Quizzes- 3306

A 62 year old client visits the clinic and tells the nurse that she feels chest pain and pain down her left arm. The nurse should refer the client to a physician for possible

myocardial infarction

A client comes to the clinic with reports of a reddened, tender lump on the left breast. What would the nurse document about the lump?

size

The sternal angle at the right 2nd rib space is also known as what?

the aortic area

A client in the ED tells a nurse that she feels short of breath. The nurse would document this finding as dyspnea.

true

What techniques can be performed when palpating the breasts? Select all that apply.

-Circular pattern -Wedge pattern -Vertical pattern

When educating a client about healthy habits relating to cardiovascular health, it is important to include which of the following? Select all that apply.

-Undergo regular cholesterol screening -Quit or do not start smoking -Exercise Regularly

A nurse is inspecting a client's nipples. Which of the following findings should the nurse regard as a cause for concern?

A recently retracted nipple that was previously everted

A new nurse on the long-term care unit is learning how to assess a client's risk for skin breakdown. What would be the most likely instrument this nurse would use?

Braden scale

Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would most likely suspect the client is compensating for what pathophysiological disorder?

Chronic obstructive pulmonary disease

What characteristic nail color should the nurse recognize as an indication of hypoxia?

Cyanotic

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?

Dermis

What does HOH stand for?

Hard of hearing

Which formula will the nurse use to calculate cardiac output?

Heart rate x stroke volume

A client is admitted to the health care facility with reports of chest pain, elevated blood pressure, and shortness of breath with activity. The nurse palpates the carotid arteries as 1+ bilaterally and a weak radial pulse. A Grade 3 systolic murmur is auscultated. Which nursing diagnosis can the nurse confirm based on this data?

Ineffective Tissue Perfusion

A client tells a nurse about a raised lesion on the client's leg. What is the nurse's first nursing action?

Inspect the area

Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields?

Listen to the lungs starting in the apices

A client has a 7-mm lesion with irregular borders and color variation that has grown over the last several weeks. The nurse knows that this lesion could possibly be what type of cancer?

Melanoma

A client complains of difficulty sleeping, stating he has to sit up with the help of several pillows and cannot breathe when lying flat. This client has a condition known as what?

Orthopnea

The nurse manager on a cardiac unit should immediately intervene when observing which staff nurse's assessment technique?

Palpating carotid pulses simultaneously

While performing an admission assessment, the nurse auscultates a high-pitched, scratching, and grating sound at the left lower sternal border. The nurse should use what term to document the sound?

Pericardial friction rub

What does PERRLA stand for?

Pupils Equal Round Reactive Light Accommodation

The nurse performs an admission assessment on an adult client admitted through the ED with a myocardial infarction. The nurse auscultates a swooshing sound over right carotid artery. What phrase should the nurse use to correctly document this finding?

Right carotid bruit auscultated

When describing the cardiac cycle to a group of students, the instructor correlates heart sounds with events of the cycle. Which heart sound would the instructor explain as being associated with systole?

S1

An elderly client comes to the clinic for evaluation. During the skin assessment, the nurse noted considerable skin tenting. Why does this finding require further assessment?

Tenting indicates dehydration

The nurse recognizes that the 60-year-old patient may have difficulty reading fine print because of

The loss of accommodation

The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs?

The right lung has three lobes, while the left lung has two lobes

The nurse should recognize that the presence of a wheeze can result from air passing through constricted passageways.

True

When using an otoscope to assess the inner ear the nurse should hold the patient's ear at the helix, lifting up and back for best visualization.

True

The nurse is preparing to palpate the breasts of a female client. Which technique would be most appropriate?

Use the flat pads of three fingers

Peripheral vision is evaluated by the burse using the

confrontation test