HOB 30 degrees

After an eye assessment, it was determined that the client's visual acuity is 20/60. What is the accurate interpretation of this result? A. the client can read at 60 feet what a person of normal vision can read at 20 feet B. the client can read 20 of the 60 letters on the Snellen Chart C. the client can read at 20 feet what a person of normal vision can read at 60 feet D. the client can see only 1/3 of what a person of normal vision can see

C. the client can read at 20 feet what a person of normal vision can read at 60 feet

The nurse is caring for a client with a cognitive impairment. What are some strategies the nurse can use to communicate with this client? Select all that apply. A. assistance of trained language interpreter B. detailed video viewing explaining information to the client C. therapeutic communication techniques D. problem-free conversations and support strategies E. role play F. detailed interventions framed in a positive manner

C. therapeutic communication techniques E. role play D. problem-free conversations and support strategies

The nurse is asking the client if their shoes, rings or belts ever feel tighter than usual. Which of the following problems of the cardiovascular system is the nurse trying to determine? A. Cyanosis B. Nocturia C. Edema D. Paroxysmal noncturnal dyspnea

C.edema

Clear to Auscultation?

CTA

Contact guard during ambulation.

CTG Assist

Short term for cardiovascular.

CV

What does evolving mean?

Change in size, shape, or color

A nurse is caring for a light-skinned client who has an ileostomy. Nurse Notes: Day 1: Abdomen soft, non distended Ileostomy present. Stoma is red. Stoma draining brown liquid stool. Client will not look at stoma. Client states they are not interested in learning about stoma care. Day 2: Ileostomy pouch changed. Skin surrounding stoma is reddened and has small open areas. Click to highlight the findings that require intervention by the nurse.

Client will not look at stoma. Client states they are not interested in learning about stoma care. Skin surrounding the stoma is reddened and has small open areas.

An elderly client is being admitted to the hospital for surgery. Which priority question should the nurse ask to better understand what type of diet would be safe to order? A. "Do you have any trouble with chewing or digesting food?" B. "Do you have any cultural or religious requirements or preferences?" C. "Do you have enough money for groceries?" D. "Are there any foods you prefer to eat?"

D. "Are there any foods you prefer to eat?"

The nurse is conducting a thorough musculoskeletal assessment. She hopes to assess passive joint movements in a client. What would she ask the client to do? A. Rotate the shoulders B. Kick the pillow C. Tense the muscles of the upper arm D. Relax as the nurse extends the elbow

D. Relax as the nurse extends the elbow

The nurse is examining the skin of legs of a client with arterial insufficiency. Which of the following assessment findings is not consistent with the client's diagnosis? A. Hairless B. Pallor C. Cold skin D. With brownish pigments around the ankles

D. With brownish pigments around the ankles

A full mental status examination should be completed if the patient: A. has a new diagnosis of type 2 diabetes mellitus. B. complains of insomnia. C. develops problems swallowing certain foods. D. has a change in behavior and the family is concerned.

D. has a change in behavior and the family is concerned.

A nurse is caring for a client who has express aphasia following a cerebrovascular accident (CVA). Which of the following parameter should the nurse use first in order to assess the client's pain level? A. Pulse and blood pressure findings B. Behavioral indicators and effect C. Scheduled treatments and client illness D. A self-report pain rating scale

D. A self-report pain rating scale

A nurse is caring for a client who has impaired speech. Which of the following actions should the nurse take? A. Finish sentences for the client B. Avoid using visual aids for communication C. Ask open-ended questions D. Allow extra time to communicate with the client

D. Allow extra time to communicate with the client

A nurse is providing teaching to a newly licensed nurse about the purpose of documentation in the client's health record. Which of the following information should the nurse include? A. Allows nurses to document for other nurses on client care B. Authorizes providers to co-sign on nurses' notes C. Grants billing to review client care provided D. Allows health care team members to document client care

D. Allows health care team members to document client care

A nurse on a medical unit is planning care for several clients. Which of the following clients should benefit most from the nurse acting as an advocate? A. A client who has previously undergone a procedure that its to be performed for a second time B. A client who has been educated on treatment options and chooses alternative treatments C. A client who makes informed decisions not to participate in chemotherapy treatment D. An older adult client who has no family and is uncertain about moving to assisted living

D. An older adult client who has no family and is uncertain about moving to assisted living

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength ? A. Ask the client how strong she feels today B. Ask the client to touch her finger to her nose C. Palpate the client's pedal pulses D. Ask the client to push her feet against the nurse's palms

D. Ask the client to push her feet against the nurse's palms

A nurse is reviewing communication styles. Which of the following characteristics should the nurse identify as being exhibited by a passive communicator? Select all that apply. A. Use sarcasm when responding to others B. Rarely interrupt others during conversation C. Tend to blame others for misunderstandings D. Avoid standing up for themselves when boundaries are crosses E. Respond in agreement to avoid conflict F. Use "I" statements rather than "you" statements when communicating

D. Avoid standing up for themselves when boundaries are crosses E. Respond in agreement to avoid conflict

A nurse is assessing a client who is a professional athlete. Which of the following findings should the nurse expect? A. Decreased oxygen saturation B. Hypothermia C. Hypertension D. Bradycardia

D. Bradycardia

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III? A. Testing visual acuity B. Observing for facial symmetry C. Eliciting the gag reflex D. Checking the pupillary response to light

D. Checking the pupillary response to light

The nurse wants to assess for flank pain caused by inflamed kidneys. Which anatomical landmark should use to locate the kidneys? A. Costal margin B. Hypogastric area C. Xiphoid process D. Costovertebral angle

D. Costovertebral angle

A nurse is assessing a client who has dehydration. Which of the following findings should the nurse expect? A. Urine specific gravity of 1.015 B. Cloudy urine C. Urine osmolality of 200 most/kg D. Dark-colored urine

D. Dark-colored urine

A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse? A. Speak using his usual tone of voice B. Stand directly in front of the client C. Rephrase statements the client does not hear D. Determine if the client uses hearing aids

D. Determine if the client uses hearing aids

A nurse is completing a client assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse? A. Symmetrical convex sphere shape B. Concave umbilicus C. Bilateral bowel sounds in lower quadrants D. Ecchymosis

D. Ecchymosis

A nurse is planning to provide discharge teaching for a client who has hearing loss? Which of the following action should the nurse plan to take? A. Dim the lights in the client's room B. Answer client's question using medical terminology C. Increase the rate of speech when talking with the client D. Face the client while talking

D. Face the client while talking

A nurse is teaching a group of teenage clients about the use of condoms for the prevention of sexually transmitted infections (STIs). Which of the following statements should the nurse include in the teaching? A. Use natural membrane condom rather than a polyurethane condom B. You may use a condom more than once C. Use an oil based lubricant when you use a condom D. Female condoms can help prevent transmission of sexually transmitted viruses

D. Female condoms can help prevent transmission of sexually transmitted viruses

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? A. Jugular venous distention B. Abdominal distension C. Dependent edema D. Hacking cough

D. Hacking cough

The section of the healthy history is a complete, clear and chronologic account of the problems prompting the patient to seek care. A. Past History B. Health Patterns C. Chief Complaints D. History of Present Illness (HPI)

D. History of Present Illness (HPI)

A nurse is assessing a client who reports acute pain at a level of 7 on a scale of 0 to 10. Which of the following findings should the nurse expect? A. Decreased respiratory rate B. Bradycardia C. Hypertension D. Hypoglycemia

D. Hypoglycemia

A nurse is teaching a client who has history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. I will keep my walker at the end of my bed B. I will keep the fluorescent ceiling light on in my room at night C. I will place an area rug at the entry of my bathroom D. I will place a bath seat in my shower to use when I bathe

D. I will place a bath seat in my shower to use when I bathe

A nurse is caring for a client whose family wishes to actively participate in the client's care. The nurse encourages and values the family's contribution. The nurse is demonstrating which of the following concepts? A. Assimilation B. Acculturation C. Emic knowledge D. Inclusion

D. Inclusion

A nurse is assessing an older adult client. Which of the following findings should the nurse expect? A. Increased sensitivity of touch B. Increase peripheral vision C. Increase size of pupils D. Increase in cerumen in the ear canal

D. Increase in cerumen in the ear canal

A nurse is teaching a class about vulnerable populations that are at risk for health disparities. The nurse should include that a client who lives in a crowded apartment building is at risk for which of the following conditions? A. Rheumatoid arthiritis B. Weight gain C. Deep vein thrombosis D. Infectious diseases

D. Infectious diseases

A nurse is working in an elderly facility wants to identify who is at risk for falls. Which tool is most appropriate to use? A. functional assessment of ADLs B. cognitive test C. ROM tests D. Morse Falls scale

D. Morse Falls scale

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following is a manifestation of a stage 3 pressure ulcer? A. Exposed bone B. Blood filled blisters C. Partial-thickness skin loss D. Necrotic subcutaneous tissue

D. Necrotic subcutaneous tissue

A nurse is teaching a class about pain management in older adult clients. Which of the following information should the nurse include? A. Pain perception decreased with aging B. Opioids should not be used in older adult clients C. Clients who are cognitively impaired do not feel pain D. Older adult clients frequently underreport pain

D. Older adult clients frequently underreport pain

A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse? A. Clamps the NG tube during auscultation between meals B. Performs auscultation before meals C. Auscultates bowel sounds for 3 to 5 min D. Palpates the abdomen to performing auscultation

D. Palpates the abdomen to performing auscultation

A nurse is teaching a class on professionalism. The nurse should include that which of the following is an example of responsibility? A. Supporting a client's decision to discontinue a treatment B. Contacting a social worker for a client who requires assistance with finances C. Speaking to a provider on behalf of a client D. Performing hand hygiene caring for a client

D. Performing hand hygiene caring for a client

A nurse is caring for a client who recently had a stroke. The client requires assistance with strengthening the affected side. Which of the following referrals should the nurse anticipate the provider to make? A. Social worker B. Occupational therapist C. Respiratory therapist D. Physical therapist

D. Physical therapist

A nurse is caring for a client who is experiencing a stroke. Which of the following actions should the nurse take? (Select all that apply.) A. Loosen restrictive clothing B. Insert a bite stick into the client's mouth C. Place the client into a supine position D. Place a pillow under the client's head E. Apply restraints

D. Place a pillow under the client's head

A nurse is caring for a client who is experiencing suicidal thoughts. Which of the following actions should the nurse take? A. Encourage visitors to bring items to client B. Place the client on 12-hour observation C. Encourage visitors for the client at any time D. Remove harmful objects from the client's room

D. Remove harmful objects from the client's room

A nurse is assessing a client who has pneumonia. Which of the following findings should the nurse expect? A. Hypothermia B. Bradycardia C. Pulse deficit D. Tachypnea

D. Tachypnea

A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse take? A. Use high-pitched tones to speak to client B. Speak to the client using a loud voice C. Stand next to the client's side when speaking D. Talk slowly when speaking to the client

D. Talk slowly when speaking to the client

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data? A. The client can follow simple motor commands B. The client is unable to make vocal sound C. The client is unconscious D. The client open his eyes when spoken to

D. The client open his eyes when spoken to

A nurse is teaching a newly licensed nurse about gynecological examination. Which of the following information should then nurse include in the teaching? A. A speculum is used to assess the perineum B. The cervix is assessed by spreading the labia major C. The anal opening is assessed to visualize the Bartholin glands D. The urethral office is assessed by separating the labia majora

D. The urethral office is assessed by separating the labia majora

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds? A. Crackles B. Rhonchi C. Stridor D. Wheezes

D. Wheezes

A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown? A. an adolescent who has cervical fracture and is in a halo brace B. a young adult who has a femur fracture and is in skeletal balanced suspension traction C. a middle adult who has a fractured radius and an arm cast D. an older adult who has a hip fracture and is in Buck's traction

D. an older adult who has a hip fracture and is in Buck's traction

A nurse is caring for a client with seizure. She wants to know if the client is experiencing an aura prior to an episode. Which of the following is the most appropriate to ask the client to assess for aura? A. are you having palpitations prior to having a seizure? B. do you feel any light-headedness before having a seizure? C. do you feel numbness anywhere when you are having a seizure? D. do you have any warning signs before experiencing a seizure?

D. do you have any warning signs before experiencing a seizure?

Which of the following questions if asked by the nurse, assess for artificial insufficiency in the lower extremities? A. is the pain worse with prolonged standing? B. is the pain in your leg alleviated by elevating your leg on a pillow? C. is the calf painful to touch D. do you have coldness, numbness or pallor in the legs and feet?

D. do you have coldness, numbness or pallor in the legs and feet?

A nurse is teaching a class about cultural bias in health care. The nurse should include that which of the following can occur as a result of cultural bias? A. increased amount of time spent with each client B. improved assessment of clients C. reduced health care disparities D. impaired therapeutic relationship with clients

D. impaired therapeutic relationship with clients

A client tells the nurse that he is concerned because his provider told him he has a heart murmur. The nurse should explain to the client that a murmur? A. is a high-pitched sound due to a narrow valve B. is an extra sound due to blood entering an inflexible chamber C. means that there is some inflammation around the heart D. indicates turbulent blood flow through a valve

D. indicates turbulent blood flow through a valve

The nurse asked a client to turn his face against resistance from the hand of the nurse on his face. Which cranial nerve is the nurse assessing? A. vagus B. glossopharyngeal C. acoustic D. spinal accessory

D. spinal accessory

When assessing older adults, the nurse knows that one of the first things that should be assessed before drawing conclusions about their mental status is: A. their intelligence B. the presence of irrational thinking patterns C. the presence of phobias D. their sensory-perceptive abilities

D. their sensory-perceptive abilities

Which of the following can the nurse instruct the patient to do assess for coordination? A. blink B. clench both fists C. bend laterally D. walk

D. walk

Abbreviation for date of birth

DOB

Dyspnea on exertion?

DOE

What does E stand for in PERRLA?

Equal

What is CN IV?

Eye muscle movement

What is CN VI?

Eye muscle movement (part 2)

VII

Facial

What is CN VII?

Facial muscle movement

When you tell a patient "Show me some muscle", what movement are they demonstrating?

Flexion

Gastrointestinal?

GI

Genitourinary?

GU

IX

Glossopharyngeal

Abbreviation for history of present illness

HPI

What is CN VIII?

Hearing

Define uriticaria

Hives, skin rash with red, raised and itchy bumps

XI

Hypoglossal

Pound(s)?

Ibs

Define pruritus

Intense itching of the skin

What does diameter mean?

Irregular moles are usually >5mm

Liter?

L

Limited Range of Motion

LROM

Lung sounds?

LS

Lung sounds clear to auscultation?

LSCTA

What does OS mean?

Left eye

What does L stand for in PERRLA?

Light

Morse Fall Scale

MFS

Musculoskeletal

MSK

Milligram?

Mg

What CN IX?

Mouth and throat motor movement

What is CN V?

Mouth eye movement

Short term for muscle.

Myo

Nausea?

N

Abbreviation for no know drug allergies

NKDA

Nothing by mouth?

NPO

III

Oculomotor

I

Olfactory

II

Optic

What color is carotene?

Orange

Abbreviation for past medical history

PMH

Define pallor.

Pale or lighter skin color than usual

What color is erythema?

Pink (caucasian)

When the patient's palm is facing down, what is this position called?

Pronation

What does P stand for in PERRLA?

Pupils

What is CN III?

Pupils and eye muscle movement

Abbreviation for rule out

R/O

Right Lower Lobe?

RLL

Right middle lobe?

RML

Range of Motion.

ROM

Right upper lobe?

RUL

What does R stand for in PERRLA?

Reactive

Define Petechiae.

Reddish/purple spots

What does R stand for in PERRLA?

Round

Shortness of breath?

SOB

What is CN I?

Smell

When a patient's palm is facing up, what movement is that called?

Supination

Tablespoon?

Tbsp

Passive range of motion involves ___ moving a joint.

The healthcare provider

What does border mean?

The mole has blurred or jagged edges

What does color mean?

The mole has more than one pigment

Active range of motion means ____ moves joint through its ROM.

The patient

Short term for chest.

Thorac (o)

Short term for blood clot.

Thromb (o)

V

Trigeminal

Which cranial nerves are involved in the face and neck? Select all that apply

Trigeminal Facial Spinal Accessory

IV

Trochlear

Vesicular?

V

Vomit?

V

What is CN X and what is its function?

Vagus: Swallowing, guttural speech sounds, sensation behind ear and part of external ear canal, secretion of digestive enzymes, peristalsis, carotid reflex, involuntary action of heart, lungs and digestive tract.

Short term for veins + arteries.

Vas (c)

What is CN II?

Vision

What color is pallor?

White/Grey

The nurse understands there are 7 attributes of a symptom. Which attribute is the nurse referring to when she asks the patient "is there anything that makes it better or worse?" Select one: a. Relieving/exacerbating factors b. Onset c. Duration d. Associated Manifestations

a. Relieving/exacerbating factors

What does A stand for in PERRLA?

accommodation

Trans is

across

Peri is

around

What does A stand for in ABCDE?

asymmetry

Inter is

between

Define hematoma

blood clot in organ, space or tissue

What color is deoxyhemoglobin?

blue

What does B stand for in ABCDE?

border

What does OU mean?

both eyes

What color is oxyhemoglobin?

bright red

Cup?

c

Abbreviation for complains of

c/o

Abbreviation for chief complaint

cc

Cubic centimeter?

cc

What does C stand for in ABCDE?

color

A nurse is preparing to teach a client who has low literacy level. Which of the following methods should the nurse plan to include? a. emphasize four important points at each sessions b. use a passive voice to explain the information c. refer to the client in the third person during the session d. have short teaching sessions

d. have short teaching sessions

Abbreviation for discharge or discontinue

d/c

Abbreviation for due to

d/t

Define hypopigmentation

decrease in skin color

What does D stand for in ABCDE?

diameter

root= abdomin (o)?

digestive organs in abdomen

Define xerosis

dry skin

Abbreviation for diagnosis

dx

esoph (a) ?

esophagus

What does E stand for in ABCDE?

evolving

Full range of motion.

fROM

My patient is able to properly use a pencil and pen, and utilize their cell phone to sent a text. I can conclude their _____ is intact.

fine motor movement (FMM)

cholecyst ?

gallbladder

Gram?

gm or g

Abbreviation for history

hx

Define Hyperpigmentation

increase in skin color

Define erythema

inflammation of skin area

Kilogram?

kg

colo ?

large intestine

hepat (o) ?

liver

Millimeter?

mL

Define nevus

mole

Define seborrhea

oily skin

Ounce?

oz

Partial range of motion

pROM

Define diaphoresis

profuse perspiration

Abbreviation for related to

r/t

What does OD mean?

right eye

Abbreviation for status post

s/p

Abbreviation for signs & symptoms

s/s

My patient was complaining about how bad their lunch was. By complaining about what they ate, they are exhibiting their ____ intact.

short term memory (STM)

Define vitiligo

skin areas without usual brown pigmentation

Define pigmentation

skin color

ileo ?

small intestines

What is CN XI?

spinal accessory

Define Ecchymosis

spot or blotch larger than petechia, bruises

gastro (o)?

stomach

Define edema

swelling, presence of excess interstitial fluid

What is flatulence?

the passage of gas

What is CN XII?

tongue movement

Teaspoon?

tsp

Endo is

within or inside

Weight?

wt

What color is jaundice?

yellow

Define jaundice

yellowish color of the skin