A&P Gurnick Midtemr
A charge nurse is discussing hearing tests with a newly licensed nurse. Which of the following information should the charge nurse include?
A tuning fork is placed against the client's mastoid bone during the Rinne test
A nurse is assessing a client whose family is concerned that the client has developed dementia. Which of the following findings should the nurse identify as a manifestation of dementia?
Difficulty problem-solving
A nurse is assessing a client who reports an increase in their stress level related to the demands of their job. Which of the following interventions should the nurse recommend for the client to reduce their stress?
Discuss the benefits of meditation with the client.
A nurse is providing teaching to a client who reports acne on their face and chest which of the following client statement indicates an understanding of the teaching?
I should wash the areas frequently with warm water and soap
A nurse is providing teaching to a client who has osteoporosis about the adequate intake of calcium. Which of the following intake amounts should the nurse recommend?
1,000 to 1,200 mg daily
a nurse is examining the texture of an older adult clients skin. which of the following findings should the nurse report to the provider?
Velvety Skin
A nurse is a evaluating assessment findings of a client's skin the nurse should identify which of the following findings is associated with the possible infection?
Vesicles
Stage I pressure injury
nonblanchable erythema of the intact skin
Which of the following conditions involves the bones of the joint
osteoarthritis
A nurse is inspecting the sinuses of a client who has allergies. Which of the following findings should the nurse expect?
pale mucosa
A nurse is performing range of motion exercises on a clients feet. The nurse should provide which of the following instructions to the client to assess plantar flexion of the feet?
point your toes toward the floor
place the steps for assessing a client's skin turgor and mobility in the order of performance.
position pinch note the ease open pinch note time to return
A nurse is assisting with a staff in-service regarding pain control. Which of the following statements by a staff member indicates an understanding of the information?
"A client's religious beliefs might affect the way they respond to pain." "The client's past pain experiences are not related to their current pain and pain management." "Pain control might be harder to achieve if the nurse and client speak different primary languages."
A nurse is evaluating a client's pain level using the PQRST mnemonic. Which of the following questions should the nurse ask to evaluate the letter "R"?
"Can you point to where you are having your pain?"
A nurse is teaching about behaviors that promote cardiovascular health. Which of the following client statements indicate an understanding of the teaching?
"I am going to start walking several times a week." "I plan to join a support group to help me stop smoking." "I will be sure to have my blood pressure checked at least every year."
A nurse is collecting a wound culture from a client's arm wound. The nurse explains to the client the reason for needing to rinse the wound with 0.9% sodium chloride during the procedure. Which of the following statements should the nurse include?
"I am rinsing the wound to prevent your normal skin micro-organisms from contaminating the culture."
you are providing health promotion education for a client. which client statement requires further education?
"I use an indoor tanning bed to improve my skin color"
A nurse is reviewing discharge instructions for a client who has a prescription for morphine oral solution 10 to 20 mg every 4 hr PRN. Which of the following statements by the client indicates an understanding of the instructions?
"I will keep the morphine bottle in a locked cabinet in my kitchen."
A nurse is caring for a client who states, "My doctor said I should have an EMG. What is that?" Which of the following responses should the nurse make?
"It is a test that determines if there is nerve damage affecting a muscle."
A nurse is teaching staff about the ethical principle of justice and how it relates to pain management for clients. Which of the following statements should the nurse make?
"Justice allows the client the opportunity to be treated fairly."
A charge nurse is discussing sensory processing disorder (SPD) with a newly licensed nurse. Which of the following statements should the charge nurse make?
"SPD causes clients to be overly sensitive to stimuli, such as the feel of fabric on their skin."
A nurse is preparing to perform a cardiovascular assessment on a client. The client asks, "Why do you need to use a penlight?" Which of the following responses should the nurse make?
"The penlight will allow me to look at the pulses in your neck."
A nurse is reviewing the process of how a refraction assessment is performed with a client. Which of the following statements should the nurse make?
"This test is performed using lenses of various prescription strengths."
A nurse is discussing transcutaneous electrical nerve stimulation (TENS) treatment with a client who has chronic lower back pain. Which of the following statements should the nurse include?
"You can be taught how to use TENS therapy at home." "The TENS therapy delivers low-voltage electrical impulses to the skin over the painful areas." "We will adjust the intensity, pulse rate, and duration of the electrical pulses during your therapy."
A nurse is reviewing a new prescription with a client who reports difficulty managing their chronic pain. Which of the following statements should the nurse include?
"You should write down the pain interventions you use and your pain rating before and after."
A nurse is caring for a client who is scheduled for an otoacoustic emissions (OAE) test. The client asks what to expect during the test. Which of the following responses should the nurse make?
"You will have a small probe placed in your ear canal during the test."
A nurse is providing end-of-life care for a client who is unresponsive and near death. The client's family asks the nurse about managing the client's pain. Which of the following statements should the nurse make to the client's family?
"Your family member has the right to receive effective pain management."
you are collecting subjective data prior to performing a skin assessment on a client. which of the following responses requires additional investigation?
"one of my moles now has several colors on it"
A nurse is assessing a client who has a lump on their neck. What questions should the nurse ask the client?
1. "Are you experiencing difficulty breathing?" 2."How long has the lump been on your neck?" 3."Is the lump causing you discomfort?" 4."Are you having difficulty swallowing?"
A nurse is caring for a client who has a prescription for heat therapy for knee pain. The nurse should apply heat therapy to the client's knee for how long?
20 min
The nurse is providing teaching about adequate daily intake of vitamin D to a client. Which of the following intake amount of the nurse recommend?
800 IU daily
which of the following are characteristics of the dermis layer of skin
>contains blood vessels, hair follicles, and nerve endings >composed of thick fibrous connective tissue
which of the following findings are associated with a possible malignant lesion? select all that apply
>several colors within a single mole >a mole that is larger than a pencil eraser >a report of a mole being itchy >occasional bloody drainage from a mole > a mole that becomes elevated
which of the following client findings are priority reasons for the nurse to conduct a thorough additional investigation? select all that apply
>the client appears agitated. itching has kept him awake at night for three nights, and he reports a pain level of 8 > the client's rash is getting worse every day. the treatment of petroleum jelly has not stopped that progression
A nurse is caring for a group of clients on the pediatric unit. For which of the following clients should the nurse use the FLACC Pain Scale to determine their pain level?
A 3-year-old toddler who has a fractured femur A 14-year-old client who has severe cognitive and developmental delays A 5-year-old preschooler who is experiencing pain during a sickle cell crisis
A nurse is preparing an in-service for a group of staff members about types of tests used to diagnose sensory impairments. Which of the following information should the nurse include?
A bone oscillator test measures how efficiently sound waves are transmitted through the ossicles.
A nurse is reviewing information for several clients on the unit. The nurse should recognize that which of the following clients is at greatest risk for respiratory depression?
A client who had surgery 3 hr ago and is receiving IV hydromorphone PRN
A nurse is evaluating a group of clients who are experiencing pain. Which of the following clients should the nurse identify as experiencing neuropathic pain?
A client who has diabetes mellitus and reports bilateral burning foot pain without signs of injury
A nurse in a provider's office is preparing to assess a young adult male client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect?
A concave lumbar spine posteriorly Muscles slightly larger on his dominant side
A nurse, who is assessing a client's neurologic system, should ask the client to close their eyes and identify which of the following items?
A familiar object the nurse places in the hand
A nurse is assessing the anterior chest of a client. Which of the following findings should the nurse report to the provider?
A forceful chest movement at the midclavicular line in the fourth intercostal space
A nurse is planning to teach coworkers about the legal and ethical principles used with pain management. Which of the following examples should the nurse include as an example of autonomy?
A nurse provides a client with the opportunity to take an intramuscular injection or oral medication for pain relief.
A nurse is caring for a client who has a prescription for hydromorphone 1 to 2 mg IM every 4 hr as needed for a pain rating of 4 to 6 on a 0 to 10 scale. The client has never taken hydromorphone before. Which of the following actions should the nurse plan to take?
Administer 1 mg IM
A nurse is reviewing the medial record of a client who reports recent anosmia. The nurse should identify which of the following conditions as a risk factor for developing anosmia?
Alzheimer's disease
A nurse is auscultating heart sounds in a group of clients. Which of the following should the nurse identify as an expected variation?
An adolescent who has an S3 heart sound
A nurse is providing teaching to a client who boards extremely dry skin which of the following intervention should the nurse recommend?
Apply an alcohol-free lotion
A nurse is caring for a client who has a traumatic injury to a lower extremity. Which of the following action should the nurse take?
Apply compression to the injured area of the extremity
A nurse is assessing a client for hearing loss. Which of the following findings should the nurse identify as an indication of a possible hearing loss?
Asks for questions to be repeated Withdraws from social activities Describes sounds as being muffled
A nurse is preparing to conduct a cardiovascular assessment on a client. Which of the following actions should the nurse plan to take?
Auscultate the apical pulse. Ask the client if they experience shortness of breath. Check the color of the client's skin. Inspect the extremities for the presence of edema.
A nurse is reviewing discharge instructions with a client who has macular degeneration. Which of the following information should the nurse include in the instructions?
Availability of aids to enhance vision
A nurse is assessing the mouth of a client who has a vitamin B12 insufficiency. Which of the following findings should the nurse expect?
Beefy red tongue
A nurse is preparing to inspect the outer ears of a client who has been in a motor-vehicle crash. The nurse should identify that which of t the following findings indicates the client might have. Skull fracture?
Bloody drainage
When assessing the ear, which of the following is an emergency and requires immediately contacting the provider?
Bloody drainage from the ear following head trauma
A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect?
Capillary refill 2 seconds Thick skin on the soles of the feet Numerous light brown macules on the face
A nurse has completed a cardiovascular assessment on a client. Which of the following findings should the nurse report to the provider?
Capillary refill of 3 seconds
A nurse is preforming a focused assessment on a client who reports having difficulty swallowing and a continuous headache. The nurse should identify that these findings can indicate which of the following conditions?
Central Nervous System Disorders
A nurse is preparing to perform a cranial nerve assessment on a client. Which of the following actions should the nurse take to assess cranial nerve II?
Check the client's visual acuity using a Snellen chart.
A nurse is caring for a client who reports muscle pain to the lower back that has persisted for over a year after a motor-vehicle crash. In which way should the nurse categorize this client's pain?
Chronic Pain
For which of the following findings should you contact the provider?
Clear one-sided nasal drainage in a client who fell down the stairs
A nurse is reviewing the plan of care for several clients who are receiving treatment for pain. Which of the following actions should the nurse plan to take to evaluate the clients' pain control?
Consider each client's cultural preferences Determine the effectiveness of nonpharmacological strategies Use a pain scale specific to each client's cognitive abilities
A nurse is instructing a group of nursing students in the priorities of care in performing an integumentary assessment for their clients. Which of the following findings should the students recognize as requiring immediate intervention?
Cyanosis
A nurse is assessing an older adult client's mouth. The nurse should identify that which of the following is an expected variation for this client?
Darkening of the mucosa
A nurse is caring for a client who is 7 days postoperative following abdominal surgery. The client reports nausea, vomiting, and pain at the incision site. The nurse observes serosanguineous discharge on the client's gown, and the abdominal incision is partially open. Which of the following postoperative complications is the client experiencing?
Dehiscence
A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect?
Difficulty maintaining attention Agitation Hallucinations Rambling speech
A nurse is preparing a community program about injury prevention for a group of adults. Which of the following information should the nurse include?
Do not text and drive Maintain spinal alignment when working at a desk remove loose rugs from the home wear a helmet when riding a bicycle
Which of the following foods promote bone health?
Egg yolks Salmon Yogurt Broccoli
A nurse is performing a head and neck assessment on a client. The client reports a high-pitched ringing in their ears. In which of the following sections of the client's electronic health record (EHR) should the nurse document this finding?
Encounter
A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse use to enhance communication with the client?
Ensure the client wears their hearing aids Use a sign language interpreter Communicate using paper and pen Face the client when speaking
which of the following documentation provides the most accurate info to include in the medical record as an objective assessment of the client's lower extremities?
Erythema and hyperthermia noted on bilateral lower extremities with 4+ pitting edema below the knees. ulcerated area noted on bilateral mid shin areas: left measures 3 x 3 cm, right measures 2 x 2 cm. small amount of yellow drainage noted from both wounds
A nurse is caring for an older adult client who has a cognitive impairment and is postoperative. Which of the following actions should the nurse take?
Evaluate the client for pain by observing their behavior.
A nurse is discussing the FLACC scale with a newly licensed nurse. Which of the following categories should the nurse include?
Face Legs Consolability
A nurse is caring for a client who reports internal rotation of the right shoulder. The discomfort can affect the client's ability to perform which of the following activities?
Fastening or zipping closures on the back while dressing
A nurse is discussing end-of-life pain management with a group of coworkers. Which of the following should the nurse include as barriers to end-of life pain management?
Fear of addiction Belief that pain is an expected part of their illness Inadequate pain assessment
A nurse is inspecting and palpating the neck vessels of a client. Which of the following findings should the nurse report to the provider?
Full, bounding pulse noted bilaterally in the carotid arteries upon palpation. Distention of the jugular vein on one side of the neck. The left carotid artery pulse is weak.
A nurse is caring for a client who reports decreased peripheral vision. The nurse should identify this as a manifestation of which of the following visual impairments?
Glaucoma
A nurse is assessing a client who is nonverbal for the presence of pain. Which of the following findings indicate an increased level of discomfort?
Grimacing Restlessness Increased diaphoresis
A nurse is assessing a client's jugular veins and carotid arteries. The nurse should assist the client into which of the following positions?
Have the client lay supine with the head of their bed at a 45° angle.
A nurse is obtaining a client's health history. Which of the following questions should the nurse ask the client to obtain a focused history of the ears?
Have you had trouble hearing Do you ever lose your balance Have you ever used hearing aids Do you have ringing in your ears
A nurse is teaching a group of older adult clients about the sensory system. The nurse should include that the aging process is most likely to cause which of the following changes?
Hearing loss
A nurse is reviewing the various types of lesions nursing students might encounter when performing integumentary assessments for their clients. Which of the following lesions should the nursing students recognize as vesicles?
Herpes simplex Varicella
Place the lower extremities in the order that they should be assessed
Hips Knees Ankles Feet -order from proximal to distal ends of lower extremities
What are the universal skin prevention measures utilized in skin care plans?
Hydration, nutrition, hygiene, circulation
A nurse is collecting data from a client about their skin and nails which of the following statements by the client should the nurse identify as needing further assessment?
I noticed that my fingernails have changed recently.
A nurse is preparing to assess the skin turgor of a client who has manifestations of dehydration and which of the formula location should the nurse perform the assessment?
Inferior to the collar bone
A nurse is performing a musculoskeletal and neurological assessment. Which of the following action should the nurse take?
Inspect for symmetry and both sides of the body
A nurse is providing discharge teaching to a client who has diabetic neuropathy. Which of the following information should the nurse include?
Inspect the feet every day wear closed toe shoes manage glucose levels
A nurse is caring for a client who has a peripheral venous ulcer. Which of the following actions should the nurse take?
Instruct the client to sit with their legs uncrossed. Encourage the client to avoid tobacco products. Instruct the client to cleanse the area with mild soap. Instruct the client to wear shoes when ambulating.
A nurse is admitting a client who has had a stroke. Which of the following actions should the nurse take.
Keep client's bed in the lowest position
A nurse is providing care for a client who has a sensory deficit. Which of the following actions is the nurse's priority for the client?
Keep the client's environment free from clutter
Which of the following maneuvers should you assess during ROM of the spine?
Lateral flexion Hyperextension Rotation
Which of the following statements should the nurse include in the medical record
Left pupil is dilated to 7mm and has a sluggish reaction to light
A nurse is planning care for a client who has a stage 1 pressure injury on their coccyx. Which of the following interventions should the nurse plan to include?
Limit elevation of the head of the bed to 30 Degree or less.
A nurse is preparing to teach a client who has a BMI of 32 about a heart-healthy diet. Which of the following dietary recommendations should the nurse include?
Limit sodium intake to less than 3,000 mg/day.
Which of the following actions should the client take when applying cold therapy after a sprain
Limit the use of the cold pack to 20 minutes at a time
A nurse is caring for a client who has stage one pressure injury which of the following information should the nurse include when documenting the characteristics of the wound
Location of the pressure injury Size of the injury in CM Integrity of the skin surrounding the wound
A nurse is preparing to administer medications to a client. Which of the following classifications of medications should the nurse identify as being ototoxic?
Loop diuretics NSAIDS Aminoglycoside antibiotics
A nurse's assessment of an older adult client identifies significant tenting of the skin over his forearm. Which of the following can explain this finding?
Loss of adipose tissue Dehydration Diminished skin elasticity
A nurse is caring for a client who is postoperative following abdominal surgery and has a morphine PCA pump. Which of the following medications should the nurse ensure is available in case the client develops respiratory depression?
Naloxone
A nurse is caring for a client who had a suspected stroke? Which of the following actions should the nurse take?
Make the client NPO Assess the client's orientation
Which of the following findings from a musculoskeletal assessment should be reported to the provider?
Misalignment of the bones of the elbow
A nurse is assessing a clients skin color which of the following area should the nurse check to determine the presence of pallor?
Mucous Membranes
A nurse is discussing the use of heat therapy with a newly licensed nurse. The nurse should include that heat therapy is effective for which of the following conditions?
Muscular pain Backache Menstrual discomfort
A nurse is caring for a client who has severe pain and repeatedly asks for pain medication. The nurse is busy and forgets to assess the client's pain and administer prescribed pain medication. Which of the following can the nurse be charged with?
Negligence
A nurse is caring for a client who has a prescription for oxycodone 5 to 10 mg PO every 4 to 6 hr as needed for pain rating 7 to 10 on a 0 to 10 scale. Fifteen minutes after receiving the dose, the client reports to the nurse their pain is still a 7 and has not changed. Which of the following actions should the nurse take?
Offer to assist the client with nonpharmacological relief strategies--like guided imagery
A nurse is assessing a client's head. Which of the following should the nurse identify as an unexpected finding?
Oval white patches A lesion on the client's scalp Protrusion of the client's head Edema around the client's eyes
A nurse is caring for a client who has a foot ulcer. Which of the following findings should the nurse identify as consistent with peripheral venous disease?
Palpable dorsalis pedal pulse
A nurse is assessing a client who reports pins and needles sensations to their right hand. Which of the following terms should the nurse use to describe the sensations?
Paresthesia
A nurse is preparing to perform a skin assessment on a client which of the following tools should the nurse plan to use?
Penlight
Which of the following tools are used in an assessment of the head and neck
Penlight Examination gloves
Deep tissue pressure injurty
Persistent, nonblanchable, deep red, maroon, or purple discoloration of the skin
A nurse is assessing a client skin color which of the following finding report to the nurse airport through the provider?
Pinpoint areas of purplish-red coloration across the abdomen Pale-colored nailbeds
A nurse is caring for a middle adult client who asks about expected age-related changes. Which of the following sensory changes should the nurse include as an age-related change?
Presbyopia
Device-related pressure injury
Pressure injury caused by equipment, furniture, or everyday objects that are left in direct contact with the skin
A nurse is monitoring a client who is 2 hr postoperative and is receiving morphine via PCA pump. Which of the following findings should the nurse plan to monitor to detect opioid-induced ventilatory impairment (OIVI)?
Respiratory rate Capnography Oxygen saturation
A nurse is preparing a poster presentation about sensory alterations. Which of the following information should the nurse include about sensory deprivation?
Risk factors for sensory deprivation include experiencing total vision or hearing loss.
A nurse is performing a neurologic examination for a client. Which of the following assessments should the nurse perform to test the client's balace
Romberg test Heel-to-toe walk
A nurse is providing education about pressure injury development to a newly licensed nurse. Which of the following points should the nurse include in the teaching?
Shear forces occur when the skin and muscles are pulled in opposite directions. Pressure injuries most often develop over bony prominences. Factors contributing to pressure injury development include immobility, malnutrition, reduced perfusion, and sensory loss.
Which of the following is a ball and socket joint
Shoulder
A nurse is completing a medical history on a client. Which of the following findings indicates the client has a family history of cardiovascular disease?
Sibling who has hypertension
Which of the following areas should the technique of palpation be used as part of the assessment
Sinus cavities
A nurse is examining a lesion on a client's back which of the following characteristics should the nurse identify as a possible indication of a Malignant skin lesion?
Size of pencil eraser
A nurse is caring for a client who is postoperative following knee surgery. Which of the following should the nurse examine to assess the client's peripheral vascular system?
Skin color Edema Skin temperature
A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated with aging?
Slower light touch sensation Some vision and hearing decline Slower fine finger movement Some short-term memory decline
A nurse is caring for an older adult client who reports unintended weight loss. The client reports that their food does not taste right. The nurse should inform the client that ability to taste which of the following can decrease with age?
Sour Bitter Salty
A nurse is inspecting the fingernails of an older adult client which of the following findings should the nurse report to the provider?
Spongy Nail Base
A nurse is assessing flexion I have a client's elbows. The nurse should provide which of the following instructions to the client?
Start with your arms straight out in front of you then bend your elbows up and bring your fingers toward your shoulders
A nurse is assessing an older adult client while they walk. Which of the following findings should the nurse report to the provider?
The client walks with a shuffling gait
A charge nurse is reviewing factors that can affect a client's perception of pain with a newly licensed nurse. Which of the following should the charge nurse include?
Stress Culture Social support Disease severity
Which of the following are unexpected findings of the eye
Subconjunctival hemorrhage Ptosis Conjunctivitis Entropion
A nurse is discussing cutaneous stimulation with a client who has back pain. Which of the following methods should the nurse include?
TENS unit Massage Acupuncture Cold therapy
A nurse is a nurse is teaching a young adult about risk factors for developing Melanoma which of the following client state may indicates an understanding of the teaching?
The blistering sunburns I had as a child increase my risk for melanoma as an adults
A nurse is palpating a client's extremities and notes the lower left leg is cooler to the touch than the clients right leg or arms how should the nurse interpret this finding?
The client might have blood clot.
Which of the following statements would be most appropriate to include in the medical record
The left side of the mouth is noted to be drooping. Speech is slurred but is understandable with appropriate word choices.
A nurse is teaching a group of older adults at a community center about the functions of the skin. which of the following statements should the nurse include in the teaching
The skin plays an important role in the production of vitamin D The skin protects against bacteria and viruses The skin helps regulate the body temperature
A nurse is assessing the range of motion of the Queens head and neck. The nurse should provide which of the following instructions to assess hyper extension?
Tilt the head back and look up at the ceiling
A nurse is preforming an eye assessment on a client. Which of the following should the nurse identify as the cornea of the eye?
Transparent layer that covers the iris and pupil
A nurse is reviewing the medical history of a client who has conductive hearing loss. The nurse should identify which of the following factors as a potential cause of conductive hearing loss?
Trauma to the outer ear Inflammation Cerumen buildup Otitis media
Foods that promote wound healing
Turkey (protein) Shellfish (zinc) Broccoli (vitamin A) Salmon (omega 3) Orange (vitamin C)
Which of the following instructions should you include while teaching a client about actions to promote the health of their head and neck?
Use ear protection when attending a loud event Wear eye protection when cutting the grass Wear a bike helmet if you are going to partake in a bike race Limit music volume when using headphones
A nurse is teaching an older adult client about health promotion. The nurse should instruct the client to have which of the following examinations preformed on a regular basis?
Vision screening every year Dental exam every 6 months
A nurse is preparing to collect data about cranial nerve function for a client. Which of the following actions should the nurse take to collect data about cranial nerve VIII?
Whisper something in one ear while occluding the other ear
A nurse is performing a skin assessment on a client. Which of the following findings should the nurse report to the provider?
Yellow Discoloration of the palms.
A nurse is preparing to assess the eyes of a client who has liver disease. Which of the following findings should the nurse expect?
Yellow sclera
Which of the following statements should you include in a teaching about health promotion screenings for adults
You should have your vision checked every 2 years
A nurse is providing teaching about safe ambulation to a client who has vision loss. Which of the following items should the nurse include in the teaching?
a walking cane a walker
A nurse is assessing the eye of a client who experienced a subconjunctival hemorrhage as a result of vomiting. Which of the following findings should the nurse expect?
defined reddened area of the sclera
you are performing an assessment on a client and observe a shallow wound on the client's leg. the wound only penetrates the epidermis and there is no bleeding present. which of the following terms correctly describes this wound?
erosion
place the following actions to check capillary refill in the order of performance
explain press release note time to return document
A nurse is performing range of motion exercises on a clients hips. The nurse is assessing which of the following motions by instructing a client to bend the knee and bring it up to where the chest?
flexion of the hip
A nurse is taking a health history from a client. Which of the following statements by the client requires further questioning by the nurse?
for some reason I have been experiencing falls
Stage 3 pressure injury
full-thickness tissue loss, with no bones or tendons exposed
A nurse is assessing a client spinal range of motion. Which of the following motions is the nurse assessing by asking the client to bend backwards as far as it can go?
hyperextension
Which of the following is a finding of scoliosis?
lateral curvature of the spine
A nurse is recommending sources of food with high calcium content to a client. Which of the following foods should the nurse recommend?
milk mustard greens legumes
A nurse is assessing a clients wrist and hands. Which of the following findings indicates the client may have arthritis?
nodules on the joints fingers deviated toward the ulnar
A nurse is preforming a head and neck assessment on a client. After checking the client's vision, the nurse notes the client has a difficulty reading fine print. In which of the following sections of the client's electronic health record should the nurse document this finding?
review of symptoms
you are assessing the texture of a client's skin. which of the following findings require additional investigation?
smooth, velvety skin
A nurse is assessing the range of motion of a clients hands. The nurse should provide which of the following instructions to assess abduction and adduction of a client fingers?
spread the fingers apart then move them back together
you are assessing a client and note a pressure injury on the client's sacrum. the lesion is a deep depression below the level of the skin and subcutaneous fat is visible. what stage of pressure injury would you document for this wound?
stage III
A nurse is caring for a client who has kidney stones. Which of the following manifestations is an objective indicator of pain?
the client is diaphoretic
which of the following would you include as a subjective finding within the medical record?
the client reports, "I don't get around very well"
A nurse is assessing a client head and neck. Which of the following findings should the nurse report to the provider?
there is locking of the jaw joint
A nurse is preforming a head-to-toe assessment on a client and notes a lump on the anterior portion of their neck. The nurse should identify that this finding can indicate which of the following conditions?
thyroid disorder
A nurse is assessing the mouth of a client who has candidiasis, an oral fungal infection. Which of the following findings should the nurse expect?
white patches on the tongue
