210 exam 2

A client presents to the health care clinic with reports of inability to concentrate at work and daily frontal headaches for the past two weeks. What additional information should the nurse ask this client?

"Are you experiencing sinus pressure and congestion?'

When the nurse is assessing a client's mental status as part of the neurological examination, which question would be most appropriate to ask?

"Can you tell me where you are right now?"

The nurse is conducting an assessment of Maggie, an 12-year-old child. Which statement by the mother would concern the nurse most?

"Maggie's dresses and shirts don't hang right."

How many vertebrae make up the spinal column?

33

You are assessing visual fields on a client newly admitted for eye surgery. The client's left eye repeatedly does not see your fingers until they have crossed the line of gaze. You would document that the client has what?

A left temporal hemianopsia

Which of the following changes in vision is expected with normal aging?

Blurring of near vision

During the health history a client reports a decrease in his ability to smell. During the physical assessment, the nurse would make sure to assess which cranial nerve?

CN I

The nurse assess for kidney tenderness at what location?

Costovertebral angle

The nurse is preparing to test a client's eyes for accommodation. The nurse would have the client focus on an object in which sequence for this test?

Far, then near

A nurse is assessing the effect of a client's chronic back pain on his affective dimension. Which question should the nurse ask for this assessment?

How does the pain influence your overall mood?

An older adult client who wears dentures reports having soreness of the gums. Which intervention should the nurse recommend to the client to alleviate this problem?

Massage the gums daily.

The nurse is completing a head-to-toe assessment of a newborn infant. How should the nurse determine if the infant's anus is patent?

Observe for the passage of meconium.

A client comes to the clinic and reports pain when he touches his ear. With what is this finding most consistent?

Otitis externa

On a health history, a client reports no visual disturbances, last eye exam two years ago, and does not wear glasses. The nurse notices that the client squints when signing the consent for treatment form and holds the paper close to the face. What should the nurse do next?

Perform both the distant and near visual acuity tests

Which terms refers to the progressive hearing loss associated with aging?

Presbycusis

What finding should a nurse expect when performing the Phalen's test on a client with suspected carpal tunnel syndrome?

Reports of tingling, numbness, and pain in the involved wrist

A client's patellar reflex is normal for the right side but diminished on the left. Using the scale for grading reflexes, how should the nurse document this finding?

Right knee +2; Left knee +1

The nurse is assessing a client with a bladder disorder. Where would the nurse expect the pain to be?

Suprapubic

The nurse is conducting a musculoskeletal assessment of an older adult client. What aspect of the client's medical history requires the nurse to alter the usual sequence or content of this assessment?

The client had a total hip replacement 2 years ago.

A 19-year-old construction worker presents for evaluation of a rash. He says that it started on his back with a multitude of spots and is also on his arms, chest, and neck. It itches a lot. He has been sweating more than before, because being outdoors is part of his job. Physical examination reveals dark tan and reddish patches with sharp borders and fine scales, scattered more prominently around the upper back, chest, neck, and upper arms as well as under the arms. Based on this description, what is the most likely diagnosis?

Tinea versicolor

A sign of infection in the elder that is more common than fever is

confusion

What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?

fainting

An adult client tells the nurse that he eats sardines every day. The nurse should instruct the client that a diet high in purines can contribute to

gouty arthritis.

The nurse is assessing the bowel sounds of an adult client. After listening to each quadrant, the nurse determines that bowel sounds are not present. The nurse should refer the client to a physician for possible

paralytic ileus.

Anticipatory guidance for parents of newborns and infants focuses primarily on

safety

The nurse is planning to conduct the Weber test on an adult male client. To perform this test, the nurse should plan to

strike a tuning fork and place it on the center of the client's head or forehead.

A nurse conducts a physical examination of the musculoskeletal system of a client who reports upper arm pain. Which instruction should the nurse provide the client when assessing flexion of the elbow?

"Bend your elbow."

A new graduate nurse asks a clinical nurse educator, "I know abuse is a problem, but why must we screen all women during routine health contacts for potential abuse?" Which response by the clinical nurse educator would be most appropriate?

"Consistent risk factors for women at risk have not been identified."

The nurse is providing teaching to a client with type 1 diabetes. When providing information about reducing the risk of diabetic neuropathy, the nurse should be sure to include which point?

"Effective blood glucose regulation can prevent this problem."

A nurse is assessing a survivor of intimate partner violence. During the interview, the nurse determines that the survivor's partner is using power and control over the client through coercion and threats. Which client statement would lead the nurse to suspect this?

"He tells me that he'll tell child services I'm a bad mother."

A previously healthy 64-year-old man has been recently diagnosed with osteoarthritis. The client is motivated to maintain his quality of life and slow the progression of his new health problem. What advice can the nurse provide for the client in his efforts to minimize the effects and progression of osteoarthritis?

"It's important for you to maintain a healthy body weight."

While assessing children and adolescents, it is important to ask about violence. Which of the following is an example of an appropriate assessment question for the nurse to ask regarding violence?

"Tell me about a time where you did not fit in well with your friends at school."

The nurse performs a Mini-Mental Status Examination of a client with altered thought processes. Which total score would indicate cognitive impairment?

20

The nurse assesses the respiratory rate of a 5-year-old boy. Which finding would indicate to the nurse that his rate is within the age-appropriate range for this child?

24 breaths/minute

Senior-year nursing students are spending a clinical day with the school nurse of an elementary school. Today, vision and hearing screenings are being conducted, and the students are expected to help with the screenings. With what age group would the students be expected to screen for color blindness?

4 to 8

A nurse examines a client with complaints of a sore throat and finds that the tonsils are enlarged and touching one another. Using a grading scale of 1+ to 4+, how should the nurse appropriately document the tonsils?

4+

When evaluating a client's risk for cerebrovascular accident, which client would the nurse identify as being at highest risk?

68-year-old African American with hypertension

A newborn is being assessed at 1 minute after birth. A score that indicates the newborn is adapting well to the extrauterine environment is in what range?

7 to 10

You are teaching a class on diseases of the ear. What would you teach the class is the most characteristic symptom of otosclerosis?

A progressive, bilateral loss of hearing

Otoscopic examination of a 69-year-old client's tympanic membrane reveals that it is red, bulging, and distorted. The nurse also notes a diminished light reflex. To what should the nurse most likely attribute this assessment finding?

Acute otitis media

Which of the following is usually the first sign of neurological deterioration?

Altered mentation and decreasing level of consciousness

The nurse is assessing a 39-year-old woman who has a 20-year history of cigarette smoking. When reviewing the client's current medication administration record, what drug would the nurse identify as increasing the woman's risk of stroke?

An oral contraceptive

The nurse is preparing to conduct a physical examination of an 18-year-old client. To support this client's developmental level, how should the nurse approach this assessment?

As an adult

While assessing a young child who appears anxious and afraid of healthcare personnel, the nurse should follow which steps? (Place the nursing actions in the correct order.)

Ask the parent to continue holding the child. Clean stethoscope with alcohol. Listen to heart sounds. Listen to breath sounds. Assess range of motion.

Which technique by the nurse demonstrates proper use of the ophthalmoscope?

Asks the client to fix the gaze upon an object and look straight ahead

A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCD" characteristic of malignant melanoma?

Asymmetrical shape

Inspection of a client's knee reveals swelling, and the nurse suspects that there is significant fluid in the knee. What test would the nurse perform to confirm the suspicion?

Ballottement test

An elderly male client presents to the health care clinic with reports of urinary frequency, nocturia, and difficulty starting his stream. A nurse knows that the most common cause of these symptoms is what condition?

Benign prostatic hypertrophy

A client is being assessed following a motor vehicle accident. The client's right eye is swollen shut and very painful. Why does this require further assessment?

Blunt-force trauma often results in fracture of the orbit

A nurse cares for a client with a stage II pressure ulcer on the right hip. The nurse anticipates finding what type of appearance to the skin over this area?

Broken with the presence of a blister

Which vessel is the nurse assessing if the major artery of the neck is being examined?

Carotid

Which data collected in a health history interview of a client should the nurse document as risk factors for the development of cataracts? Select all that apply.

Cigarette smoking Works in lawn maintenance Eats very few fruits or vegetables

A college student presents to the health care clinic with reports of no bowel movement for 4 days, bloating, and generalized abdominal discomfort. She states that she has not been eating and drinking correctly and is stressed because she has a final exam in 2 days. A nurse assesses the abdomen and finds positive bowel sounds in all four quadrants and tenderness in the left lower quadrant with a few small, round, firm masses. The Rovsing's sign and Psoas sign are negative. What nursing diagnosis can the nurse confirm for this client?

Constipation related to decrease in fluid intake

Which additional health history question related to the abdominal system is appropriate for people of African American decent?

Do you or your parents have sickle cell disease or trait?

The nurse notes that a sleeping newborn's heart rate is 102 bpm. What action should the nurse take first?

Document the heart rate

The nurse selects the chart shown here to assess a client's vision. Which client characteristic caused the nurse to select this chart?

Does not speak English

During assessment of the oral cavity, the nurse examines the salivary glands. Which area of the mouth should the nurse assess to inspect for the Wharton's ducts?

Either side of the frenulum on the floor of the mouth

The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. What can the nurse focus on while doing discharge teaching?

Encourage the use of safety equipment

The nursing student hopefuls are taking a pre-nursing anatomy and physiology class. What will they learn is the anatomical feature that equalizes air pressure in the middle ear?

Eustachian tube

The nurse in the emergency department is caring for a 4 year-old brought in by his parents with complaints that the child will not stop crying and pulling at his ear. Based upon information collected by the nurse, which of the following statements applies to a diagnosis of external otitis?

External otitis is characterized by pain when the pinna of the ear is pulled.

A nurse is providing care for an 84-year-old client who has diagnoses of middle-stage Alzheimer disease and a femoral head fracture. What assessment tool should the nurse use to assess the client's pain?

Faces Pain Scale-Revised (FPS-R)

A 29-year-old woman comes to the office. During history taking, the nurse notices that the client is speaking very quickly and jumping from topic to topic so rapidly that it is difficult to follow her. The nurse can find some connections between ideas, but it is difficult. Which word best describes this thought process?

Flight of ideas

The nurse is meeting the parents of an ill child for the first time and is preparing to perform the health interview. In addition to gathering health data, what additional goal should the nurse prioritize during this interaction?

Foster trust with the child's parents.

When the nurse palpates the neck of an infant, crepitus at the right shoulder area is noted. The infant also exhibits decreased movement in the right arm. What would the nurse suspect?

Fractured clavicle

A client is complaining of pain in the right upper quadrant and also in the right shoulder. Which organ would the nurse suspect as being involved?

Gallbladder

A client presents at the clinic with an enlarged, swollen, hot, and red metatarsophalangeal joint and bursa of the great toe. What medical diagnosis would the nurse suspect?

Gouty arthritis

The nurse obtains the following data about a 3-year-old child during an assessment at the neighborhood health clinic. Which finding would indicate a need for further evaluation of the child?

Has an undescended testes.

When assessing a child with respiratory distress, it is important to ask further questions. What is the priority question that the nurse needs to ask?

Has the infant been exposed to anyone with a communicable illness?

Which activity may assist the nurse in assessing the breath sounds of a 5-year-old child?

Have the child blow a pinwheel.

A nurse is instructing a client who suffers from peptic ulcer disease about the causes of this condition. Which of the following should the nurse mention as a common bacterial cause?

Helicobacter pylori

The nurse's inspection of a young child's anus reveals the presence of hemorrhoids. How should the nurse best interpret this assessment finding?

Hemorrhoids are unusual in children and warrant further assessment.

A client presents to the clinic with "sores around the mouth." The nurse notes vesicular lesions on the upper lip and right corner of the lips. The client describes these as painful. The nurse suspects what condition?

Herpes simplex

The client states, "I just know I have cancer. My doctor has run every test in the book and says there is nothing wrong with me. I don't believe any test. I know how sick I am!" This client is exhibiting what type of thought process disturbance?

Hypochondriasis

A nurse is assessing a newborn and observes the baby's skin to be cool. The newborn has cyanotic nail beds, pallor, and a temperature of 96 degrees Fahrenheit. What would be the priority nursing diagnosis for this newborn?

Ineffective thermoregulation related to immaturity of neurologic and endocrine systems

A middle-aged client reports difficulty in reading. Which action by the nurse is appropriate to test the near visual acuity using a Jaeger reading card?

Instruct the client hold the chart 14 inches from the eyes

The nurse assesses the motor system as part of the full neurological examination. In order to effectively assess this system, which of the following instructions should be given to the client?

Instruct the client to flex and extend the right elbow

A nurse asks a client the following question: "What do you do if you have pain?" The nurse is assessing which of the following?

Judgment

A nurse would like to assess an elderly client's general functional status in performing daily chores. Which of the following should the nurse implement to make this assessment?

Katz Activities of Daily Living tool

A nurse auscultates for bowel sounds on a client admitted for nausea and vomiting and hears no gurgling in the right lower quadrant after 1 minute. What is an appropriate action by the nurse?

Listen for a total of 5 minutes

When using hand gel to clean the hands, what must the nurse do before touching a client's eyes?

Make sure the hands are completely dry

Risk factors for cancers of the neck include which of the following? Select all that apply.

Male gender Alcohol consumption Tobacco use

A nurse finds that a 14-year-old girl's breasts are red, edematous, and tender. Which of the following conditions should she suspect?

Mastitis

A nurse is examining a client who is complaining of sinus pressure in his face and congestion. The nurse discovers tenderness on palpation of the sinuses and a large amount of exudate. Over which sinuses should the nurse expect to feel crepitus in this client?

Maxillary

A client expresses to the nurse that he has a "giving in" or "locking" sensation in the knee. Which test should the nurse perform to elicit related findings of a possible tear in the meniscus of the client's knee?

McMurray's

The nurse notes limitation in active range of motion of a client's right shoulder. What would the nurse to do next?

Measure range of motion with a goniometer.

Which risk factor for traumatic brain injury should a nurse include in a discussion about prevention for a group of adolescents?

Modes of transportation are the leading cause

A nurse is providing a client with instructions on how to perform self-examination of the skin. The nurse would encourage the client to perform this examination at which frequency?

Monthly

When teaching a class of school-age children about hygiene, the nurse should include which information about the ears?

Never put anything smaller than your elbow in your ears.

Which method should a nurse use when assessing respirations in a newborn?

Observe the respiratory effort for one full minute

Which of the following principles should the nurse integrate into the pain assessment and pain management of pediatric clients?

Pain assessment may require multiple methods in order to ensure accurate pain data.

A client has been brought to the emergency unit of a health care facility following an automobile accident. Which finding about the lips supports the diagnosis of anemia and shock?

Pallor

Examination of a client's gait reveals that the client is stooped over when walking and that he slowly shuffles. As well, the client maintains a stiff posture when walking. The nurse should document what type of gait?

Parkinsonian gait

An older adult client has received a diagnosis of stress incontinence, and the nurse is planning the client's subsequent care. What health education is most relevant to this client's needs?

Pelvic floor strength training and activity management

The nurse is testing a client for carpal tunnel syndrome. The client flexes the wrists at an angle of 90° and holds the backs of the hands to each other for 60 seconds. The client tells the nurse that he is experiencing a burning pain as a result. Which test is the nurse performing on this client?

Phalen's

To promote relaxation of the abdominal muscles, which of the following would be most appropriate for the nurse to do?

Place a pillow under both of the client's knees.

A nurse is assessing the hip and legs of a newborn. The nurse suspects congenital hip dysplasia based on which of the following?

Positive Ortolani's sign

A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present, and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. How would the nurse document this finding?

Positive Rovsing's sign

A client reports severe pain in the posterior region of the neck and difficulty turning the head to the right. What additional information should the nurse collect?

Previous injuries to the head and neck

A client expresses to the nurse visiting her home that her husband has threatened to kill her. The nurse understands that threats of harm and intimidation are which type of abuse?

Psychological

Which assessment of the tongue should a nurse recognize as abnormal?

Red with loss of papillae

Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media?

Red, bulging, with an absent light reflex

Assessment of a client's mouth reveals a lesion on the client's buccal membrane that is approximately 0.5 cm in diameter. On further questioning, the client states that the lesion has been present for 3 months and that it bleeds intermittently. How should the nurse follow up this assessment finding?

Refer the client to her primary care provider promptly.

A nurse is reviewing an infant's Apgar score. Which of the following areas was assessed during the calculation of the score?

Reflex irritability

During the health assessment interview, a nurse should ask the parents of a 9-year-old male questions related to which activities to elicit age-related development of psychosexual stage?

Relative sexual indifference and interaction with same-sex peers

The staff educator for a pediatric unit is presenting a class to a group of new nurses. Today they are talking about emergent situations in infants. What would the staff educator identify as the most common cause of emergent situations in infants?

Respiratory decompensation

The nurse is evaluating a new nursing graduate's ability to perform a rebound tenderness test for suspected appendicitis. The nurse determines correct technique when the new graduate is observed pressing deeply at which anatomic location?

Right lower quadrant

Pelvic floor strength training and activity management

Sedation

A group of students is reviewing information about pain transmission and the fibers involved. The students demonstrate understanding when they state that A-delta primary afferent fibers transmit pain that is felt as which of the following?

Sharp

On examination of a client, the nurse detects a fecal odor to the breath. The nurse recognizes this finding as characteristic of what disease process?

Small bowel obstruction

When the nurse is assessing the motor function of cranial nerve VII as part of the neurological examination, what should the nurse instruct the client to do?

Smile

What would a nurse suspect if dullness is percussed at the last left interspace at the anterior axillary line on deep inspiration?

Splenomegaly

A group of students are reviewing the structure and function of the skin in preparation for a test on the material. The students demonstrated understanding when they identify which layer as the outermost layer of the epidermis?

Stratum corneum

A 15-year-old high school student presents to the emergency department with his mother for evaluation of an area of blood in the left eye. He denies trauma or injury but has been coughing forcefully with a recent cold. He denies visual disturbances, eye pain, or discharge from the eye. On physical examination, the pupils are equal, round, and reactive to light with a visual acuity of 20/20 in each eye and 20/20 bilaterally. There is a homogeneous, sharply demarcated area at the lateral aspect of the base of the left eye. The cornea is clear. Based on this description, what is the most likely diagnosis?

Subconjunctival hemorrhage

In addition to providing privacy, which of the following would be most appropriate initially in situations involving suspected abuse?

Tell the client, "Injuries like these don't usually happen by accident."

As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test?

The client and the examiner see the examiner's finger at the same time

The nurse is performing the Romberg test as part of a client's focused neurological assessment. What finding would constitute a positive Romberg test?

The client moves her feet apart to prevent herself from falling.

The nurse is assessing a 2-day-old infant prior to discharge home from the hospital with his mother. When assessing the infant's eyes, what finding would the nurse consider to be abnormal?

The infant's sclerae have a yellowish tint.

The nurse is assessing the older adult for anosmia. Which nursing action would the nurse perform?

The nurse asks the client to identify common scents.

Which action by the nurse is consistent with the Rinne test?

The nurse strikes the tuning fork and places it on the client's mastoid process to measure bone conduction.

A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. What opioid neuromodulator may be responsible for this increased level of comfort?

The release of endorphins

Palpation of a 15-year-old boy's submandibular lymph nodes reveals them to be enlarged and tender. What is the nurse's most reasonable interpretation of this assessment finding?

There is an infection in the area that these nodes drain.

While conducting the physical examination, which of the following assessments would require the nurse to auscultate the abdomen?

To identify bowel sounds

A young man is concerned about a hard mass in the midline of his palate that he has just noticed. Examination reveals that it is indeed hard and in the midline. No mucosal abnormalities are associated with this lesion. The client has no other symptoms. What is the most likely diagnosis?

Torus palatinus

Which area of the body should a nurse inspect for possible loss of skin integrity when performing a skin examination on a female who is obese?

Under the breast

Mrs. Anderson presents with an itchy raised rash that appears and disappears in various locations. Each lesion lasts for many minutes. Which most likely accounts for this rash?

Urticaria or hives

Which of the following, if obtained during the health history, would alert the nurse to a possible ear-related problem?

Use of cotton swabs inside the ear

The nurse manager in a pediatric clinic should intervene when observing which assessment technique by a staff nurse?

Using the pneumatic bulb while trying to visualize the tympanic membrane

The nurse plans to test which cranial nerve when testing an elderly client's hearing status?

VIII

A nurse begins the mental status exam of an older adult. Before assessing the client's thought processes and perceptions, the nurse should first obtain the results of what other assessments?

Vision and hearing

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

XI

A nurse visits an older adult client at home in order to conduct a risk assessment for falls. Which factors would most likely increase the risk for falls for this client? Select all that apply.

a throw rug in the dining room bathtubs in all bathrooms a television cord runs across the floor

The functional reflex that allows the eyes to focus on near objects is termed

accommodation

When the nurse asks the client to say "No ifs, ands, or buts," the client tries but is unable to repeat the phrase with fluency. The nurse understands that this may indicate a form of

aphasia

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the

areola of the breast.

During a physical examination a 4-month old baby begins to cry. Which assessment finding should the nurse expect at this time?

bulging anterior fontanelle

A client is concerned about tripping when walking and feeling uncoordinated. Which part of the brain might be causing this client's symptoms?

cerebellum

While assessing the neurologic system of a confused older adult, the nurse observes that the client is unable to recall past events. The nurse suspects that the client may be exhibiting signs of

cerebral cortex disorder.

The client reports two nosebleeds in the past week. Which medication taken by the client would the nurse suspect is contributing to the nosebleeds?

clopidogrel (Plavix)

The nurse is preparing an educational program on effective hygiene methods for a group of high school teens. When discussing the need for antiperspirants and effective bathing, the nurse will focus on which layer of the skin?

dermis

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

dermis

A client who is bedfast responds only to painful stimuli, never eats a complete meal, and moves occasionally in bed. Which term should the nurse use to describe this client's risk for skin breakdown?

high

What is one of the leading causes of unexpected death during infancy?

injury

Bones in synovial joints are joined together by

ligaments

A female client visits the clinic and tells the nurse that she began menarche at the age of 16 years. The nurse should instruct the client that she is at a higher risk for

osteoporosis

The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should

position the client 609.6 cm (20 ft) away from the chart.

A nurse performs a hearing test on an elderly client. Which result should the nurse recognize as an indication that presbycusis is present? An inability to hear:

whispered sounds