Javis overall

While assessing the range of motion (ROM) of a client a nurse should? SATA

?

Upon admission to the surgical unit, a nurse obtained a clients pulse and respiratory rates and noted an irregular pulse rhythm. The nurses next action should be to ? a. document the findings in the client's chart B. ask the client had recently exercised. C. notify the physician D. check the client for a pulse deficit

???/D. check the client for a pulse deficit

The movement of the leg in the picture below is referred to as ? A. adduction B. Abduction C. Extension D. Flexion

B. Abduction

An 85 year old client is lyesturgic and hypotemive. When the nurse assesses the clients tounge its appears dry, cracked with deep furorws. These findings suggest what a. The aging process b. dehydration c. infection d. poor oral hygeine

B. dehyration

While assessing a client's wrist and hand, a nurse asks him to turn his hand palm upward to turn his hand palm downward. These positions of the hand are referred to as See the picture below a. 1= flexion, 2= Extension B. 1= extension, 2= flexion C. 1= pronation, 2= supination D. 1= supination, 2= pronation

D. 1= supination, 2= pronation

While auscultating a clients lungs a nurse hears adventitious breath sounds at the bases. Which of the following would the nurse do first ? a. Refer the client for further medical evaluation B. Auscultate for egophony C. Preform bronchophony D. Ask the client to cough and then listen again

D. Ask the client to cough and then listen again

A client tells a nurse that they are very unsteady on their feet and have difficulty maintaining their balance. Based on these findings, which areas of the brain would the nurse be most concerned? A. extrapyramidal tract B. Thalamus C. Brain Stem D. Cerebellum

D. Cerebellum

During a neurological assessment a nurse asks a client to frown, wrinkles their forehead, smile, and puff out their cheeks. These maneuvers assess which of the following cranial nerves? A. Cranial Nerce IV (Trochlear) B. Cranial Nerve V ( Trigeminal ) C. Cranial nerce VI ( Abducens) D. Cranial Nerce VII (facials)

D. Cranial Nerce VII (facials)

73. While assessing the muscle strength of a client a nurse should a. Assess each muscle for strength and range of motion b. Assess each muscle group for strength only c. Document findings using a 1-4 grading scale d. Document normal findings as grade 4

a. Assess each muscle for strength and range of motion

80. A school nurse notices that a girl in gym class is unable to move her arms to effectively jump rope. In order to jump rope the shoulder must be capable of a. Adduction b. Protraction c. Circumduction d. Abduction

c. Circumduction

67. A nurse encourages a client who had surgery two days ago for shoulder repair to perform active range of motion exercises as prescribed by the client's physician. The client begins to raise his arm and then stops ad says, "I am afraid to make it hurt." The best response by the nurse would be a. "You will get a contracture if you don't do these exercises." b. "If you will do these exercises, I will give you a pain medication right afterwards." c. "I will call the doctor to ask for a consult with a physical or occupational therapist." d. "Let me try using passive range of motion on your arm first."

d. "Let me try using passive range of motion on your arm first."

54. The nurse is caring for a client who asks about the functions of the thymus, spleen, and lymph nodes. Which of the following responses is correct? a. "These organs assist vitamin absorption." b. "These organs regulate electrolyte balance." c. "These organs are used in digestion." d. "These organs support immunity."

d. "These organs support immunity."

34. A nurse is preparing to perform an abdominal assessment on a client. Identify the sequence of steps the nurse should take to conduct the assessment 1. Auscultate the abdomen for bowel sounds 2. Inspect the abdomen for skin integrity 3. Ask if the client has abdominal pain 4. Palpate the abdomen lightly for tenderness 5. Percuss the abdomen in each of the four quadrants i. 3,2,1,5,4 i. 2,1,3,5,4 ii. 3,1,2,5,4 iii. 2,1,4,5,3

i. 3,2,1,5,4

A patient states, " I hear a crushing or grating sounds when I kneel. It is very difficult to get out of bed in the morning because of stiffness and pain in my joints." The nurse should assess for signs of what problems? A. Crepitation B. Bone sprain C. Loose tendon D. FLuid in the knee joint

A. Crepitation

A nurse is performing a physical assessment on a client and notes the findings as seen in the picture below. These findings support SATA A. Clubbing B. bilateral 3+ edema C. nail bed angle > 180 D. Neuromuscular defects E. Possible respiratory problems

A. Clubbing C. nail bed angle > 180 E. Possible respiratory problems

The wife of a 65 year old women reports her husband personality had changed. He cries very easily and becomes very angry. The nurse recalls a certain lobe is responsible for these behavior which lobe is it ? A. frontal B. parietal C. temporal D. occipital

A. frontal

During-the neurologic assessment of an adult well visit, the nurse asks the patient to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find? a. Firm, rigid, resistance to movement B. Mild, even resistance to movement C. Hypotonic muscle as a result of total relaxation D. Slight pain with some direction of movement

B. Mild, even resistance to movement ??

While performing a skin assessment of an 82 year old client, which of the following findings would suggest possible elder abuse? A. Purpura on both shoulders B. Port-wine stain on the forehead C. Wounds in various stages of healing D. Lichenification on the soles of both feet

C. Wounds in various stages of healing

The nurse has completed the musculoskeletal examination of a patient's knee and has found a positive bulge sign. The nurse interprets this finding to indicate: A. Irregular bony margins B. soft tissue swelling in the joint C. Swelling from fluid in the epicondyle D. Swelling from fluid in the suprapatellar pouch

D. Swelling from fluid in the suprapatellar pouch

76. A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find? a. Lordosis b. Ankylosis c. Kyphosis d. Scoliosis

c. Kyphosis

66. A nurse is conducting an interview with a 75 year old post-menopausal client. Which of the following focused questions would be appropriate to assess bone heath? Select all that apply a. "Do you exercise regularly?" b. "What is your marital status?" c. "Tell me about your usual diet?" d. "Do you take hormone replacement therapy?" e. "When was your last menstrual period?"

a. "Do you exercise regularly?" c. "Tell me about your usual diet?" d. "Do you take hormone replacement therapy?"

58. Which of the following statements is true regarding the function of the brain? a. Hypothalamus is the center for speech and emotions b. Basal ganglia are responsible for controlling voluntary movements c. Temporal lobe controls sensations and visual reception d. Cerebellum controls balance and coordination

a. Hypothalamus is the center for speech and emotions

71. A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? a. Increased respiratory rate from 18 to 28 breaths per minute b. Increase blood pressure from 112/68 to 120/72 mmHg c. Increased heart rate from 68 to 82 beats per minute d. Increased oral temperature from 36.5 C to 37.4 C

a. Increased respiratory rate from 18 to 28 breaths per minute

3. A nurse is nearing the end of an interview. Which statements by the nurse is appropriate at this time? a. "Did we forget something?" b. "Is there anything else you would like to mention?" c. "I need to go on to the next patient. I will be back." d. "While I am here, let's talk about your upcoming surgery."

b. "Is there anything else you would like to mention?"

38. A client comes to the clinic with a chief complaint of infection in his left hand and wrist. Which of these findings should the nurse expect to see during an assessment of this client? a. Left-sided hard and fixed cervical nodes b. Left-sided enlarged and tender inguinal nodes c. Left-sided enlargement of the epitrochlear lymph nodes d. Left-sided "pellet-like" nodes in the supraclavicular region

c. Left-sided enlargement of the epitrochlear lymph nodes

27. Using the diagram below, identify the precordial landmark for auscultating the tricuspid valve. a. 1 b. 2 c. 3 d. 4 e. 5

d. 4

Which of the following statements are true regarding normal physiological musculoskeletal changes in older adults ? SATA A. Height may decrease B. ROM may decrease C. Bone demineralization occurs D. Subcutaneous tissue and weight increase

A. Height may decrease B. ROM may decrease C. Bone demineralization occurs

While conducting an eye assessment, a 77-year-old client reports to the nurse that he has difficulty seeing the LEFT side of the picture placed on the wall. The nurse would document these findings as (See image below) : A. left visual field deficit B. Right visual field deficit C. Ectropion D. Nystagmus

B. Right visual field deficit

A client had a left mastectomy 1 year ago. While assessing the clients's arms, a nurse notices that the clients left arm is swollen from the shoulder down to the fingers with non-pitting brawny edema. No swelling of the right arm is noted. These findings suggest which of the following? A. Venous stasis B. lymphedema C. Arteriosclerosis D. Deep vein thrombosis

B. lymphedema

While conducting a physical examination of the abdomen, a nurse observes pulsation in the epigastric area. The client tells the nurse " i have a funny moving sensation in my belly" Given these findings in what order would the nurse conduct the abdominal assessment over the epigastric area? A. inspection, palpation, auscultation B. Auscultation, inspection, palpation C. Inspection auscultation, palpation D. Auscultation, percussion, inspection

C. Inspection auscultation, palpation

The results of a near vision test in an adults is 14/14. The nurse would consider these findings to be a. Presbyopia B. Stabismus C. Abnormal findings D. Expected findings

D. Expected findings

A nurse palpates just under the ligament in order to assess which of the following pulses? A. Pedal pulse B. Brachial Pulse C. popliteal pulse D. Femoral pulse

D. Femoral pulse

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

D. Instruct the client to look up and down without moving his ear

A client comes in with a thick bronchial secretion, the nurse would expect to palpate: A. decreased fremitus B. increased fremitus C. phonchal fremitus D. Pleural friction fremitus

D. Pleural friction fremitus

Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called: A. bursa B. tendons C. Muscles D. ligaments

D. ligaments

61. During an assessment of the neurological system, a nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding? a. Stereognosis b. Graphesthesia c. Extinction d. Tactile discrimination

a. Stereognosis

44. A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? Select all that apply a. Tachycardia b. Tachypnea c. Weak pulse d. Low blood pressure e. Bibasal crackles

a. Tachycardia b. Tachypnea e. Bibasal crackles

18. A 50 year old client is admitted to the emergency Department following a motor vehicle accident. Chest X-Ray reveals left-sided pneumothorax. Which of the following assessment findings would the nurse expect when examining this client? Select all that apply. a. Tachycardia, cyanosis b. Tracheal deviation to the left c. Hyperresonance on the left side of the chest d. Decreased breath sounds on the affected side e. Increased anterior-posterior diameter = 2:2

a. Tachycardia, cyanosis c. Hyperresonance on the left side of the chest d. Decreased breath sounds on the affected side e. Increased anterior-posterior diameter = 2:2

15. A nurse assesses four clients. Which client assessment will require the nurse to perform an immediate focused assessment? a. Difficulty sleeping at night b. 3+ edema in the ankles c. Lack of bowel movement in 2 days d. Blanchable erythema in the sacral area

b. 3+ edema in the ankles

33. Before assessing the client's jugular venous pressure, a nurse should position the head of the bed to how many degree elevation? a. 0 degrees b. 45 degrees c. 60 degrees d. 90 degrees

b. 45 degrees

16. A nurse is educating a group of older adults about weight management using the BMI scale. Which of the following clients has a healthy BMI? a. 70 year old female with a weight of 128 lbs. and height of 70 inches. b. 65 year old male with a weight of 150 lbs. and height of 68 inches c. 78 year old male with a weight of 200 lbs. and height of 72 inches d. 90 year old female with a weight of 133 lbs. and height of 60 inches.

b. 65 year old male with a weight of 150 lbs. and height of 68 inches

41. A nurse is caring for a hospitalized client with a rectal bleeding. Which of the following findings would the nurse report immediately to the physicians? a. Hypertension b. Bloody diarrhea c. Rebound tenderness d. T = 99.2 degrees F oral

b. Bloody diarrhea

25. When assessing the carotid arteries of a 72 year old client with a history of peripheral vascular disease, a nurse would first a. Auscultate using the diaphragm of the stethoscope b. Palpate the carotid arteries simultaneously c. Auscultate using the bell of the stethoscope d. Inspect for signs of bruits

c. Auscultate using the bell of the stethoscope

53. Which of the following would be considered an expected finding when assessing accommodation in an adult client? a. Dilation of pupils and convergence of eyes bilaterally b. No change in pupil size and parallel alignment of both eyes c. Constriction of pupils and convergence of eyes bilaterally d. Nystagmus when object is moved close to the client's nose

c. Constriction of pupils and convergence of eyes bilaterally

78. A nurse is assessing the reflexes of a client who suddenly becomes stuporous. Which of the following findings indicates that the client is exhibiting Babinski's Sign? a. Pinpoint pupils b. Pronation of the arm c. Dorsiflexion of the great toe d. Hamstring muscle spasm

c. Dorsiflexion of the great toe

10. When conducting a focused assessment of an older adult, the nurse would assess the client's a. Physical signs of aging b. Immunological function c. Functional abilities d. History of chronic illness

c. Functional abilities ???

9. A nurse needs to obtain anthropometric measures of an 80 year old client. Which of the following statements is true regarding this situation? a. Increased muscle mass will affect the mid-calf circumference measurements b. Muscle atrophy will increase BMI c. Height may decrease due to changes in bone density d. Increased skin elasticity will affect the waist-hip ratio

c. Height may decrease due to changes in bone density

2. A nurse asks a student to describe the term abdominal borborygmi. The student's response should include which of the following? a. Loud continual hum b. Peritoneal friction rub c. Hyperactive bowel sounds d. Hypoactive bowel sounds

c. Hyperactive bowel sounds

23. A client was admitted to the emergency department for a suspect drug overdose. Respirations are shallow and irregular with a rate of 9 per minute. The nurse would interpret this respiration pattern as a. Tachypnea b. Cheyne-Strokes respirations c. Hypoventilation d. Agonal breathing

c. Hypoventilation

26. During a cardiovascular assessment of an 80-year old adult a nurse should consider which of the following as expected findings? a. Narrowing of the inferior vena cava causing bilateral lower extremity varicosities b. Hormonal changes causing vasodilation resulting in hypotension c. Peripheral blood vessels become more rigid producing a rise in systolic blood pressure d. Atrophy of the muscles causing venous insufficiency

c. Peripheral blood vessels become more rigid producing a rise in systolic blood pressure

51. When preforming a physical assessment of a client's maxillary sinuses to determine the presence of an infection, the nurse should a. Apply pressure anteriorly to the tragus b. Ask if the client has a history of sinus infections c. Press above and below the cheek bones d. Ask if the client has a history of headaches

c. Press above and below the cheek bones

42. The day after abdominal surgery, a nurse auscultates a client's abdomen and notes faint bowel sounds in all four quadrants. The client also reports experiencing flatus. The nurse interprets those findings as a. Gastroenteritis b. Intestinal obstruction c. Return of peristalsis d. Paralytic ileus

c. Return of peristalsis (involuntary constriction or release of bowel movement )

47. Which of the following tests should the nurse perform to assess a client who has varicose veins? a. Arteriography b. Romberg's Test c. Trendelenburg Test d. Iliopsoas Test

c. Trendelenburg Test

While assessing the spine of client A the nurse notes the findings below. While assessing the spine of client B the nurse notes the findings below. These findings suggest which of the following conditions? a. client a= scoliosis, client= kyphosis b. client a= scoliosis, client= Lordosis C. client a= kyphosis, client= scoliosis D. client a= lordosis, client= kyphosis

client a= scoliosis, client= kyphosis

12. A client reports eating 3 servings a day every day for a week of the item below. How many total calories from fat did the client consume in 7 days? a. 164 calories b. 227 calories c. 1462 calories d. 1701 calories

d. 1701 calories

17. The client smoked 2 packs of cigarettes a day for 10 years and then 1 pack-a-day for 3 years. The nurse would calculate the smoking pack years as a. 3.5 pack years b. 11.5 pack years c. 20 pack years d. 23 pack years

d. 23 pack years **(40/20) * 10 = 20 + (20/20) * 3 = 3 = 23**

79. While performing a peripheral vascular assessment of an adult client, the nurse should palpate the posterior tibial pulse in which of the following locations? Refer to diagram below a. 1 b. 2 c. 3 d. 4 e. 5

d. 4

20. While auscultating a client's lungs, a nurse hears adventitious breath sounds at the bases. Which of the following would the nurse do first? a. Refer the client for further medical evaluation b. Auscultate for egophony c. Perform bronchophony d. Ask the client to cough and then listen again.

d. Ask the client to cough and then listen again.

32. A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take first? a. Assess the pedal pulses with a Doppler b. Assess the pedal pulses for a full minute c. Assess the apical pulse with a Doppler d. Assess the apical pulse for a full minute

d. Assess the apical pulse for a full minute

1. When obtaining a cardiovascular health history the nurse should ask the client which of the following questions? Select all that apply. a. "Have you had any recent changes in your weight?" b. "Do you know your triglyceride and cholesterol levels?" c. "How often do you have a bowel movement?" d. "Are you able to perform your ADLs?" e. "Do you suffer from sinusitis or have a runny nose?"

a. "Have you had any recent changes in your weight?" b. "Do you know your triglyceride and cholesterol levels?" d. "Are you able to perform your ADLs?"

45. A client was admitted to the hospital with a medical diagnosis of intestinal obstruction. Which of the following assessment findings would a nurse expect given this diagnosis? a. Abdominal distention, hypoactive bowel sounds, no bowel movements for 3 days b. Hyperactive bowel sounds, prominent abdominal veins, nausea and vomiting c. Abdominal distention, hyperactive bowel sounds, poor skin turgor d. Diarrhea for 2 days, round abdomen, borborygmus

a. Abdominal distention, hypoactive bowel sounds, no bowel movements for 3 days

70. A nurse is testing the deep tendon reflexes of a 45 year old client. When striking the Achilles heel and quadriceps muscle, the nurse is unable to elicit a reflex. The nurse's next action should be to a. Ask the client to lock their fingers and pull b. Document reflexes as 0 on a scale of 0 to 4+ c. Refer the client to a specialist for further testing d. Complete the exam and then test these reflexes again.

a. Ask the client to lock their fingers and pull

46. A nurse is assessing a client who reports new skin lesions on the back as seen in the picture below. The nurse should document the lesions as a. Confluent b. Annular c. Petichiae d. Circular

a. Confluent

28. While performing a peripheral vascular assessment of a client, a nurse is unable to palpate ulnar pulses bilaterally. The client's skin is warm and dry and capillary refill time is <2 seconds. Based on these findings the nurse would a. Consider these normal findings b. Refer the client for a vascular consult in one week c. Ask client if they have numbness or tingling in her left arm d. Check for the presence of claudication bilaterally

a. Consider these normal findings

64. The nurse stands behind the client and whispers the word "lava." This technique is use to assess which of the following Cranial Nerves? a. Cranial Nerve IV (Trochlear) b. Cranial Nerve VI (Abducens) c. Cranial Nerve VIII (Vestibulocochlear) d. Cranial Nerve X (Vagus)

a. Cranial Nerve VIII (Vestibulocochlear)

6. Upon entering the client's room, a nurse asks the client to turn down the volume of the television. The nurse's request was intended to a. Create a quiet environment b. Control the client's behavior c. Manipulate the client's responses d. Uphold unit policy.

a. Create a quiet environment

39. A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? Select All that apply a. Dyspnea b. Barrel chest c. Clubbing of the fingers d. Bradycardia

a. Dyspnea(difficulty breathing) b. Barrel chest c. Clubbing of the fingers

14. A client arrives in the Emergency Department via ambulance with the following signs: ptosis of the left eye, increase left-sided nasolabial fold, and slurred speech. What priority level should the nurse identify for this client? a. First level priority b. Second level priority c. Third Level priority d. Routine

a. First level priority

60. An adult client is admitted to the nursing unit with a medical diagnosis of Acute Stroke. The client does not respond to verbal stimuli. In this situation, what is the best action by the nurse to provoke a client response? a. Gently shake the client's shoulders b. Squeeze the trapezius muscle c. Apply pressure to the temporomandibular joint (TMJ) d. Press hard on the client's sternum

a. Gently shake the client's shoulders

72. While assessing a client's right knee joint, a nurse should a. Inspect join shape, contour, and ROM while supine and during ambulation. b. Percuss the knee with thumb and fingers for adults c. Consider a bulge sign as normal findings for adults d. Consider swelling as a normal sign of again.

a. Inspect join shape, contour, and ROM while supine and during ambulation.

11. While assessing an adult client's cardiovascular system, where should the nurse palpate for pulsations in the pulmonic area? a. Left second intercostal space b. Right second intercostal space c. Left fifth intercostal space d. Right fifth intercostal space

a. Left second intercostal space

52. While conducting an eye assessment, a client reports to the nurse that he has difficulty seeing the right side of the pictures placed on the wall (See images below). The nurse would document these findings as a. Left visual field deficit b. Right visual field deficit c. Bilateral visual field deficit d. Nystagmus

a. Left visual field deficit

75. A nurse is caring for a client who suddenly becomes confused and drowsy. Vital signs: Pulse = 98/min, Respiratory Rate = 24/min, BP = 132/76 mmHg, and Temperature = 36.8 C orally. Which of the following actions should the nurse perform first? a. Neurologic Assessment b. Cardiac Assessment c. Respiratory Assessment d. Abdominal Assessment

a. Neurologic Assessment

22. A nurse suspects that a client has cholecystitis. Which of the following tests should the nurse perform to assess the client's abdomen? a. Obturator test b. Rebound tenderness c. Murphy's sign d. Iliopsoas muscle test

c. Murphy's sign

55. While asking a client to look straight ahead, a nurse shines a light into the eyes and notes that the light reflects asymmetrically on the corneas. The nurse would document these findings as a. Positive Hirschberg Test b. Negative Romberg Test c. Normal findings d. Impaired visual acuity

a. Positive Hirschberg Test

24. A client who has no significant medical history is admitted to the emergency department with difficulty breathing. Which of the following assessment finds should be of most concern to the nurse? a. Pulse oximetry reading of 90% b. Low-pitched wheezing in lower lobes c. Report of dyspnea on exertion d. Respiratory rate of 22 per minute

a. Pulse oximetry reading of 90%

50. A nurse is auscultating a client's heart sounds and hears an extra heart sound at the beginning of the cardiac cycle. The nurse should document this finding as which of the following heart sounds? a. S4 b. S1 c. S3 d. Split S2

a. S4

56. While a nurse conduct the Weber Test, the client states that the vibrations are louder in the right ear than the left ear. The findings suggest a. Sensorineural of conductive hearing loss b. Inflammation of the ear canal in the left ear c. Normal age-related findings d. AC>BC

a. Sensorineural of conductive hearing loss

1. What type of data does the nurse collect during the interview portion of a comprehensive health assessment? a. Subjective b. Historical c. Objective d. Physical

a. Subjective

29. A nurse is assessing a client for dehydration. Which of the following findings should the nurse expect if dehydration is present? a. Protruding eyeballs b. Dry furrows in the tongue c. Elevated blood pressure d. Bradycardia

b. Dry furrows in the tongue

37. A nurse is caring for a client who is being evaluated for acromegaly. Which of the following should the nurse expect to observe inspection? a. Moonlike face b. Enlarged distal extremities c. Facial drooping d. Sunken eyeballs

b. Enlarged distal extremities

65. A client was admitted from the emergency department with a medical diagnosis of Stroke. The client opens their eyes when spoken to, has localized movements in response to painful stimuli, and their verbal responses are not appropriate to the situation. Using the scale below, the nurse would document the client's Glasgow Come Scale as a. GCS = 8 b. GCS =11 c. GCS= 10 d. GCS= 9

b. GCS =11

4. While conducting a cultural health assessment a nurse should include which of the following? a. Medical history b. Health-related beliefs c. Chief complaint d. Family history

b. Health-related beliefs

36. While performing an assessment of an adult client who was admitted to the Emergency Department with chest pain, a nurse notes the following findings: BP = 98/60, HR = 130, jugular vein pulsations = 4cm. above the sternal angle while the client's HOB is elevated at 45 degrees, difficulty breathing when supine, bilateral ankle edema, and an S3 heart sound on auscultation. Which of the following conditions best explains these findings? a. Pulmonary Embolism b. Heart Failure c. Myocardial infarction d. Atrial septal defect

b. Heart Failure

59. A nurse is assessing a client who was involved in a motor-vehicle accident. Which of the following techniques should the nurse use to test corneal reflexes? a. Visualize the red reflex of the eye b. Lightly touch the eyes with a wisp of cotton c. Instill drops of dye into the eyes d. Examine the eyes with a penlight

b. Lightly touch the eyes with a wisp of cotton

7. A nurse is reviewing data collected after conducting a health assessment. Which of the following would be considered related cues that would be clustered together during data analysis? Select all that apply. a. Hypoactive bowel sounds b. Nonproductive cough c. Respiratory rate of 16 breaths per minute d. Inspiratory wheezing noted in the left lower lobes e. 2+ edema noted on the left hand

b. Nonproductive cough c. Respiratory rate of 16 breaths per minute d. Inspiratory wheezing noted in the left lower lobes

68. While assessing a client's gait during ambulation, which of the following would indicate a need for further evaluation? a. Heels strike the ground before the toes b. Right arm and leg move forward together c. Each foot raises off the floor with each step d. Feet stay parallel when moving forward

b. Right arm and leg move forward together

74. While assessing the left hip joint of a client, a nurse would consider which of the following to be normal findings? a. Pain score = 5 on palpation b. Symmetrical iliac crests, gluteal folds, and buttocks c. Presence of small subcutaneous nodules in the older adult d. Redness and swelling over the joint

b. Symmetrical iliac crests, gluteal folds, and buttocks

5. A nurse is admitting an adult male client who was transferred to a long-term care facility. The nurse should use closed-ended questions when assessing if the client a. Is eating a well-balanced diet b. Took his medications this morning ( b) c. How he completes his ADLs d. About how he feels about the transfer

b. Took his medications this morning

30. A client has a history of mitral valve stenosis and murmur. What action should the nurse take to auscultate this murmur? a. Use the diaphragm of the stethoscope b. Use the bell of the stethoscope c. Ask the client to turn on his right side d. Place the client in the supine position

b. Use the bell of the stethoscope

13. When evaluating a client's report of acute pain in the lower back, pain score=8, a nurse should consider which of the following as the most likely source of the pain? a. Fibromyalgia b. Lordosis c. Kidney stones d. Arthritis

c. Kidney stones

21. Which of the following respiratory assessment findings is expected in a healthy adult client? a. Adventitious sounds and limited chest expansion b. Increased tactile fremitus and dull percussion tones c. Muffled voice sounds and symmetrical tactile fremitus d. Absent voice sounds and hyperresonant percussion tones

c. Muffled voice sounds and symmetrical tactile fremitus

57. While performing an otoscopic examination of a client's ears, a nurse cannot visualize the cone of light in the right ear. The cone of light in the left ear is located at the 7 o'clock position. These findings might suggest a. Hearing loss in the left ear b. Perforated tympanic membrane in the left ear c. Otisis media in the right ear d. Increase cerumen in the left ear

c. Otisis media in the right ear

8. A nurse is planning to use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the "B" step? a. "The client should be seen by a neurologist." b. "The client is disoriented; pupils are slow to respond to light" c. "There are no provider's prescriptions available" d. "The client was found unconscious on the floor at home"

d. "The client was found unconscious on the floor at home"

19. A nurse would anticipate hearing which type of breath sounds at the site indicated on the picture below? a. Adventitious b. Bronchial c. Vesicular d. Bronchovesicular

d. Bronchovesicular

40. A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the client's affected arm? a. A bounding distal pulse b. Acute pain c. Ecchymosis of the surrounding skin d. Increasing edema

d. Increasing edema

77. A nurse is caring for a client who has a fracture right femur. Which of the following techniques should the nurse perform to assess the neurovascular status of the client's right leg? a. Measure the circumference of the thigh b. Palpate the radial pulse c. Monitor the client's calf for edema d. Instruct the client to wiggle his toes

d. Instruct the client to wiggle his toes

35. A nurse is caring for a client who has diverticular disease of the sigmoid colon. When palpating the client's abdomen, in which of the following locations should the nurse expect the client to report pain? a. Upper right quadrant b. Lower right quadrant c. Upper left quadrant d. Lower left quadrant

d. Lower left quadrant

49. A client reports having pain when swallowing medications and food. The nurse would document these findings as a. Dysphasia b. Dysphagia c. Aphasia d. Odynophagia

d. Odynophagia

62. A nurse is caring for a client who has a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which if the following types of disability? a. Paresthesia b. Quadriplegia c. Hemiplegia d. Paraplegia

d. Paraplegia

43. To enhance muscle relaxation prior to an abdominal examination the nurse would a. Avoid examination of painful areas b. Expose the chest and abdomen for examination c. Ensure adequate lighting d. Place a small pillow under the knees.

d. Place a small pillow under the knees.

48. A client tells a nurse that "this dark spot on my left shoulder has gotten bigger, changed from a reddish to a brownish color, and used to be flat but is now like a small bump." The nurse knows that these findings may suggest a. That the client does not use UV protection b. That there is nothing to be concerned about c. Normal would healing d. Possible malignancy

d. Possible malignancy

69. While assessing the Range of Motion (ROM) of a client a nurse should: Select all that apply. a. force the joint beyond its normal range b. stop passive motion if the client expresses pain c. use the same techniques for clients of all ages d. compare bilateral strength and mobility e. note presence and location of crepitation

d. compare bilateral strength and mobility e. note presence and location of crepitation b. stop passive motion if the client expresses pain