NURS 212: Quizzes

A newborn appears to be in respiratory distress with a respiratory rate of 70 breaths/min, nasal flaring, and intercostal retractions. The newborn has a temperature of 37.2°C (98.9°F;) and a pulse rate of 190 beats/min. What is the normal range for a newborn's heart rate?

120-160 bpm

mitral valve

2 leaflet valve, between atrium and left ventricle

The nurse is assess assessing a client who has been diagnosed with a neuromuscular disorder. The nurse notes the patient cannot lift the left leg off the bed when the nurse is applying resistance. The nurse would document the muscle strength in the left leg as:

2/5

During the history, a young adult woman tells the nurse, "My mother has osteoporosis. What can I do to help reduce my risk?" Which response by the nurse would be most appropriate? A. "Try to avoid drinking too much coffee or other caffeinated fluids." B. "Increase the amount of non-weight-bearing physical activity that you do." C. "Avoid being out in the sun for long periods of time." D. "Keep your calcium intake around 800 milligrams each day."

A

The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. What would be most appropriate for the nurse to include? A. Thoroughly chew small amounts of food with each mouthful. B. Drink fluids before and after, but not during, meals. C. Be aware of the possibility of temporomandibular joint pain. D. Sit with the head of the bed at 45 degrees during meals.

A

Which of the following would lead the nurse to suspect meningeal irritation? A. Pain and flexion of the hips and knees with neck flexion B. Hips and knees remain relaxed and motionless when neck is flexed C. Discomfort behind the knee with full extension of the leg D. Reports of decreased pain with flexion of the hips and knees

A

he newborn receives an Apgar score of 9 at 1 minute and 10 at 5 minutes. What do these scores indicate to the nurse? A. The newborn is adapting well to the extrauterine environment. B. The newborn requires immediate resuscitation. C. The newborn is having difficulty adapting to extrauterine life and requires care in a neonatal intensive care unit (NICU). D. The newborn will require closer observation than a more vigorous newborn.

A

The mother of a 9-month-old girl calls the clinic. She tells the nurse that her daughter has developed a rash. The nurse asks a series of questions to assess the rash. Why would it be important for the nurse to ask these questions? A. Helps pinpoint possible causes B. Helps the nurse know if this is a childhood communicable disease C. Helps the nurse determine if the child is contagious D. Helps the nurse conceptualize the rash

A. Many skin conditions have predictable patterns of spread, parts of the body affected, and associated symptoms, such as pruritis (itching). It is important to differentiate if the symptoms are localized versus systemic or if there might be an infectious versus an allergic origin. All the other opinions fail to address the need to find the cause and treatment for the rash.

Ethnic variations have an impact on the serverity of coronary artery disease (CAD). Which individual is more likely to suffer from CAD?

African American female

When documenting the findings of a neurologic assessment, which of the following would be most important? A. Record objective data primarily. B. Describe the client's response. C. Label the client's behavior. D. Verify the data before documenting.

B

Which assessment finding in a 12-hour-old infant would be cause for concern? A. Milia B. Jaundice C. Erythema toxic D. Mongolian Spot

B Jaundice appearing in the first 24 hours is considered pathologic and is most likely due to hemolytic disease. Milia, erythema toxicum, and Mongolian spot are considered normal skin variations.

Mrs. Johnson, a secretary at the local college, reports pain and burning in her right hand. What assessment procedures should the nurse perform? (Select all that apply) A. Ballottement test B. Phalen test C. Murphy test D. Tinel test

B, C

When reviewing the neural pathways, a group of students is identifying sensations that travel via the spinothalamic tract. Which sensations are carried by this tract? Select all that apply. A. Position B. Temperature C. Vibration D. Pain E. Light touch

B, D, E

The nurse assesses thick white plaques on the hard palate of a client. Which of the following would the nurse do next? A. Further evaluate for AIDS. B. Refer the client for medication. C. Asses laboratory values for zinc deficiency. D. Assess the client for signs of jaundice.

B. The thick white plaques are indicative of yeast infection requiring treatment with medication

The nurse is caring for a client who has been experiencing dysphagia secondary to a stroke. What risk nursing diagnosis should the nurse associate with this health problem? A. Risk for injury related to potential esophageal trauma B. Risk for oral infection related to dysphagia C. Risk for aspiration related to decreased swallowing ability D. Risk for excess fluid volume related to decreased peristalsis and difficulty swallowing his or her food.

C

The nurse is providing instructions to newly hired graduates about the Mini-Mental State Examination. Which statement best describes this examination? A. Scores below 30 indicate cognitive impairment. B. It is a good tool to evaluate mood and thought processes. C. It is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness. D. It is useful for an initial evaluation of mental status. Additional tools are needed to evaluate cognition changes over time.

C

What would be most appropriate for the nurse to do when assessing motor function of a client's trigeminal nerve (V)? A. Have the client smile, frown, and wrinkle the forehead. B. Ask client to differentiate sharp and dull sensations on the face. C. Palpate temporal and masseter muscles while client clenches the teeth. D. Assess dilatation of the client's pupils with direct light.

C

Which technique would the nurse use to perform scoliosis screening in a school-age child? A. Measure the distance between the knees and the ankles. B. Ask the child to walk across the room. C. Have the child bend forward at the waist. D. Measure the length of each leg.

C

Which test would be most appropriate for the nurse to perform when assessing eye muscle strength and cranial nerve function? A. Visual fields test B. Corneal light reflex test C. Eye positions test D. Cover test

C

While checking the preadmission history, the nurse notes that the client's history reveals deep tongue fissures. Which of the following orders would take priority? A. Anterior-posterior and lateral chest x-ray B. Dietitian referral C. Intravenous fluid replacement D. Complete blood count with differential

C

A nursing student is preparing to demonstrate how to test the range of motion for the elbow. Which of the following would the student include? Select all that apply. A. Abduction B. Rotation C. Extension D. Pronation E. Flexion

C, D, E

A nurse is demonstrating the technique for auscultating heart murmurs. Which of the following would be most important for the nurse to emphasize? A. Most murmurs are high pitched and the diaphragm of the stethoscope should be used B. Most murmurs are low pitched and the diaphragm of the stethoscope should be used C. Most murmurs are high pitched and the diaphragm of the stethoscope should be used D. Most murmurs are low pitched and the bell of the stethoscope should be used

D

A parent of an ill infant states, "We gave him ibuprofen for a fever, and he had an allergic reaction." Which response would be most appropriate? A. "Is he allergic to any other medications?" B. "I will write that on his chart so he won't be given any." C. "How often has he received ibuprofen?" D. "Describe what happens to him when he takes ibuprofen."

D

The nurse is performing the Romberg test as part of a client's focused neurological assessment. What finding would constitute a positive Romberg test? A. The client experiences pain when clenching her teeth. B. The client is unable to consistently touch her finger to her nose while her eyes are close. C. The client experiences pain during neck flexion and extension. D. The client moves her feet apart to prevent herself from falling.

D

When explaining how the nurse would test graphesthesia, which of the following would the nurse include? A. The nurse will briefly touch the client and the client will need to identify where the touch occurred. B. The client is to identify the numbers of points felt when the nurse touches the client with the ends of two applicators at the same time. C. The nurse will simultaneously touch the client in the same area on both sides of the body and the client will identify where the touch occurred. D. Client will close the eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object.

D

While examining a client, the nurse notes fasciculation of the tongue. Which of the following would the nurse do next? A. ave the client do a 24-hour diet recall B. Prepare the client for a thyroid screening C. Review the client's medication regimen D. Assess the client's cranial nerves

D

During auscultation of breath sounds, the nurse should use the stethoscope correctly, in which of the following ways? A. Listen as the patient inhales and then go to the next site during exhalation. B. Have the patient breathe in and out rapidly while the nurse listens to the breath sounds. C. If the patient is modest, listen to sounds over his or her clothing or hospital gown. D. Listen to at least one full respiration in each location.

D.

A nurse is assessing the hip and legs of a newborn. The nurse suspects congenital hip dysplasia based on which of the following? A. Equal gluteal folds B. Full hip abduction C. Negative Barlow's sign D. Positive Ortolani's sign

D. Congenital hip dysplasia is manifested by unequal gluteal folds, limited hip abduction, and positive Ortolani's and Barlow's signs.

he nurse is assessing a patient with a barrel-shaped chest. The nurse knows that a barrel shape chest has which dimensions?

Equal anteroposterior transverse diameter and ribs being horizontal

When auscultating the lungs, what should the nurse do first if adventitious sounds are heard?

Have the client cough, then the nurse should listen again.

When taking a history, the patient describes a burning, painful sensation that moves around the toes and bottoms of the feet. These symptoms suggest:

Neuropathic pain

The most reliable indicator of pain in the adult is:

The patient's self-report

The nurse is assessing a client's ability to shrug her shoulders against resistance. The nurse is assessing which cranial nerve?

XI spinal accessory never

During a cardiovascular assessment, the nurse knows that a "thrill" is:

a vibration that is palpable.

afterload

amount of resistance the ventricles have to contract against

shunt

an abnormal passage of blood between two blood vessels or between the sides of the heart

The nursing instructor teaches students the most accurate location to auscultate the right middle lobe of the lung is where?

anteriorly

When assessing a client for possible oral cancer, the nurse should most closely inspect which area?

area under the tongue

A nurse caring for a patient in the emergency room notes that the patient's blood pressure rises from 140/90 to 180/100 mm/Hg. What effect does this have on the patients cardiac output? A. cardiac output does not change B. cardiac output decreases first, then increases C. cardiac output increases D. cardiac output decreases

cardiac output decreases

The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs would reveal:

dullness

Examination of the shoulder includes 4 motions. These are:

forward flexion, internal and external rotation, and abduction

The nurse is preparing to assess balance in an older adult client. Which test would the nurse plan on possibly omitting from the exam? A. tandem walking B. Hop on one foot C. Rombert test D. gait testing

hop on one foot

During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:

increased density of lung tissue

The nurse completes the initial newborn assessment and notes the presence of fine, downy hair on the infant's shoulders and back. How would the nurse document this finding?

lanugo

When examining a client with a rotator cuff tear, which of the following would the nurse expect to find?

limited abduction

A nurse is preparing a program on osteoporosis for a local women's group. Which of the following would the nurse include as a modifiable risk factor? A. age B. low estrogen levels C. small-boned, thin frame D. personal history of fractures

low estrogen levels

When testing the range of motion of the cervical spine, the nurse notes impaired range of motion and neck pain. A review of the client's history reveals fever, chills, and headache. What would the nurse suspect?

meningitis

At what ausculatory site would S1 best be heard?

mitral valve area - fifth intercostal space at around left midclavicular line

stenosis

narrowing of a heart valve opening or blood vessel

When examining for tactile fremitus it is important to:

palpate the chest symmetrically

During a health history, a 48-year-old client states, "I've noticed that I need to hold my newspaper farther away so that I can read it." Which of the following would the nurse suspect?

presbyopia

When performing a musculoskeletal assessment, the nurse knows that the correct approach for the examination should be?

proximal to distal

The emergency department nurse's rapid assessment of a young adult client admitted unresponsive reveals fixed, constricted pupils bilaterally. The nurse should consider what possible cause for this assessment finding?

recent narcotic use

A nursery nurse is assessing the neurologic status of a newborn. What area would the nurse be assessing?

reflexes

When interviewing an adolescent, which health issue would be least appropriate to discuss with the client while a parent is present?

sexuality, drugs, and alcohol

The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is ____ comparison.

side-to-side

The nurse is teaching a class regarding cardiac health. The nurse states that there is link between family history and premature coronary artery disease. The nurse tells the participants that they are more at risk of developing premature CAD if which of their relatives has CAD? A. mother B. sister C. grandfather D. father

sister

The bulge sign is a test for:

swelling in the suprapatellar pouch

cardiac output

the amount of blood pumped by the heart per minute

A medical nurse is preparing to administer a topical antifungal medication to a client who has just been diagnosed with an oral candida infection. On inspection of the patient's tongue, the nurse should anticipate what appearance?

thick, white plaques on the tongue surface

diastole

ventricles fill with blood