NUR133

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye? A.Test the corneal reflexes. B.Test the 6 cardinal positions of gaze. C.Test visual acuity, using a Snellen eye chart. D.Test sensory function by asking the client to close the eyes and then lightly touching the forehead, cheeks, and chin.

B

The nurse is testing a client for graphesthesia and asks the client to close his eyes. The nurse should next ask the client to take which action? A.Identify 3 objects placed in the hand, 1 at a time. B.Identify 3 numbers or letters traced in the client's palm. C.Identify the smallest distance between 2 skin pricks after pricking the skin with 2 pins at varying distances. D.State whether 1 or 2 skin pricks are felt, after applying sharp stimuli bilaterally to symmetrical areas of the client's skin.

B

The nurse would perform which action to assess for a pulse deficit? A.Count the carotid pulsations for 1 full minute. B.Measure the blood pressure in both the arm and leg. C.Auscultate the apical heartbeat while palpating the radial artery. D.Place the diaphragm of the stethoscope directly over the skin at the mitral area.

C

The emergency department nurse is performing an assessment on a child suspected of being sexually abused. Which assessment data obtained by the nurse most likely support this suspicion? A.Poor hygiene B.Difficulty walking C.Fear of the parents D.Bald spots on the scalp

C

In what area of the chest would the nurse expect to auscultate these breath sounds? clear lung sounds A.Over the peripheral lung fields B.Over the manubrium in the large tracheal airways C.Anteriorly and posteriorly over the major bronchi D.Throughout the chest and in the bases of the lungs

C

The nurse is reviewing a client's record and notes that the result of a vision test using a Snellen chart is 20/30. How should the nurse explain these results to the client? A."You have normal vision." B."You have some degree of blindness." C."You can read at a distance of 20 ft (6 meters) what a person with normal vision can read at 30 ft (9 meters)." D."You can read at a distance of 30 ft (9 meters) what a person with normal vision can read at 20 ft (6 meters)."

C

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which? A.Lub-dub sounds B.Scratchy, leathery heart noise C.A blowing or swooshing noise D.Abrupt, high-pitched snapping noise

B

The nurse prepares to take the blood pressure of a school-age child. To obtain an accurate measurement, how should the nurse position the blood pressure cuff? A.One half of the distance between the antecubital fossa and the shoulder B.One third of the distance between the antecubital fossa and the shoulder C.Two thirds of the distance between the antecubital fossa and the shoulder D.One quarter of the distance between the antecubital fossa and the shoulder

C

The nurse reviews the findings from a physical exam done on a client for ear or hearing disorders and notes documentation that the client has hyperacusis. Which would the nurse expect to note on assessment of the client? A.Complaints of ringing in the ear B.An excessive amount of cerumen in the ear canal C.Intolerance for sound levels that do not bother other people D.Complaints of dizziness and sensations of being "off balance"

C

A child is seen in the school nurse's office with complaints of pain in his right forearm. In reviewing the child's record the nurse notes that he has a history of being physically abused by the mother. Which should be the initial intervention with this child? A.Assess the child's physical status. B.Ask the child how the injury occurred. C.Report the case as suspected child abuse. D.Observe the interactions between the child and his friends

A

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply. A.Auscultating lung sounds B.Obtaining the client's temperature C.Assessing the strength of peripheral pulses D.Obtaining information about the client's respirations. E.Performing a musculoskeletal and neurological examination F.Asking the client about a family history of any illness or disease

A,B,D

The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply A.Set the room temperature at a comfortable level. B.Remove distracting objects from the interviewing area. C.Place a chair for the client across from the nurse's desk. D.Ensure comfortable seating at eye level for the client and nurse. E.Provide seating for the client so that the client faces a strong light. F.Ensure that the distance between the client and nurse is at least 2 feet (2.1 meters).

A,B,D

The nurse is preparing to test the sensory function of cranial nerve V in a client. The nurse should obtain which item to test the sensory function of this nerve? A.Coffee beans B.A tuning fork C.A wisp of cotton D.An ophthalmoscope

B

A chest x-ray report states that the client has a left apical pneumothorax. The nurse caring for the client monitors the status of breath sounds in that area by placing the stethoscope at which location? A.Near the lateral 12th rib B.Just under the left clavicle C.In the fifth intercostal space D.Posteriorly under the left scapula

B

The nurse has obtained a personal and family history from a client with a neurological disorder. Which factors in the client's history are associated with added risk for neurological problems? Select all that apply. A.Allergy to pollen B.History of headaches C.Previous back injury D.History of hypertension E.History of diabetes mellitus

B

The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse implement to test the motor function of this nerve? A.Ask the client to puff out the cheeks. B.Separate the client's jaw by pushing down on the chin. C.Place a small amount of sugar on the client's tongue and ask him or her to identify the taste. D.Ask the client to rotate the head forcibly against resistance applied to the side of his or her chin.

B

The nurse is performing a physical examination on an assigned client. Which item should the nurse select to test the function of cranial nerve II? A.Flashlight B.Snellen chart C.Reflex hammer D.Ophthalmoscope

B

The nurse is planning to test the sensory function of the olfactory nerve (cranial nerve 1). The nurse would gather which items to perform the test? A.Tuning fork and audiometer B.Cloves, peppermint, and soap C.Flashlight, pupil size chart, and millimeter ruler D.Safety pin, hot and cold water in test tubes, and cotton wisp

B

A confrontation test is prescribed for a client seen in the eye and ear clinic. How should the nurse perform this test? Arrange the actions in the order that they should be performed. All options must be used. A.Asks the client to cover 1 eye B.Examiner covers eye opposite to the eye covered by the client. C.Asks the client to report when object is first noted. D.Stands 2 to 3 ft (60 to 90 cm) in front of client and faces the client. E.The examiner brings in an object gradually from periphery

B,C,E,A,D

A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which is the best action for the nurse to take? A.Have 1 of the client's family members interpret. B.Have the Spanish-speaking triage receptionist interpret. C.Page an interpreter from the hospital's interpreter services. D.Obtain a Spanish-English dictionary and attempt to triage the client.

C

A client is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to use in obtaining the client's health history? A.Focus only on the physical examination. B.Obtain all information from family members. C.Plan short sessions with the client to obtain data. D.Use the primary health care provider's medical history

C

A client is diagnosed with external otitis. Which finding would the nurse expect to note on assessment of the client? A.A wider than normal ear canal B.A pearly gray tympanic membrane C.Redness and swelling in the ear canal D.An excessive amount of cerumen lodged in the ear canal

C

The registered nurse (RN) is educating a new RN on how to interpret vision tests using a Snellen chart. After the client's vision is tested with a Snellen chart, the results of testing are documented as 20/40. Which statement by the new RN indicates that the teaching has been effective? A."The client's vision is normal, but the client may require reading glasses." B."The client is legally blind, and glasses or contact lenses will not be helpful." C."The client can read at a distance of 40 ft (12 meters) what a person with normal vision can read at 20 ft (6 meters)." D."The client can read at a distance of 20 ft (6 meters) what a person with normal vision can read at 40 ft (12 meters)."

C

When assessing a client's liver during an assessment, the nurse should palpate which abdominal quadrant? A.Left upper quadrant B.Left lower quadrant C.Right upper quadrant D.Right lower quadrant

C

The nurse is performing an abdominal assessment on a client. The nurse determines that which finding should be reported to the primary health care provider (PHCP)? A.Absence of a bruit B.Concave, midline umbilicus C.Pulsation between the umbilicus and the pubis D.Bowel sound frequency of 15 sounds per minute

C.Pulsation between the umbilicus and the pubis

The nurse is assessing a client with a history of cardiac problems. Where should the nurse place the stethoscope to hear the first heart sound (S1) the loudest? A.Over the second intercostal space at the left sternal border B.Over the fourth intercostal space at the right sternal border C.Over the second intercostal space at the right sternal border D.Over the fifth intercostal space in the left midclavicular line

D

The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How should the nurse best determine the presence of erythema? A.Assess for drainage from the wound. B.Assess for redness around the wound edges. C.Palpate for swelling around the wound edges. D.Palpate for increased skin temperature around the wound edges.

D

The nurse is performing a respiratory assessment and is auscultating the client's breath sounds. On auscultation, the nurse hears a grating and creaking type of sound. The nurse interprets this to mean that client has which type of sounds? A.Wheezes B.Rhonchi C.Crackles D.Pleural friction rub

D

The nurse is teaching breast self-examination (BSE) to a client who has had a hysterectomy. The appropriate instruction regarding when the BSE should be performed is at which time? A.At ovulation time B.7 to 10 days after menses C.Just before menses begins D.At a specific day of the month and on that same day every month thereafter

D

A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding? A.Provide the client with materials on legal blindness. B.Instruct the client that he or she may need glasses when driving. C.Inform the client of where he or she can purchase a white cane with a red tip. D.Inform the client that it is best to sit near the back of the room when attending lectures.

A

A nursing student is performing a respiratory assessment on a female adult client and is assessing for tactile fremitus. Which action by the nursing student indicates a need for further teaching? A.Palpating over the lung apices in the supraclavicular area B.Asking the client to repeat the word ninety-nine during palpation C.Palpating over the breast tissue to assess and compare vibrations from 1 side to the other D.Comparing vibrations from 1 side to the other as the client repeats the word ninety-nine

A

The nurse is preparing to measure the apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope over which cardiac site? A.Mitral area B.Right atrium C.Right ventricle D.Pulmonic valve

A

The nurse conducting a health screening is performing hearing assessments on clients. Senior nursing students are assisting the nurse with the assessments. The nurse instructs the students to perform a voice test by taking which action? A.Whisper a statement while the client blocks both ears. B.Quietly whisper a statement and test both ears at the same time. C.Whisper a statement with the examiner's back to the client. D.Stand 1 to 2 ft (30 to 60 cm) away from the client and ask the client to block 1 external ear canal.

A

The nurse in a health care clinic is preparing to test a client for accommodation. Initially, the nurse should ask the client to take which action? A.Focus on a close object. B.Focus on a distant object. C.Close 1 eye and read letters on a chart. D.Raise 1 finger when the sound is heard

A

The nurse is preparing to perform a Weber test on a client. The nurse should obtain which item needed to perform this test? A.A tuning fork B.A stethoscope C.A tongue blade D.A reflex hammer

A

The nurse performs a physical assessment on a client and gathers both subjective and objective data. Which would the nurse document as subjective data? A.pedal pulses are present. B.Temperature is 99.6º F (37.6º C). C.Client reports difficulty sleeping at night. D.Client has an apical pulse rate of 56 beats/min.

C

A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which statement demonstrates that the client correctly understands the instructions for the test? A."I will tell you when I see the colored dots." B."I will tell you when I see the flash of bright light." C."I will tell you when the small object is in my visual field." D."I will tell you when the blocks and shapes are in my visual field."

C

A nursing student is asked about the procedure used to elicit Homans' sign. Which response by the student indicates an understanding of this assessment technique? A."I will ask the client to raise the legs up to the waist and then to lower the legs slowly." B."I will ask the client to raise the legs and to try to lower them against pressure from my hand." C."I will ask the client to extend the legs flat on the bed, and I will gently dorsiflex the foot forward." D."I will ask the client to extend the legs flat on the bed, and I will grasp the foot and sharply extend it backward."

C

The community health nurse who is conducting a teaching session about the risks of testicular cancer has reviewed a list of instructions regarding testicular self-examination (TSE) with the clients attending the session. Which statement by a client indicates a need for further instruction? A.TSE is performed once a month." B."TSE should be performed on the same day each month." C."It is best to do TSE first thing in the morning before a bath or shower." D."The scrotum is held in 1 hand and the testicle is rolled between the thumb and forefinger of the other hand."

C

The nurse assesses a client for the presence of Homans' sign. Which could be an indication that this sign is positive? A.Absent bowel sounds B.Client complaints of wound pain C.Pain with dorsiflexion of the foot D.Crackles on auscultation of the lungs

C

The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam? A.After a shower or bath B.While standing to void C.After having a bowel movement D.While lying in bed before arising

A

The nurse is performing a neurological assessment on a client with a head injury. The nurse should use which technique to assess the plantar reflex? A.Stroking the foot from the heel to the toe B.Gently inserting a gloved finger in the rectum C.Directing a flashlight onto the pupils of the eyes D.Using a tongue depressor and stimulating the back of the throat

A

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding? A.Rhythmic respirations with periods of apnea B.Regular rapid and deep, sustained respirations C.Totally irregular respiration in rhythm and depth D.Irregular respirations with pauses at the end of inspiration and expiration

A

The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? A.The client rigidly extends the arms with pronated forearms and plantar flexion of the feet. B.The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. C.The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. D.The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.

C

The nurse is performing a neurological assessment on a client who had a stroke (brain attack). The nurse checks for proprioception using which assessment technique? A.Tapping the Achilles tendon using the reflex hammer B.Gently pricking the client's skin on the dorsum of the foot in 2 places C.Firmly stroking the lateral sole of the foot and under the toes with a blunt instrument D.Holding the sides of the client's great toe and, while moving it, asking what position it is in

C

The nurse is performing an abdominal assessment and inspects the skin on the client's abdomen. Which assessment technique should the nurse perform next? A.Palpate the abdomen for size. B.Palpate the liver at the right rib margin. C.Listen to bowel sounds in all 4 quadrants. D.Percuss the right lower abdominal quadrant.

C

The nurse is preparing to check the breath sounds of a client. When auscultating for bronchovesicular breath sounds, the nurse should place the stethoscope over which area? A.The major bronchi B.The trachea and larynx C.The peripheral lung fields D.The lower posterior thorax

C