NURS146 Final Exam

A 52-year-old male client is seen in the primary health care provider's office for a physical examination after experiencing unusual fatigue over the last several weeks. The client's height is 5 feet 8 inches, and his weight is 220 pounds. Vital signs are temperature, 98° F (36.6° C) orally; pulse, 86 beats per minute; and respirations, 18 breaths per minute. The blood pressure (BP) is 184/100 mm Hg. Random blood glucose is 122 mg/dL (6.97 mmol/L). Which question would the nurse ask the client first?

"Is there a history of diabetes mellitus in your family?"

Where can a nurse assess for dark skinned patient presence of pallor.Select all that apply.

1. Pallor is best seen in the buccal mucosa or conjunctiva, particularly in dark-skinned clients. 2. Cyanosis is best seen in the nail beds, conjunctiva, and oral mucosa. 3. Jaundice is best seen in the sclera, the junction of the hard and soft palate, and over the palms.

Normal respiratory rate for adults

12-20 breaths/min

Normal blood pressure for adults

120/80 mm Hg

The nurse is assessing a client's respiratory status. Which assessment data indicate a problem?

28 breaths/min and audible

Normal pulse rate for adults

60-100 bpm

Normal temperature for adults

98.4

The clinic nurse is providing a screening clinic to identify clients at risk for an integumentary disorder. Which client seen at the clinic would be most at risk for developing a skin disorder?

A Farmer

The nurse is making an initial home visit to a client who was recently discharged from the hospital after coronary artery bypass graft surgery. The nurse would use which type of database to obtain information from the client?

A comprehensive health database

The nurse is conducting a health history of a child. The parent states that the client continually has a cold all winter with a runny nose, is not doing well in school, and is itching all the time. The nurse suspects the child has which condition?

Allergies

What does Mcburney's point signify?

Appendicitis

What does the nursing process consist of?

Assessment Diagnosis Planning Implementation Evaluation "ADPIE"

As part of cardiac assessment, to palpate the apical pulse, the nurse places the fingertips at which location?

At the left mid clavicular line at the fifth intercostal space

During the admission assessment, the nurse asks the client to run the heel of 1 foot down the lower anterior surface of the other leg. The nurse notices rhythmic tremors of the leg being tested. The nurse would conclude that the client has an alteration in which area?

Balance and coordination

To evaluate a client's cerebellar function, a nurse should ask

Balancing functions are ok

A client is admitted to the hospital with a diagnosis of right lower lobe pneumonia. The nurse auscultates the affected lung area, expecting to note which type of breath sounds?

Bronchial

Name the pulse nurses should not check at the same time when doing bilateral assessment

Carotid

To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), a nurse should palpate which pulse site?

Carotid

Blue discoloration of skin is called

Cyanosis

The nurse is examining a client who was seen in the clinic 2 weeks ago with reports of fatigue. The client now is complaining of a sore throat and sinus congestion. The nurse would proceed with the examination by collecting which data?

Data related to the upper respiratory tract

The nurse is conducting a developmental assessment on an infant who is in the clinic for a 6-month checkup. Which behavioral sign suggests possible cognitive impairment and the need for follow-up and further developmental testing?

Diminished spontaneous play activity

The nurse is preparing to auscultate bowel sounds. Which actions suggest appropriate assessment techniques and interventions?

Do not feed the client if no sounds are audible in 5 minutes.

The nurse conducts a nutritional assessment of a client. What is the most important question for the nurse to ask to help identify the client's risk for osteoporosis?

Do you drink Milk everyday?

A client arrives at the emergency department with chest and stomach pain and a report of black, tarry stools for several months. Which diagnostic testing would the nurse anticipate?

ECG (electrocardiogram), complete blood count, testing for occult blood, and comprehensive serum metabolic panel, PT, PTT, INR

The nurse is reviewing the assessment data of a client. Which finding is most important for the client to modify to lessen the risk for coronary artery disease (CAD)?

Elevated low-density lipoprotein (LDL) levels

Which area can a nurse auscultate maximum impulse of heart?

Erbs point

What does +4 tonsils represent?

Excessively large tonsils

The nurse assesses cranial nerve XII in the client who sustained a stroke. To assess this cranial nerve, which action would the nurse ask the client to perform?

Extend the tongue

Excessive yellow skin is called

Jaundice

Name the point of maximum impulse on the chest

Mitral valve

What are two identifiers of patient

Name DOB MR Number

A client has a nursing diagnosis of fluid volume deficit. Which nursing assessment finding would support this diagnosis?

Orthostatic hypotension

A clinic nurse is performing an assessment on a child. Which finding indicates the presence of an inguinal hernia?

Painless inguinal swelling that appears when the child cries or strains

Why should the nurse avoid palpating both carotid arteries at one time?

Palpating both arteries at one time may cause severe bradycardia

What is Turner's sign?

Pancreatitis

A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method?

Place a tongue blade lightly on the posterior aspect of the pharynx.

The nurse is assessing a client for a pericardial friction rub. Which action by the nurse indicates the best method in assessing this abnormality?

Placing the diaphragm of the stethoscope over the left sternal border

The nurse is listening to the client's breath sounds and hears a creaking, grating sound on inspiration and expiration over the posterior right lower lobe. How would the nurse correctly document this on the client's record?

Pleural Friction rub

A nurse is examining the abdomen of a client with suspected peritonitis. How does the nurse elicit rebound tenderness?

Press the affected area firmly with one hand, release pressure quickly, and note any increased tenderness on release.

Name the pulse present on the wrist

Radial

A nurse determines that a client has 20/40 vision. Which action by the nurse is most appropriate?

Refer the client to a healthcare provider for possible corrective lenses

When percussing a client's chest, what should the nurse expect to hear?

Resonance

The school nurse is responsible for routine health assessments of 11-year-old children. During the health assessment, what would the nurse specifically screen for?

Scoliosis

A client arrives at the emergency department and reports that his heart is "skipping beats." The client is placed on a cardiac monitor, which reveals the presence of premature ventricular contractions every third heartbeat. How would the nurse proceed with data collection?

Simultaneously ask health history questions while performing the examination and initiating pharmacological measures.

After performing an initial abdominal assessment on a client with a diagnosis of cholelithiasis, the nurse documents that the bowel sounds are normal. When asked, how would the nurse describe this finding to the client?

Soft gurgling or clicking sounds auscultated in all four quadrants

The school nurse is performing health screening for scoliosis on children aged 9 through 15. Which instruction would the nurse provide to the child?

Stand with equal weight on both feet with the legs straight and the arms hanging loosely at both sides.

Pain is subjective or Objective

Subjective

When assessing a child with meningitis, which finding would indicate the presence of Kernig's sign?

The inability of the child to extend the legs fully when lying supine

The nurse is performing a physical assessment on a client with rheumatoid arthritis. The nurse assesses the client's hands and notes which characteristic deformities?

Ulnar drift

The registered nurse is observing a new nurse auscultate the breath sounds on a client with pneumonia. Which action by the new nurse would lead the registered nurse to determine that there is a need for further teaching?

Uses the bell of the stethoscope

What are Vesicular breath sounds, Egophony, Whispered pectoriloquy, consolidation?

Vesicular breath sounds are normal sounds that are heard over peripheral lung fields where the air enters the alveoli.

The nurse is performing an assessment on a pregnant client with a history of cardiac disease. Which body area will venous congestion most commonly be noted in?

Vulva

The nurse who is performing a respiratory assessment is listening to the client's breath sounds. The nurse hears musical, whistling noises on inspiration and expiration scattered throughout the right lung fields. What would the nurse interpret these sounds to be?

Wheezing

Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes that the client has no active gag reflex. What is the next action by the nurse?

Withhold food and fluids.

A client is transferred to the acute stroke unit, and the nurse initiates a neurologic flow sheet to provide ongoing data about the recovery phase of care. The nurse is aware this information indicates what regarding a client's clinical status?

changes in level of consciousness or responsiveness as evidenced by movement and orientation to time, place, and person

Excessive milk production in mammary glands is called

galactorrhea

Overproduction of hormones can lead to false breasts in male patients also called

gynecomastia

In a care conference, the social worker is asking if a psychosocial assessment has been completed. Which areas would the nurse report on as part of this assessment?

health habits, family relationships, affect, and thought patterns

A nurse is assessing a client at the beginning of the shift. Which signs of hypoxia would alert the nurse to take further action?

increased pulse rate, oxygen saturation of 88%, and circumoral cyanosis

A client has just been transferred to the post anesthesia recovery room following a laparotomy. The nurse has completed assessing vital signs. What other important initial assessments would the nurse make?

level of consciousness, pain level, and wound dressing

A nurse is caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are

progressively deeper breaths followed by shallower breaths with apneic periods.

A nurse assesses the client's pulse as weak and thready in both lower extremities. How would the nurse best document this finding?

pulse amplitude +1 bilateral lower extremities

A client has been experiencing abdominal cramps, loose stools, and concentrated urine for the past 2 days. Which signs would be included in a focused assessment?

signs of dehydration, including loss of weight; poor tissue turgor; and dry, cracked mucous membranes

A nurse prepares to auscultate a client's carotid arteries for bruits. For this procedure, the nurse should

use the bell of the stethoscope

The nurse is performing a memory assessment on a client with early-stage Alzheimer's dementia. The nurse assesses remote memory by asking which question?

"In what city were you born?" Rationale :Remote, or long-term memory, can be tested by asking clients about their place of birth, their birth date, schools they attended, or any other piece of information from the past that can be verified. Recall, or recent memory, can be tested while obtaining the client's history and can be verified by the medical record. The nurse can ask about things such as the accuracy of the medical history, dates of clinic or doctor appointments, the time of admission, doctors seen within the past few days, and the mode of transportation to the hospital or clinic.

The nurse is working at an osteoporosis screening clinic and is interviewing and performing health assessments on women. Which clients are at greatest risk for developing osteoporosis? Select all that apply.

1.A client with an inadequate intake of calcium and vitamin D 2.A client with a family history of the disease 3.A client who started menopause early 4.An older adult woman

Percussion is a physical assessment technique that is used to identify which findings? Select all that apply.

1.Fluid in body cavities 2.Borders of body organs 3.Consistency of body organs 4.Location, size, and density of an underlying structure

What is a Wood's light test?

A Wood's lamp is a light that uses long wave ultraviolet light. When an area of the scalp that is infected with tinea (a type of ringworm fungus) is viewed under a Wood's light, the fungus may glow.

The nurse assesses a client with hepatic encephalopathy for the presence of asterixis. What would the nurse do to appropriately test for asterixis?

Ask the client to extend the wrist and the fingers

A new graduate nurse has been hired by the health care clinic to assist in conducting hearing tests in a local neighborhood. The clinic nurse is observing the graduate perform a voice test to assess hearing in a client. Which observation indicates that the graduate nurse is performing the procedure correctly?

Asks the client to block one ear, quietly whispers a statement, and asks the client to repeat it

Which is the most appropriate step for performing an otoscopic examination on an adult client?

Pull pinna up and backward

The nurse is performing an abdominal assessment on a client. Which finding should the nurse report to the primary health care provider?

Pulsation between the umbilicus and pubis

The nurse is reviewing a client's record and notes that the result of the client's vision test using a Snellen chart is 20/50. How would the nurse interpret this finding?

The client can read at a distance of 20 feet what a client with normal vision can read at 50 feet.

The nurse caring for a client after shoulder arthroplasty for rheumatoid arthritis monitors the client for brachial plexus compromise. To assess the status of the median nerve, which action would the nurse perform?

While grasping the nurse's hand, note the strength of the client's first and second fingers.

Skin color is sometimes more difficult to assess in the dark-skinned client. If impaired gas exchange is suspected, the nurse would examine which areas? Select all.

the lips, tongue, nail beds, conjunctivae (not sclera) of the eye, and palms of the hands and soles of the feet In a client with cyanosis, the lips and tongue are gray, and the palms, soles, conjunctivae, and nail beds have a bluish tinge.