ATI Fundamentals 2023

A nurse is examining a client's head and neck lymph nodes. Match the name of the lymph node with the location of the lymph node. Submental Postauricular Nodes Anterior Cervical Nodes Tonsillar Nodes Occipital Nodes Base of the skull Over the mastoid Angle of the mandible Under the chin Along the sternocleidomastoid muscle

-Base of the skull - Occipital nodes -Over the mastoid - Postauricular nodes -Angle of the mandible - Tonsillar nodes -Under the chin - Submental -Along the sternocleidomastoid muscle - Anterior cervical nodes

A nurse is teaching a newly licensed nurse about urine specimen collection. Match the following tests to the procedure. Random urinalysis Clean-catch midstream for culture and sensitivity (C&S) Timed urine specimen Catheter urine specimen for C&S Collect urine for a 24-hour period Obtain a non-sterile urine specimen Obtain a sterile urine specimen from an indwelling urinary catheter Clean the urethral meatus prior to obtaining the urine specimen

-Random urinalysis - Obtain a non-sterile urine specimen -Clean-catch midstream for culture and sensitivity (C&S) - Clean the urethral meatus prior to obtaining the urine specimen -Timed urine specimen - Collect urine for a 24-hour period -Catheter urine specimen for C&S - Obtain a sterile urine specimen from an indwelling urinary catheter

A nurse is providing a client with a complete bed bath. When providing care, the nurse must recognize the order in which areas of the body will be bathed. Place the options in the correct order. Trunk Feet Face Legs 1. 2. 3. 4.

1. Face 2. Trunk 3. Legs 4. Feet When providing the client with a complete bed bath, the nurse should begin with the cleanest area and work down toward the feet. The nurse cleanses the face first. Next, the nurse should wash the client's trunk and upper extremities followed by the legs and then the feet.

A nurse is preparing to administer a cleansing enema to a client. Place the steps the nurse should plan to take in the correct order. Slowly insert the rectal tube into the client's rectum Warm the enema solution Ask the client to retain the solution Lubricate the end of the rectal tube Hang the enema container 30-45 cm (12-18 in) above the client's anus

1. Warm the enema solution 2. Lubricate the end of the rectal tube 3. Slowly insert the rectal tube into the client's rectum (7.5-10 cm or 3-4 in) 4. Hang the enema container 30-45 cm (12-18 in) above the client's anus 5. Ask the client to retain the solution

A nurse is caring for a client who weighs 80 kg (176 lb) and is 1.6 m (5 ft 3 in) tall. Calculate the body mass index (BMI) and determine whether this client's BMI indicates a healthy weight, underweight, overweight, or obese.

32.2 Obese Equation is either (kg/m^2) or (lb/in^2) x 703

The ostomy nurse is preparing to educate the client about caring for the new colostomy. Place the following actions the ostomy nurse should take in the correct order. 1. Demonstrate how to care for the colostomy. 2. Select instructional materials about colostomy care to give to the client. 3. Ask the client to explain how to care for their colostomy. 4. Determine what the client knows about colostomies.

4, 2, 1, 3 When taking action, the ostomy nurse uses the nursing process to educate the client about caring for the colostomy. The first action the nurse should take is to determine what the client knows about colostomies. The ostomy nurse can base the education for the client on preexisting knowledge. The second action the ostomy nurse should take using the nursing process is to plan to use instructional materials to educate the client about colostomy care. The third action the ostomy nurse should take using the nursing process is implementation. The ostomy nurse demonstrates how to care for the colostomy. The fourth action the ostomy nurse should take using the nursing process is evaluation. The ostomy nurse evaluates the client's understanding of how to care for their colostomy. NCLEX Connection: Reduction of Risk Potential, Therapeutic Procedures

A nurse in a provider's office is preparing to auscultate and percuss a client's abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Tympani B. High-pitched Clicks C. Borborygmi D. Friction Rubs E. Bruits

A & B Tympani Tympani is the expected drum-like percussion sound over the abdomen. It indicates air in the stomach. High-pitched clicks Typical bowel sounds are expected high-pitched clicks and gurgles occurring about 5 to 35 times/min. Borborygmi Borborygmi are unexpected loud, growling sounds that indicate increased gastrointestinal motility. Possible causes include diarrhea, anxiety, bowel inflammation, and reactions to some foods. Friction rubs Friction rubs result from the rubbing together of inflamed layers of the peritoneum and are unexpected findings. Bruits Bruits indicate narrowed blood vessels and are unexpected findings.

A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (Select all that apply.) A. Older adults are more prone to dehydration than younger adults. B. The recommended intake of daily fiber decreases in older adults. C. Many older adults need calcium supplementation. D. Older adults need more calories than they did when they were younger. E. Older adults should consume a diet low in carbohydrates.

A, B, & C Older adults are more prone to dehydration than younger adults. A. When taking actions, the nurse should include that sensations of thirst diminish with age, leaving older adults more prone to dehydration. B. The recommended intake of daily fiber decreases in older adults. The recommended amount of daily fiber intake decreases in the older adult due to their lower caloric intake. C. Many older adults need calcium supplementation. Many older adults need an increased intake of calcium, whether through their diet or through calcium supplements to help prevent bone demineralization (osteoporosis). Older adults need more calories than they did when they were younger. Older adults have a slower metabolic rate, so they require less energy (unless they are very active) and, therefore, need fewer calories. Older adults should consume a diet low in carbohydrates. Older adults should consume a healthy diet with an appropriate intake of calories through a balanced diet while limiting intake of fat, salt, refined sugars, and alcohol.

A nurse is instructing a client who has an injury on the left lower extremity about the use of a cane. Which of the following instructions should the nurse include?​ (Select all that apply.) A. Hold the cane on the right side. B. Keep two points of support on the floor. C. Place the cane 38 cm (15 in) in front of the feet before advancing. D. After advancing the cane, move the weaker leg forward. E. Advance the stronger leg so that it aligns evenly with the cane.

A, B, & D A. Hold the cane on the right side. When taking action, the nurse should instruct the client to hold the cane on the uninjured side to provide support for the injured left leg. B. Keep two points of support on the floor. When taking action, the nurse should instruct the client to keep two points of support on the ground at all times for stability. D. After advancing the cane, move the weaker leg forward. When taking action, the nurse should instruct the client to advance the weaker leg first, followed by the stronger leg. Place the cane 38 cm (15 in) in front of the feet before advancing. The client should place the cane 15 to 25 cm (6 to 10 in) in front of their feet before advancing. Advance the stronger leg so that it aligns evenly with the cane. The client should advance the stronger leg past the cane.

The nurse is educating the client about ways to improve sleep. Which of the following recommendations should the nurse include? (Select all that apply.) A. Practice muscle relaxation techniques. B. Exercise each morning C. Take two 30 min naps each day. D. Avoid heavy meals before bedtime E. Limit fluid intake at least 1 hr before bedtime

A, B, & D A. Practice muscle relaxation techniques. B. Exercise each morning D. Avoid heavy meals before bedtime

A nurse is assessing a client who reports insomnia. Which of the following findings can contribute to the client's insomnia? (Select all that apply.) A. Irregular Schedule B. Stress C. Warm Bath D. Alcohol Intake E. Morning Walk

A, B, & D Irregular schedule Stress Alcohol intake

A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse take?​​​​​​ (Select all that apply.) A. Using a facility-approved medical interpreter B. Determining the client's understanding several times during the conversation C. Looking at the interpreter when asking the client questions D. Using medical terms during the conversation E. Asking one question at a time

A, B, & E A. Using a facility-approved medical interpreter C. Looking at the interpreter when asking the client questions E. Asking one question at a time

Which of the following actions should the nurse take when demonstrating an empathetic presence to a client? (Select all that apply.) A. Using an open posture​​​​​ B. Writing down what the client says to avoid forgetting details​​​​​​​ C. Establishing and maintaining eye contact D. Nodding and agreeing with the client throughout the conversation E. Sitting facing the client

A, B, C, & E Using an open posture​​​​​ Having an open posture, facing the client, and leaning forward are ways that can demonstrate an empathetic presence. Writing down what the client says to avoid forgetting details​​​​​​​ Writing down everything the client says can interfere with the ability to convey full attention and interest. Establishing and maintaining eye contact​​​​​​​ Establishing and maintaining eye contact are ways that can demonstrate an empathetic presence. Sitting facing the client Sitting while facing the client directly can demonstrate an empathetic presence. It also helps clients who have hearing loss understand verbal communication. Nodding and agreeing with the client throughout the conversation If the nurse nods in agreement throughout the conversation, the client could interpret that as agreement with what the client is saying when instead the nurse meant to convey attending to and understanding what they are saying.

A nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following interventions should the nurse include? (Select all that apply.) A. Help the client see the benefits of their actions. B. Identify the client's support systems. C. Suggest and recommend community resources. D. Devise and set goals for the client. E. Teach stress management strategies.

A, B, C, & E are correct Help the client see the benefits of their actions. The nurse should plan to assist the client to recognize the benefits of their health-promoting actions while also overcoming barriers to implementing actions. Identify the client's support systems. The nurse should plan to collect information about who can help the client change unhealthy behaviors, and then suggest steps to have friends and family to become involved and supportive. Suggest and recommend community resources. The nurse should plan to promote the client's use of any available community or online resources that can help the client progress toward meeting set goals. Teach stress management strategies. The nurse should plan to teach that stress is a contributing factor to cardiovascular disease, as well as many other specific and systemic disorders. Devise and set goals for the client. The nurse and the client should work together to devise and set mutually agreeable goals that are also realistic and achievable.

A nurse is teaching a client who has recurrent UTIs. Which of the following instructions should the nurse include?​​​​​​​ (Select all that apply.) A. Urinate after sexual intercourse B. Drink at least 1L of fluid each day C. Clean perineum from the front to back D. Wear nylon undergarments E. Avoid bubble baths

A, C, & E A. Urinate after sexual intercourse When taking action, the nurse should instruct the client to urinate after sexual intercourse to flush bacteria from the urinary system. C. Clean perineum from the front to back The client should clean the perineum from the front to back to reduce the risk of introducing bacteria in the urinary system and avoid bubble baths that might irritate the urethra. Avoid bubble baths The client should clean the perineum from the front to back to reduce the risk of introducing bacteria in the urinary system and avoid bubble baths that might irritate the urethra.

A nurse is talking with an older adult client about improving nutritional status. Which of the following interventions should the nurse recommend? (Select all that apply.) A. Increase protein intake to increase muscle mass. B. Decrease fluid intake to prevent urinary incontinence. C. Increase calcium intake to prevent osteoporosis. D. Limit sodium intake to prevent edema. E. Increase fiber intake to prevent constipation.

A, C, D, & E The nurse should identify that older adults should increase protein intake to increase muscle mass and improve wound healing, increase calcium intake to reduce the risk for osteoporosis, limit sodium intake to reduce the risk for edema and hypertension, and increase fiber intake to prevent constipation.

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? (Select all that apply.) A. Capillary refill less than 3 seconds B. 1+ pitting edema C. Pale nail beds in one hand D. Thick skin on the soles of the feet E. 2+ pulses on the client's lower extremities

A, D, & E Capillary refill less than 3 seconds 2+ pulses on the client's lower extremities Thick skin on the soles of the feet

A nurse is assessing a client's thyroid as part of a comprehensive physical exam. Which of the following findings should the nurse expect? (Select all that apply.) A. Palpating the thyroid in the lower half of the neck B. Visualizing the thyroid on inspection of the neck.​​​​​​​ C. Hearing a bruit when auscultating the thyroid. ​​​​​​​ D. Feeling the thyroid when the client swallows. ​​​​​​​ E. Finding symmetric extensions of the trachea on both sides of the midline.

A, D, & E Palpating the thyroid in the lower half of the neck. ​​​​​​​ The thyroid is located in the anterior lower neck on both sides of the trachea. Feeling the thyroid when the client swallows. ​​​​​​​ When a client swallows a sip of water, the nurse should expect to feel the thyroid move upward with the trachea. Finding symmetric extensions of the trachea on both sides of the midline. The thyroid gland lies in front of the trachea and extends symmetrically to both sides of the midline. Visualizing the thyroid on inspection of the neck.​​​​​​​ An average size thyroid gland is not visible on inspection. Visualization of the thyroid gland could indicate a thyroid disorder. Hearing a bruit when auscultating the thyroid. ​​​​​​​ A bruit indicates increase blood flow and can indicate hyperthyroidism.

A nurse in a provider's office is preparing to perform a breast examination for an older adult client who is postmenopausal. Which of the following findings should the nurse expect? (Select all that apply.) A. Smaller nipples B. Less adipose tissue C. Nipple discharge D. More pendulous E. Nipple inversion

A, D, & E Smaller nipples In older adulthood, the nipples become smaller and flatter. More pendulous In older adulthood, breasts become softer and more pendulous. Nipple inversion Nipple inversion is common among older adults, due to fibrotic changes and shrinkage. Less adipose tissue Older adults have more adipose tissue and less glandular tissue in their breasts. Nipple discharge Older adults have no nipple discharge, unless there is some underlying pathophysiology.

A nurse is using the FICA screening tool to gather more data about a client's interfaith needs. Which of the following questions should the nurse ask when using the tool? A. "What gives you a sense of purpose?" B. "Who inspires you?" C. "How has this condition affected you?" D. "Do you have a communication barrier?"

A. "What gives you a sense of purpose?" When using the FICA screening tool, the nurse should ask open-ended questions to gather more information about the client's interfaith needs. The nurse should ask questions to check the client's faith, implications/influence, community, and address. "What gives you a sense of purpose?" is an appropriate question to ask because this is addressing the client's faith. "Who inspires you?", "how has this condition affected you?", and "do you have a communication barrier?" are not appropriate questions to ask because they will not address the client's interfaith needs.

A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? A. Encouraging the client to perform antiembolic exercises every two hours B. Instructing the client to cough and deep breathe every 4 hours C. Restricting the client's fluid intake D. Repositioning the client every 4 hours

A. Encouraging the client to perform antiembolic exercises every 2 hours When generating solutions, the nurse should encourage the client to perform antiembolic exercises every 1 to 2 hours to promote venous return and reduce the risk of thrombus formation. Instructing the client to cough and deep breathe every 4 hours The nurse should instruct the client to cough and deep breathe every 1 to 2 hours to reduce the risk of atelectasis. Restricting the client's fluid intake The nurse should increase the client's intake of fluids, unless contraindicated, to reduce the risk of thrombus formation, constipation, and urinary dysfunction. Repositioning the client every 4 hours The nurse should plan to reposition the client every 1 to 2 hours to reduce the risk for pressure injuries.

The client is experiencing difficulty swallowing. Which of the following cranial nerves controls swallowing? A. Glossopharyngeal B. Trigeminal C. Trochlear D. Hypoglossal

A. Glossopharyngeal When analyzing cues, the nurse should identify that the glossopharyngeal nerve controls swallowing. The nurse tests the ability of the client to swallow by checking the client's gag reflex.

A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following describes the client's role problem? A. Role Conflict B. Role Overload C. Role ambiguity D. Role Strain

A. Role conflict The nurse should identify that the client is experiencing role conflict because their career is extremely physical and they can no longer perform the job duties. However, the client is the primary wage earner in the family. Role overload Although the client can feel overloaded and overwhelmed, role overload occurs when the client is trying to juggle too many roles. Role ambiguity The client is not experiencing role ambiguity because their job duties and physical limitations are quite clear. Role strain The client is not experiencing role strain. That occurs when one feels inadequate for assuming a role.

A nurse is performing a neurologic examination for a client. Which of the following assessments should the nurse perform to test the client's balance? A. Romberg Test B. Weber's Test C. Rosenbaum Test D. Snellen Test

A. Romberg Test When taking actions, the nurse should identify that the Romberg test is used to assess balance. The client stands with their eyes closed, arms at both side, and feet together. The nurse verifies balance if the client can stand with minimal swaying for at least 5 seconds.

A nurse in a health clinic is caring for a 21-year-old client who tells the nurse that their last physical exam was in high school. Which of the following health screenings should the nurse expect the provider to perform for this client? A Testicular Examination B Blood Glucose C Fecal Occult Blood D Prostate-specific antigen

A. Testicular examination The nurse should identify that starting at puberty, the client should have examinations for testicular cancer, along with blood pressure and body mass index, and cholesterol measurements. Testicular cancer is most common in males 15 to 34 years of age. Blood glucose testing begins at age 45. Testing for fecal occult blood usually begins at age 45. Testing for prostate-specific antigen usually begins at age 55.

A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A. Turning the client's head to the side B. Placing two fingers in the client's mouth to open it C.Brushing the client's teeth once per day D. Injecting a mouth rinse into the center of the client's mouth

A. Turning the client's head to the side The nurse should turn the client's head toward the mattress so that the mouth is in a dependent position. This promotes drainage of secretions away from the throat and reduces the risk of aspiration. Placing two fingers in the client's mouth to open it The nurse should avoid placing fingers in the client's mouth because the client might bite down on the nurse's fingers. Brushing the client's teeth once per day The nurse should brush the client's mouth at least twice per day.

A nurse is providing denture care for a client. Which of the following actions should the nurse take? A. Using a gauze pad to grasp and pull forward and downward to remove the upper denture B. Storing the dentures overnight in a labeled denture cup filled with a solution of water and mouthwash C. After brushing the dentures, rinse them in hot water D. Donning sterile gloves prior to performing denture care

A. Using a gauze pad to grasp and pull forward and downward to remove the upper denture The nurse should use gauze to remove the client's dentures because dentures can be slippery and the gauze helps to ensure a firm grip. Storing the dentures overnight in a labeled denture cup filled with a solution of water and mouthwash The nurse should store the dentures overnight in a labeled denture cup but should fill the cup with tepid water. After brushing the dentures, rinse them in hot water After brushing the dentures, the nurse should rinse them in tepid water because hot water can cause the dentures to warp and cold water can cause the dentures to crack. Donning sterile gloves prior to performing denture care The nurse should don clean gloves prior to performing denture care to reduce the risk of infection.

A nurse is caring for a client who asks what their Snellen eye test results mean. The client's visual acuity is 20/30. Which of the following responses should the nurse make? A. "Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet." B. ​​​​​​​​​​​"Your right eye can see the chart clearly at 20 feet, and your C. "Your eyes see at 30 feet what visually unimpaired eyes see at 20 feet." D. "Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet."

A. ​​​​​​​​​​​​​"Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet." The first number is the distance (in feet) the client stands from the chart. The second number is the distance at which a visually unimpaired eye can see the same line clearly. ​​​​​​​​​​​"Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet." Each eye has its own visual acuity, which includes both numbers. ​​​​​​​​​"Your eyes see at 30 feet what visually unimpaired eyes see at 20 feet." The numerator of visual acuity results is a constant. It does not change with a client's ability to see clearly. "Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet." Each eye has its own visual acuity, which includes both numbers.

A nurse is discussing complementary or alternative therapies with a newly licensed nurse. Match the therapy with the method. Acupuncture Massage Therapy Naturopathic medicine Chiropractic medicine Biofeedback Muscles are stretched to promote relaxation The spine is manipulated to promote healing Needles are placed along meridians to produce analgesia Instruments are used to visualize a body function to control a physiologic response Herbal remedies are used to promote healing

Acupuncture - Needles are placed along meridians to produce analgesia Massage Therapy - Muscles are stretched to promote relaxation Naturopathic medicine - Herbal remedies are used to promote healing Chiropractic medicine - The spine is manipulated to promote healing Biofeedback - Instruments are used to visualize a body function to control a physiologic response

A nurse is discussing herbal remedies with a newly licensed nurse. Match the herbal remedy with the possible therapeutic effect. Antiemetic Increases physical endurance Enhances immunity Produces sleep Improves memory Gingko Biloba Echinacea Ginger Ginseng Valerian

Antiemetic - Ginger Increases physical endurance - Ginseng Enhances immunity -Echinacea Produces sleep - Valerian Improves memory - Gingko biloba

A nurse in a provider's office is testing the cranial nerves during a head and neck examination. Which of the following cranial nerves are both sensory and motor? (Select all that apply.) A. Cranial Nerve II (Optic)​ B. Cranial Nerve V (Trigeminal) C. Cranial Nerve VII (Facial) D. Cranial Nerve VIII (Auditory) E. Cranial Nerve XI (Spinal accessory)

B & C Cranial Nerve V (Trigeminal)​​​​​​​ Cranial nerve V, the trigeminal nerve provides sensory input for the face as well as movement of the jaw; therefore, it is both sensory and motor. Cranial Nerve VII (Facial)​​​​​​​ Cranial nerve VII, the facial nerve allows for facial expression and taste, therefore, it is both sensory and motor. Cranial Nerve II (Optic)​​​​​​​ During an examination of the head and neck, the nurse should recognize that Cranial Nerve II, the optic nerve whose function is visual acuity is sensory only. Cranial Nerve VIII (Auditory)​​​​​​​ Cranial nerve VIII, the auditory nerve provides for hearing and thus, it is sensory only. Cranial Nerve XI (Spinal accessory) Cranial Nerve XI, Spinal accessory, provides for movement of the head and shoulders and is motor only.

A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (Select all that apply.) A. Instructing the client not to perform the Valsalva maneuver B. Applying elastic stockings C. Reviewing laboratory values for total protein level D. Placing pillows under the client's knees and lower extremities E. Assisting the client to change positions often

B & E B. Applying elastic stockings When taking actions, the nurse should identify that elastic stockings promote venous return and prevent thrombus formation. E. Assisting the client to change positions often When taking actions, the nurse should identify that frequent position changes prevent venous stasis. Instructing the client to not perform the Valsalva maneuver The Valsalva maneuver increases the workload of the heart, but it does not affect peripheral circulation. Reviewing laboratory values for total protein level A review of the client's total protein level is important for evaluating their ability to heal and prevent skin breakdown. Placing pillows under the client's knees and lower extremities Placing pillows under the knees and lower extremities can impair circulation of the lower extremities.

A nurse is caring for a client whose partner passed away 4 months ago. The client has a recent diagnosis of diabetes mellitus. The client is tearful and states, "How could you possibly understand what I am going through?" Which of the following responses should the nurse make? A. "It takes time to get over the loss of a loved one." B. "You are right. I cannot really understand. Perhaps you'd like to tell me more about what you're feeling." C. "Why don't you try something to take your mind off your troubles, like watching a funny movie." D. "I might not share your exact situation, but I do know what people go through when they deal with a loss."

B - "You are right. I cannot really understand. Perhaps you'd like to tell me more about what you're feeling." The nurse should identify that by stating there is a lack of understanding, the nurse is using the therapeutic communication technique of validation, whereby a person shows sensitivity to the meaning behind a behavior. The nurse is also creating a supportive and nonjudgmental environment and inviting the client to express frustrations. "It takes time to get over the loss of a loved one." Telling the client it will take more time to heal belittles the client's feelings and gives false reassurance. "Why don't you try something to take your mind off your troubles, like watching a funny movie." Telling the client to try a distraction dismisses the client's feelings and gives common advice instead of expert advice. "I might not share your exact situation, but I do know what people go through when they deal with a loss." Saying the nurse knows what clients feel is presumptive and inappropriate.

A nurse is auscultating a client's lungs. Which of the following findings are expected? (Select all that apply.) A. High-pitched musical sounds​​​​​​​ B. Expiration is longer than inspiration over the trachea upon auscultation is an expected bronchial sound. C. Soft, breezy, low-pitched sounds​​​​​​​ D. Medium pitched blowing sounds

B, C, & D Expiration is longer than inspiration over the trachea upon auscultation. ​​​​​​​ Expiration is longer than inspiration over the trachea upon auscultation is an expected bronchial sound. Soft, breezy, low-pitched sounds​​​​​​​ Soft, breezy, low-pitched sounds are vesicular sounds which are best heard over the periphery of the lungs and are expected. Medium-pitched blowing sounds Medium- pitched blowing sounds upon auscultation are bronchovesicular and are expected. High-pitched musical sounds​​​​​​​ A high-pitched musical sound upon auscultation indicates wheezing which is an adventitious or unexpected.

A nurse is preparing to inspect the ears, nose, mouth, and throat of a client. Which of the following equipment does the nurse need? (Select all that apply._) A. Ophthalmoscope B. Tongue blade C. Penlight D. Gauze Square E. Stethoscope

B, C, & D Gauze square A gauze square to grasp the tongue during the examination. Penlight A penlight to examine the color size, position and texture of the tongue. Tongue blade When examining the ears, mouth a nose of a client, the nurse needs a tongue blade to examine the client's tongue on all sides and the floor of the mouth. Ophthalmoscope An ophthalmoscope is used to examine a client's eyes. Stethoscope A stethoscope is used when the nurse is performing auscultation.

A nurse is caring for a group of clients on a medical-surgical unit. Which of the following clients are at increased risk for body-image disturbances? (Select all that apply.) A. A client who had a laparoscopic appendectomy B. A client who had a mastectomy C. A client who had a left above-the-knee amputation D. A client who had a cardiac catheterization E. A client who had a stroke with right-sided hemiplegia

B, C, & E B. A client who had a mastectomy The nurse should identify that having a mastectomy involves a change in physical appearance and can lead to body-image disturbances related to sexuality. C. A client who had a left above-the-knee amputation Having an above-the-knee amputation involves a change in physical appearance and can lead to body-image disturbances related to function, health, and strength. E. A client who had a stroke with right-sided hemiplegia Having right-sided hemiplegia involves a change in physical appearance and can lead to body-image disturbances related to function, health, and strength. A client who had a laparoscopic appendectomy According to the concept of body image, an appendectomy would not place a client at high risk for a body-image disturbance. A client who had a cardiac catheterization Depending on the prognosis post catheterization, the client can have some limitations. However, in general, a cardiac catheterization would not place a client at high risk for a body-image disturbance.

A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following nursing interventions for stress, coping, and adherence to the treatment plan should the nurse initiate at this time? (Select all that apply.) A. Suggesting coping skills for the client to use in this situation B. Allowing the client to provide input in the treatment plan C.Assisting the client with time management and address the client's priorities D. Providing extensive instructions on the client's treatment regimen E. Encouraging the client in the expression of feelings and concerns

B, C, & E B. Allowing the client to provide input in the treatment plan The nurse should identify that allowing the client to contribute to the treatment plan allows for greater adherence to the plan. C. Assisting the client with time management and address the client's priorities Helping the client to prioritize is an intervention that can reduce levels of stress for the client because, many times, time management is extremely difficult in times of stress. E. Encouraging the client in the expression of feelings and concerns By using effective communication techniques, encouraging the client to verbalize feelings is an intervention for stress, coping, and adherence that allows the client to reduce stress, validate emotions, and start planning for valid concerns. Suggesting coping skills for the client to use in this situation Although it can seem helpful to suggest specific coping skills for the client, it is best to allow the client to discuss coping skills that have worked in the past. Providing extensive instructions on the client's treatment regimen While it is necessary to provide complete information on treatment plans, simplifying treatment regimens as much as possible allows for greater adherence to the treatment plan.

A nurse is teaching a client who has diarrhea. Which of the following instructions should the nurse include? (Select all that apply.) A. Eat raw fruit with the skin B. Eat yogurt when diarrhea has stopped C. Increase fluid intake. D. Drink hot fluids E. Avoid caffeinated beverages

B, C, & E B. Eat yogurt when the diarrhea has stopped. When taking action, the nurse should instruct the client to eat yogurt once the diarrhea has stopped to restore bowel flora. C. Increase fluid intake. The nurse should instruct the client to increase fluid intake to replace fluid loss. E. Avoid caffeinated beverages. The nurse should instruct the client to avoid bowel irritants, such as caffeinated beverages.

A nurse is assessing a client who has had diarrhea for 3 days. Which of the following findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Hypotension C. Elevated temperature D. Peripheral edema E. Poor skin turgor

B, C, & E B. Hypotension When analyzing cues, the nurse should expect the client who has had diarrhea for the past 3 days to have manifestations of dehydration, such as hypotension, elevated temperature, and poor skin turgor. C. Elevated temperature When analyzing cues, the nurse should expect the client who has had diarrhea for the past 3 days to have manifestations of dehydration, such as hypotension, elevated temperature, and poor skin turgor. E. Poor skin turgor When analyzing cues, the nurse should expect the client who has had diarrhea for the past 3 days to have manifestations of dehydration, such as hypotension, elevated temperature, and poor skin turgor.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? (Select all that apply.) A. Empty the client's urinary drainage bag when it is 3/4 full. B. Keep the urinary drainage bag below the level of the client's bladder C. Assess the client's need for the indwelling urinary catheter daily. D. Rest the urinary collection bag on the floor when the client is sitting in a chair. E. Maintain a closed system of the client's urinary catheter.

B, C, & E B. Keep the urinary drainage bag below the level of the client's bladder When taking action, the nurse should keep the urinary drainage bag below the level of the client's bladder to reduce the risk of urine draining back into the client's bladder. C. Assess the client's need for the indwelling urinary catheter daily. The nurse should assess the need for the indwelling urinary catheter daily and maintain a closed urinary drainage system, to reduce the risk of a CAUTI. E. Maintain a closed system of the client's urinary catheter. The nurse should assess the need for the indwelling urinary catheter daily and maintain a closed urinary drainage system, to reduce the risk of a CAUTI.

A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following should the nurse plan to include in the presentation? (Select all that apply.) A. Human papilloma virus (HPV) immunization B. Pneumococcal vaccination C. Yearly eye examination D. Periodic mental health screening E. Annual fecal occult blood test

B, C, D, & E B. Pneumococcal vaccination The nurse should plan to include information about pneumococcal vaccines, specifically, PCV15, PCV20, and PPSV23. The nurse should also include information about a yearly eye examination to screen for glaucoma and vision changes, periodic mental health assessments, and an annual fecal occult blood test for the group of older adult clients. C. Yearly eye examination The nurse should plan to include information about pneumococcal vaccines, specifically, PCV15, PCV20, and PPSV23. The nurse should also include information about a yearly eye examination to screen for glaucoma and vision changes, periodic mental health assessments, and an annual fecal occult blood test for the group of older adult clients. D. Periodic mental health screening The nurse should plan to include information about pneumococcal vaccines, specifically, PCV15, PCV20, and PPSV23. The nurse should also include information about a yearly eye examination to screen for glaucoma and vision changes, periodic mental health assessments, and an annual fecal occult blood test for the group of older adult clients. E. Annual fecal occult blood test The nurse should plan to include information about pneumococcal vaccines, specifically, PCV15, PCV20, and PPSV23. The nurse should also include information about a yearly eye examination to screen for glaucoma and vision changes, periodic mental health assessments, and an annual fecal occult blood test for the group of older adult clients. Human papilloma virus (HPV) immunization The HPV vaccine is recommended for female clients from age 11 to 26 and male clients from age 9 to 26. It is not a recommendation for older adults.

A nurse is obtaining a health history from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? (Select all that apply.) A. Skin thickening B. Decreased height C. Increased saliva production D. Nail thickening E. Decreased bladder capacity

B, D, & E The nurse should identify that physiological changes that occur with aging can include loss in height due to the thinning of intervertebral disks, thickening of the nails of the fingers and toes, and a reduced bladder capacity. While young adults have a bladder capacity of about 500 to 600 mL, older adults have a capacity of about 250 mL. The nurse should identify that physiological changes that occur with aging can include loss in height due to the thinning of intervertebral disks, thickening of the nails of the fingers and toes, and a reduced bladder capacity. While young adults have a bladder capacity of about 500 to 600 mL, older adults have a capacity of about 250 mL. The nurse should identify that physiological changes that occur with aging can include loss in height due to the thinning of intervertebral disks, thickening of the nails of the fingers and toes, and a reduced bladder capacity. While young adults have a bladder capacity of about 500 to 600 mL, older adults have a capacity of about 250 mL. The nurse should identify that physiological changes that occur with aging can include decreased skin turgor, subcutaneous fat, and connective tissue (dermis), which can cause wrinkles and dry, thin, transparent skin. Other physiological changes that occur with aging can include decreased saliva production, making xerostomia (dry mouth) a common problem.

A nurse is assessing an adult client's internal ear canals with an otoscope as part of a head and neck examination. Which of the following actions should the nurse take? (Select all that apply.) A. Pull the auricle down and back. B. Insert the speculum slightly down and forward. C. Insert the speculum 2 to 2.5 cm (0.8 to 1 in). D. Make sure the speculum does not touch the ear canal. E. Use the light to visualize the tympanic membrane in a cone shape.

B, D, & E Use the light to visualize the tympanic membrane in a cone shape. Due to the angle of the ear canal, the nurse can only visualize the light reflecting off of the tympanic membrane as a cone shape rather than a circle. Make sure the speculum does not touch the ear canal. The lining of the ear canal is sensitive. Touching it with the speculum could cause pain. Insert the speculum slightly down and forward. Inserting the speculum slightly down and forward follows the natural shape of the ear canal. Insert the speculum 2 to 2.5 cm (0.8 to 1 in). Insert the speculum 1 to 1.5 cm (0.4 to 0.6 in). Pull the auricle down and back. The nurse should pull the auricle up and back for adults and down and back for children younger than 3 years.

A nurse at a provider's office is talking about routine screenings with a 45-year-old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands how to proceed? A. "I'll need a colonoscopy in 5 years." B. "For now, I should continue to have a clinical breast exam each year." C. "Because the doctor just did a Pap smear, I'll come back next year for another one." D. "I had my blood glucose test last year, so I won't need it again for 4 years."

B. "For now, I should continue to have a clinical breast exam each year." The female client who is between the ages of 40 and 49 should have a clinical breast exam annually, and they should consult with their provider about the frequency of mammograms. The nurse should identify that the female client who has no specific family or personal history of colorectal cancer should have a colonoscopy every 10 years beginning at age 45. The female client who is between the ages of 30 and 65, with no family or personal history of cervical cancer, should have either a Pap smear and human papilloma virus test every 5 years, or a Pap test every 3 years. The client who is age 45 should have a blood glucose test at least every 3 years. Unless there is a specific family or personal history of diabetes mellitus, annual blood glucose determinations are not necessary.

A nurse is instructing a client who has narcolepsy. Which of the following client statements indicates an understanding of the instructions? A. "I will add plenty of carbohydrates to my meals." B. "I will take a short nap when I feel sleepy." C. "I will increase the heat in my office, so I stay warm." D. "I will limit alcohol intake to one drink per day."

B. "I will take a short nap when I feel sleepy." Taking a planned daytime nap might reduce the risk of falling asleep at an inopportune time, such as when driving or at work. The nurse should also instruct the client to eat high protein meals, perform regular exercise, and avoid activities that might cause drowsiness, such as being in a warm environment and drinking alcohol.

A nurse is teaching a group of clients how to care for their colostomies. Which of the following statements indicates an issue with self-concept? A. "I was having difficulty with attaching the appliance at first, but my partner was able to help." B. "I'll never be able to care for this at home. Can't you just send a nurse to the house?" C. "I met a neighbor who also has a colostomy, and they taught me a few things." D. "It can take me a while to get the hang of this. I have to admit, I am pretty nervous."

B. "I'll never be able to care for this at home. Can't you just send a nurse to the house?" The nurse should identify that the client is displaying a lack of interest in learning how to care for the colostomy and preferring dependence on others to perform the care. Issues with self-concept should be suspected. "I was having difficulty with attaching the appliance at first, but my partner was able to help." Although the client was having difficulty at first, the client expressed how resources would be used, resulting in a positive outcome, and does not show signs of self-concept issues. "I met a neighbor who also has a colostomy, and they taught me a few things." This client is displaying a positive self-concept by reaching out and using resources to learn additional information regarding the colostomy. "It can take me a while to get the hang of this. I have to admit, I am pretty nervous." Expression of feelings is an indication of a positive self-concept even if the client admits to anxiety or hesitance about caring for the colostomy.

A nurse is providing teaching with a newly licensed nurse about incorporating culturally responsive nursing care. Which of the following statements by the newly licensed nurse indicates understanding? A. "It is a form of client ethnocentrism." B. "It involves the delivery of care that includes the client's beliefs." ​​​​​​​ C. "It involves being knowledgeable about various cultures."​​​​​​​ D. "It is the examination of the nurse's personal attitude."

B. "It involves the delivery of care that includes the client's beliefs." ​​​​​​​ Culturally responsive nursing care involves the delivery of care that considers a client's cultural beliefs that could affect their well-being. "It is a form of client ethnocentrism." ​​​​​​​ Cultural imposition is a form of ethnocentrism. "It involves being knowledgeable about various cultures."​​​​​​​ Cultural sensitivity is the term used to describe being knowledgeable about various cultures. "It is the examination of the nurse's personal attitude." Cultural awareness is self-awareness for the nurse to identify potential bias.

A nurse is caring for a client who is recovering from a myocardial infarction and a cardiac catheterization. The client states, "I am concerned that things might be a little, you know, 'different' with my partner when I get home." Which of the following statements should the nurse make? A. "It sounds like something you should discuss with them when you get home." B. "It sounds like you are concerned about sexual functioning. Let's discuss your concerns." C. "Oh, I wouldn't be too concerned. Things will be fine as soon as we get you home." D. "Just make sure you take your medication as directed, and you should be fine."

B. "It sounds like you are concerned about sexual functioning. Let's discuss your concerns." The nurse should acknowledge and allow the client to discuss their concerns regarding sexual functioning. The nurse should not give the client false reassurance. "It sounds like something you should discuss with them when you get home." The client has valid concerns. "Oh, I wouldn't be too concerned. Things will be fine as soon as we get you home." This statement is dismissing the client's feelings. "Just make sure you take your medication as directed, and you should be fine." Giving the client a directive and telling them that they should be fine is not allowing the client to express their feelings and is displaying false reassurance, which is inappropriate because the client has valid concerns.

Claire is evaluating Mr. Tuttle's understanding of the use of a sequential compression device. Which of the following client statements indicates client understanding? A. "This device will keep me from getting sores on my skin." B. "This device will keep the blood pumping through my legs." C. "With this device on, my leg muscles won't get weak." D. "This device is going to keep my joints in good shape."

B. "This device will keep the blood pumping through my legs." Claire should identify that sequential pressure devices promote venous return in the deep veins of the legs and thus help prevent thrombus formation. The skin should be assessed under the sequential pressure device every 8 hr to check for manifestations of a thrombus and skin breakdown.

The ostomy nurse is educating the client about diet. Which of the following actions should the nurse take to evaluate the client's learning? A. Encourage the client to ask questions about their diet.​ B. Ask the client to list foods to include in their diet. C. Encourage the client to fill out an evaluation form about how the nurse presented the information about diet.​ D. Ask the client if they have additional resources for further instruction about their new diet.

B. Ask the client to list foods to include in their diet. When evaluating outcomes, the ostomy nurse should identify that having the client explain the information in their own words allows the nurse to evaluate what the client remembers, whether the client comprehends the information, and if further instruction is required.

A nurse is providing information about age-related physical changes to the family member of an older adult. Which of the following information should the nurse include? A. Older adults have oilier skin than younger persons. B. Dry mouth is common for older adults. C. It is common for older adults to have increased perspiration. D. Hair in the eyebrows decreases.

B. Dry mouth is common for older adults. It is common for older adults to experience dry mouth due to decreased saliva production, and many older adults take medications that lead to dry mouth. Older adults have oilier skin than younger persons. Typically, older adults have drier skin. It is common for older adults to have increased perspiration. Due to a decrease in ability to function, older adults are expected to have less perspiration. Hair in the eyebrows decreases. It is typical for the hair in the ears, nose, and eyebrows to increase.

A nurse is caring for a client who is newly admitted to the unit. Which action should the nurse take to establish a helping relationship with the client? A. Make sure the communication is equally distributed between the nurse and the client's desires.​​​​​​​ B. Encourage the client to communicate their thoughts and feelings.​​​​​​​ C. Give unlimited time to the nurse-client communication.​​​​​​​ D. Allow communication to occur spontaneously throughout the nurse-client relationship.​​​​​​​

B. Encourage the client to communicate their thoughts and feelings.​​​​​​​ Therapeutic communication facilitates a helping relationship that maximizes the client's ability to express their thoughts and feelings openly. Make sure the communication is equally distributed between the nurse and the client's desires.​​​​​​​ When taking actions to establish a helping relationship with the client, the nurse should establish communication that is client-focused. Give unlimited time to the nurse-client communication.​​​​​​​ Limit therapeutic communication to the boundaries of the therapeutic relationship, including time. Allow communication to occur spontaneously throughout the nurse-client relationship.​​​​​​​ Plan therapeutic communication.

A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? A. Giving the client thin liquids B. Having the client use a straw C. Instructing the client to tuck their chin when swallowing D. Encouraging the client to lie down and rest after meals

B. Instructing the client to tuck their chin when swallowing When taking actions, the nurse should identify that tucking the chin when swallowing allows food to pass down the esophagus more easily. Giving the client thin liquids Thin liquids increase the client's risk for aspiration. Having the client use a straw Using a straw increases the client's risk for aspiration. Encouraging the client to lie down and rest after meals Sitting for an hour after meals helps prevent gastroesophageal reflux and possible aspiration of stomach contents after a meal.

A nurse is caring for a school-age child who is sitting in a chair.To facilitate effective communication, which of the following actions should the nurse take? A. Touching the child's arm B. Standing facing the child C. Sitting at eye level with the child D. Standing with a relaxed posture

B. Sitting at eye level with the child Being at the same eye level as the child facilitates communication. Touching the child's arm​​​​​​​ Touching can intimidate the child and block communication. Standing facing the child​​​​​​​ Standing can appear domineering and intimidating, even with a relaxed posture. Standing with a relaxed posture Standing can appear domineering and intimidating, even with a relaxed posture.

A nurse at a health department is planning strategies related to heart disease. Which of the following activities should the nurse include as part of primary prevention? A. Providing cholesterol screening B. Teaching about a healthy diet C.Providing information about antihypertensive medications D. Developing a list of cardiac rehabilitation programs

B. Teaching about a healthy diet Primary prevention encompasses strategies that help prevent illness or injury. This level of prevention includes health information about nutrition, exercise, stress management, and protection from injuries and illness. Cholesterol screening is an example of secondary prevention. Taking medication to lower blood pressure is part of secondary prevention. Cardiac rehabilitation is an example of tertiary prevention.

The ostomy nurse is educating the client about how to empty their ostomy pouch. Which of the following actions by the client indicates that psychomotor learning has taken place? A. The client states how often the ostomy pouch should be emptied. B. The client demonstrates emptying the ostomy pouch. C. The client writes the steps of how to empty the ostomy pouch on a piece of paper. D. The client states they understand how to empty their ostomy pouch.

B. The client demonstrates emptying the ostomy pouch. When evaluating outcomes, the ostomy nurse should identify that the client demonstrating that they can empty the ostomy pouch indicates psychomotor learning has taken place. The psychomotor domain of learning involves performing a physical task.

A nurse in a provider's office is preparing to test a client's cranial nerve function. Which of the following directions should the nurse include when testing cranial nerve V? (Select all that apply.) A. "Close your eyes." B. "Tell me what you can taste." C. "Clench your teeth." D. "Raise your eyebrows." E. "Tell me when you feel a touch."

C & E "Clench your teeth." Testing cranial nerve V, the trigeminal nerve, involves testing the strength of muscle contraction by asking the client to clench their teeth while the nurse palpates the masseter and temporal muscles, and then the temporomandibular joint. "Tell me when you feel a touch." Testing cranial nerve V, the trigeminal nerve, involves testing light touch by having the client tell the nurse when they feel a gentle touch on the face from a wisp of cotton. "Raise your eyebrows." Testing cranial nerve VII, the facial nerve, involves testing for a range of facial expressions by having the client smile, raise their eyebrows, puff out the cheeks, and perform other facial movements. "Tell me what you can taste." Testing the sensory function of cranial nerve VII, the facial nerve, involves testing the mouth for taste sensations. "Close your eyes." The first step of testing cranial nerve I, the olfactory nerve, is to have the client close their eyes prior to testing the sense of smell

A nurse is assessing a client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Concave thoracic B. Exaggerated lumbar curvature C. Concave lumbar spine posteriorly D. Exaggerated thoracic curvature E. Muscles slightly larger on the dominant side

C & E Concave lumbar spine posteriorly Muscles slightly larger on the dominant side

A nurse in a provider's office is preparing to auscultate and percuss a client's thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Rhonchi B. Crackles C. Resonance D. Tactile Fremitus E. Bronchiovesicular sounds

C & E Resonance Resonance is the expected percussion sound over the thorax. It is a hollow sound that indicates air inside the lungs. Bronchiovesicular sounds Bronchovesicular sounds are expected breath sounds of medium pitch and intensity and of equal inspiration and expiration time. The nurse can expect to hear them over the larger airways. Rhonchi Rhonchi are coarse sounds that result from fluid or mucus in the airways. Crackles are fine to coarse popping sounds that result from air passing through fluid or re-expanding collapsed small airways. Tactile fremitus Tactile fremitus is an expected vibration the nurse can expect to feel or palpate as the client vocalizes. Speech creates sound waves, the vibrations of which travel from the vocal cords through the lungs and to the chest wall.

A nurse is providing instructions about foot care to a client who has diabetes mellitus. Which of the following instructions should the nurse include? (Select all that apply.) A. Wear wool socks. B. Apply lotion between the toes. C. Wash the feet daily, using warm water. D. Warm the feet using a heating pad. E. Smooth the edges of the toenails with an emery board.

C, & E C. Wash the feet daily, using warm water. Clients who have diabetes mellitus often experience neuropathy, which can lead to loss of sensation; therefore, the client should wash their feet daily using warm, not hot, water because they cannot determine when the water is too hot. E. Smooth the edges of the toenails with an emery board. The client should trim the toenails every week and use an emery board or nail file to smooth the edges. Wear wool socks. The nurse should instruct the client to wear cotton socks because cotton can absorb excessive moisture. Apply lotion between the toes. The client should apply lotion to the feet to moisten the skin but avoid applying lotion between the toes because this action can lead to skin breakdown and possible infection. Warm the feet using a heating pad. The client should warm the feet using socks and blankets. Due to lack of sensation, the use of heating pads or hot water bottles places the client at risk for burns.

A nurse is providing teaching for an older adult client who has lost 4.5 kg (9.9 lb) since the last admission 6 months ago. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) A. "Eat three large meals a day." B. "Eat your meals in front of the television." C. "Eat foods that are easy to eat, such as finger foods." D."Invite family members to eat meals with you." E. "Exercise every day to increase appetite."

C, D, & E "Eat foods that are easy to eat, such as finger foods." The nurse should instruct the client to involve family members with meals and to eat finger foods because finger foods are easier for the older adult client to eat. Socialization during meals promotes nutritional intake, and daily exercise increases appetite. "Invite family members to eat meals with you." The nurse should instruct the client to involve family members with meals and to eat finger foods because finger foods are easier for the older adult client to eat. Socialization during meals promotes nutritional intake, and daily exercise increases appetite. "Exercise every day to increase appetite." The nurse should instruct the client to involve family members with meals and to eat finger foods because finger foods are easier for the older adult client to eat. Socialization during meals promotes nutritional intake, and daily exercise increases appetite. "Eat your meals in front of the television." The nurse should educate the client to eat small frequent meals and to avoid distractions during meals to increase nutritional intake. "Eat three large meals a day." The nurse should educate the client to eat small frequent meals and to avoid distractions during meals to increase nutritional intake.

A nurse is caring for a client who is concerned about being discharged to home with a new colostomy because they are an avid swimmer. Which of the following statements should the nurse make? (Select all that apply.) A. "You will do great! You just have to get used to it."​​​​​​​ B. "Why are you worried about going home?"​​​​​​​ C. "Your daily routines will be different when you get home."​​​​​​​ D. "Tell me about the support system you'll have after you leave the hospital."​​​​​​​ E. "It sounds like you are not sure how having a colostomy will affect swimming."

C, D, & E C - "Your daily routines will be different when you get home."​​​​​​​ Presenting reality is an effective communication technique that can help the client focus on what will really happen after the changes the surgery has made. D - "Tell me about the support system you'll have after you leave the hospital."​​​​​​​ Asking open-ended questions and offering general leads and broad opening statements are effective communication techniques that encourage the client to express feelings through dialogue and offer additional information. E - "It sounds like you are not sure how having a colostomy will affect swimming." Focusing is an effective communication technique that clearly directs the interaction to the relevant point. "You will do great! You just have to get used to it."​​​​​​​ Giving false reassurance and minimizing the client's feelings are both barriers to effective communication. "Why are you worried about going home?"​​​​​​​ Although option B might appear to help the client discuss their feelings, asking a "why" question is a barrier to effective communication because it could make the client react defensively.

A nurse is examining the breast of a female young adult client. The nurse should determine that which of the following are expected findings? (Select all that apply.) A. The client's nipples are inverted.​​​​​​​ B. The client has a dimple on the left breast​​​​​​​. C. The client's left breast is smaller than the right breast. D. The client's areolas are oval shaped. ​​​​​​​ E. The underlying veins in the breast are visible.

C, D, & E The underlying veins in the breast are visible. The veins can be visualized for client who is thin. The client's areolas are oval-shaped. ​​​​​​​ The client's areolas can be either round or oval-shaped. The client's left breast is smaller than the right breast. ​​​​​​​ One breast larger than the other is a common, expected finding. The client's nipples are inverted.​​​​​​​ An expected finding is that the client's nipples are everted. The nurse should determine whether the client has a lifetime history of nipple inversion because a recent inversion of the nipple can indicate an underlying mass. The client has a dimple on the left breast​​​​​​​. A dimple can also indicate an underlying mass.

A nurse is performing a head and neck examination for an older adult client. Which of the following age-related findings should the nurse expect? (Select all that apply.) A. Reddened gums B. Lowered vocal pitch C. Tooth loss D. Glare intolerance E. Thickened eardrums

C, D, & E Thickened eardrums Tympanic membranes (eardrums) thicken in older adults, and they tend to accumulate cerumen in their ear canals. Glare intolerance Older adults tend to become intolerant of glaring lights and also lose some ability to distinguish colors. Tooth loss Tooth loss and gum disease are common in older adults. Reddened gums Expect an older adult's gums to be pale. Lowered vocal pitch Expect an older adult's vocal pitch to rise.

The ostomy nurse is providing preoperative education for the client who is scheduled for a sigmoid colostomy. The nurse should identify that which of the following client statements is an indication that the client is ready to learn? A."I will not look at my incision after the surgery." B. "Will you give me pain medicine after the surgery?" C. "Can you tell me about how long the surgery will take?" D. "I can't remember what my doctor told me about the surgery."

C. "Can you tell me about how long the surgery will take?" When recognizing cues, the ostomy nurse should identify that asking a concrete question about the procedure indicates that the client is ready to learn about the surgery.

A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client's vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrome (GAS)? A. Exhaustion Stage B. Resistance Stage C. Alarm Stage D. Recovery Stage

C. - Alarm stage The nurse should identify that, in the alarm stage of GAS, body functions (blood pressure and heart rate) are heightened in order to respond to stressors. Exhaustion stage The exhaustion stage is a component of GAS; however, body functions are no longer able to respond to the stressor in this stage. Resistance stage Although the resistance stage is a component of GAS, body functions normalize in an attempt to cope with the stressor in this stage. Recovery stage While it is not technically a component of GAS, recovery stage is an alternative to the exhaustion stage, but it would not account for an elevation in blood pressure and heart rate.

A nurse is performing an integumentary assessment on a group of clients. Which of the following findings is the nurse's priority? A. Pallor B. Jaundice C. Cyanosis D. Erythema

C. Cyanosis - When prioritizing hypothesis, using the airway, breathing, and circulation approach to client care, the nurse should identify that the priority finding is cyanosis. Cyanosis is a manifestation of hypoxia and can indicate impaired oxygenation. Therefore, cyanosis is the priority finding.the

A nurse is caring for a young adult at a college health clinic. Which of the following actions should the nurse take first? A. Give the client information about immunization against meningitis. B. Tell the client to have a TB skin test every 2 years. C. Determine the client's health risks. D. Teach the client about exercise recommendations.

C. Determine the client's health risks. The first action that should be taken using the nursing process is assessment. Talk with the client first to determine what risk factors the client might have before initiating the health promotion and disease prevention measures. A. The nurse should plan to give the client information on the meningococcal vaccine as part of the primary disease prevention; however, there is another action the nurse should take first. B. The nurse should recommend TB screening depending on the client's occupation and exposure to TB as part of secondary disease prevention; however, there is another action the nurse should take first. D. The nurse should instruct the client about exercise and activity recommendations as part of health promotion; however, there is another action the nurse should take first.

During an abdominal examination, a nurse in a provider's office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect? A. Fat B. Fluid C. Flatus D. Hernias

C. Flatus Flatus With flatus, the protrusion is mainly midline, and there is no change in the flanks. Fat With fat, there are rolls of adipose tissue along the sides, and the skin does not look taut. Fluid With fluid, the flanks also protrude, and when the client turns onto one side, the protrusion moves to the dependent side. Hernias With hernias, protrusions through the abdominal muscle wall are visible, especially when the client flexes the abdominal muscles.

A nurse is caring for a client who has been sitting in a chair for 1 hour. Which of the following complications is the greatest risk to the client? A. Decreased subcutaneous fat B. Muscle atrophy C. Pressure injury D. Fecal impaction

C. Pressure Injury When prioritizing hypotheses, the nurse should identify that the greatest risk to this client is injury from skin breakdown due to unrelieved pressure over a bony prominence from prolonged sitting in a chair. Instruct the client to shift their weight every 15 mins, and reposition the client after 1 hour. Decreased subcutaneous fat The client is at risk for decreased subcutaneous fat due to altered mobility. However, there is another risk that is the priority. Muscle atrophy The client is at risk for muscle atrophy due to altered mobility. However, there is another risk that is the priority. Fecal impaction The client is at risk for fecal impaction due to altered mobility. However, there is another risk that is the priority.

A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray? A. Cooked barley B. Pureed Broccoli C. Vanilla Custard D. Lentil Soup

C. Vanilla Custard The nurse should identify that a low-residue diet consists of foods that are low in fiber and easy to digest. Dairy products and eggs (custard and yogurt) are appropriate for a low-residue diet. Cooked barley Whole grains (barley and oats) are high in fiber and thus inappropriate components of a low-residue diet. Pureed broccoli Raw and gas-producing vegetables (broccoli and the cabbage in coleslaw) are high in fiber and thus inappropriate components of a low-residue diet. Lentil soup Legumes (lentils and black beans) are high in fiber and thus inappropriate components of a low-residue diet.

The ostomy nurse is educating the client about the new colostomy. Sort the nursing actions into the cognitive, affective, or psychomotor domains of learning. Cognitive - Affective - Psychomotor- The ostomy nurse encourages the client to share their feelings about their colostomy. The client performs a return demonstration of emptying the colostomy pouch. The ostomy nurse provides the client with a list of foods they can eat and foods they should avoid in their diet.

Cognitive - The ostomy nurse provides the client with a list of foods they can eat and foods they should avoid in their diet. Affective - The ostomy nurse encourages the client to share their feelings about their colostomy. Psychomotor- The client performs a return demonstration of emptying the colostomy pouch. When taking actions, the ostomy nurse is using the cognitive domain of learning when providing the client with a list of foods they can eat and foods they should avoid in their diet. The ostomy nurse is encouraging the client to ask questions to promote understanding about the teaching. The ostomy nurse is using the affective domain of learning when encouraging the client to share their feelings about their colostomy. The affective domain promotes the expression of feelings and encourages support from others. The ostomy nurse is using the psychomotor domain of learning when demonstrating how to empty the ostomy pouch and asking the client to perform a return demonstration of the procedure. The psychomotor domain of learning involves performing a physical task.

During a cardiovascular examination, a nurse in a provider's office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following data is the nurse attempting to auscultate? (Select all that apply.) A.Ventricular gallop B. Closure of the pulmonic valve C. Murmur D. Closure of the mitral valve E. Apical heart rate

D & E Closure of the mitral valve To auscultate the closure of the mitral valve, place the diaphragm of the stethoscope over the apex, or apical/mitral site, which is on the left midclavicular line at the fifth intercostal space. Apical heart rate To auscultate the apical heart rate, place the diaphragm of the stethoscope over the apex of the heart, which is on the left midclavicular line at the fifth intercostal space. Ventricular gallop To auscultate a ventricular gallop (an S3 sound), place the bell of the stethoscope at each of the auscultatory sites. Closure of the pulmonic valve To auscultate the closure of the pulmonic valve, place the diaphragm of the stethoscope over the aortic area, which is just to the right of the sternum at the second intercostal space. Murmur To auscultate a murmur, place the bell of the stethoscope at various auscultatory sites.

A nurse is caring for a client who is 3 days postoperative following a below-the-knee amputation as a result of a motor vehicle crash. Which of the following statements indicates that the client has a distorted body image? A. "I'll be able to function exactly as I did before the accident." B. "I just can't stop crying." C. "I am so mad at that guy who hit us. I wish he lost a leg." D. "I don't even want to look at my leg. You can check the dressing."

D. "I don't even want to look at my leg. You can check the dressing." This would imply a distorted body image. The nurse should identify that refusing to look at the leg or the dressing indicates that the client is having difficulty acknowledging the fact that the leg has been amputated. "I'll be able to function exactly as I did before the accident." Denial is a normal and expected reaction when adjusting to body changes "I just can't stop crying." Depression and sadness are normal and expected reactions when adjusting to body changes. "I am so mad at that guy who hit us. I wish he lost a leg." Anger is a normal and expected reaction when adjusting to body changes.

A nurse is preparing a presentation about basic nutrients for a group of high school athletes. The nurse should include that which of the following provides the body with the most energy? A. Fat B. Protein C. Glycogen D. Carbohydrates

D. Carbohydrates When taking actions, the nurse should state that carbohydrates are the body's greatest energy source; providing energy for cells is their primary function. They provide glucose, which burns completely and efficiently without end products to excrete. They are also a ready source of energy, and they spare proteins from depletion. Fat Although the body gets more than half of its energy supply from fat, it is an inefficient means of obtaining energy. It produces end products the body has to excrete, and it requires energy from another source to burn the fat. Protein Protein can supply energy, but it has other very essential and specific functions that only it can perform. Therefore, it is not the body's primary energy source. Glycogen Glycogen, which the body stores in the liver, is a backup source of energy, not a primary or priority source.

A nurse is caring for a family who is experiencing a crisis. Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis? A. Prescribing tasks unilaterally B. Delegating care to one member C. Speaking to the primary client privately D. Convening a family meeting

D. Convening a family meeting The nurse should identify that an open structure is loose and convening a family meeting would give all family members input and an opportunity to express their feelings. Prescribing tasks and delegating care is too rigid for acceptance by a family with an open structure. Delegating care to one member Prescribing tasks and delegating care is too rigid for acceptance by a family with an open structure. Speaking to the primary client privately Speaking to the primary client privately excludes the family.

A nurse is teaching a client about performing a fecal occult blood test at home. Which of the following information should the nurse include? A. Do not eat red meat within one day of the test. B. One stool specimen is sufficient for testing. C. A red color change indicates a positive test. D. Ensure the specimen does not include urine.

D. Ensure the specimen does not include urine. When taking action, the nurse should instruct the client to avoid contaminating the stool specimen with urine or water to ensure accurate test results. Do not eat red meat within one day of the test. The consumption of red meat should be avoided for 3 days prior to testing. One stool specimen is sufficient for testing. The test should be repeated a minimum of 3 times on 3 separate stool specimens. A red color change indicates a positive test. The client should be instructed that a blue color change on the guaiac paper indicates the specimen is positive for fecal occult blood.

Claire is preparing to apply the sequential compression sleeves to Mr. Tuttle's legs. Which technique should Claire use to determine the correct size of the stocking? A. Measuring the length of the leg from the groin to the heel B. Measuring the thickest part of the calf C. Measuring the distance between the top of the thigh to the bottom of the knee D. Measuring around the largest part of the thigh

D. Measuring around the largest part of the thigh

A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? A. "I spent my whole life dreaming about retirement, and now I wish I had my job back." B. "It's been so stressful for me to have to depend on my child to help around the house." C. "I just heard my friend Al died. That's the third one in 3 months." D. "I keep forgetting which medications I have taken during the day."

D. is correct - "I keep forgetting which medications I have taken during the day." The nurse should identify that the greatest risk to this client is injury from overdosing or underdosing medications due to loss of short-term memory. The priority issue is to assist the client to implement safe medication strategies. Assist the client to use a pill organizer to help them remember to take their medications and to keep a list of all current medications. "I spent my whole life dreaming about retirement, and now I wish I had my job back." The client is at risk for social isolation and loss of independence because of retirement. However, another issue is the priority. "It's been so stressful for me to have to depend on my child to help around the house." The client is at risk for loss of independence and reduced self-esteem due to dependence upon their child. However, another issue is the priority. "I just heard my friend Al died. That's the third one in 3 months." The client is at risk for social isolation due to the loss of a friend. However, another issue is the priority.

Please sort the listed skills and techniques into the effective category or the ineffective category. Clarifying Stereotyping Challenging Active listening Approving Asking for an explanation Effective Ineffective

Effective: Clarifying Active listening Ineffective: Stereotyping Challenging Approving Asking for an explanation

A nurse is performing a skin assessment on an older adult client. Sort the following findings as expected or unexpected in older adult clients. Thin, parchment-like skin Hematoma Diminished skin elasticity Wrinkles Petechia Expected Unexpected

Expected: -Thin, parchment-like skin -Diminished skin elasticity -Wrinkles Unexpected: -Hematoma -Petechia

A nurse is examining a client's tonsils for size using a grading tool. Match the grade with the findings. Grade 1 Grade 2 Grade 3 Grade 4 The tonsils touch the uvula. The tonsils are behind the soft structures supporting the palate. The tonsils touch each other. The tonsils are between the soft structures and the uvula.

Grade 1 - The tonsils are behind the soft structures supporting the palate. Grade 2 - The tonsils are between the soft structures and the uvula. Grade 3 - The tonsils touch the uvula. Grade 4 - The tonsils touch each other. A nurse is examining a client's tonsils for size using a grading tool. Match the grade with the findings. The nurse should recognize that expected finding are that the tonsils are pink and smooth and without discharge and behind the soft structures. With each grade the tonsils are progressively larger. Grades 2, 3, and 4 are unexpected finding and should be reported to the provider.

Cranial Nerves for the Ears, Nose Mouth, and Throat

I - Olfactory: smell VIII - Auditory: hearing and balance IX - Glossopharyngeal: Sensory: Taste (sour/bitter) on posterior third of the tongue Motor: Swallowing, speech sounds, gag reflex X - Vagus Sensory: Gag Reflex Motor: Swallowing, speech quality XII - Hypoglossal: Motor - Tongue movement

Cranial Nerves for Just the Eyes

II - Optic: Sensory: Visual acuity, visual fields III - Oculomotor: PERRLA, six cardinal positions of gaze IV - Trochlear: Also PERRLA VI - Abducens: Also Perrla

A nurse is assessing a client's sensory function. The nurse asks the client to close their eyes. Match the nursing action to the associated sensory function. A nurse is assessing a client's sensory function. The nurse asks the client to close their eyes. Match the nursing action to associated sensory function. Light Touch Discrimination Vibration Position Ask the client to report when they feel a cotton ball on their skin. Ask the client to report when the feel the movement of a tuning fork on their skin. Reposition the client's arm and ask the client to report whether it is positioned up or down. Trace a number on the client's palm with the blunt end of a pencil and ask them to identify it.

Light Touch - Ask the client to report when they feel a cotton ball on their skin. Discrimination - Trace a number on the client's palm with the blunt end of a pencil and ask them to identify it. Vibration - Ask the client to report when they feel the movement of a tuning fork on their skin. Position - Reposition the client's arm and

A nurse is examining a client's chest. Matching the name of the vertical chest landmarks with their location. Midaxillary Line Anterior Axillary Line Midsternal Line The Vertebral Line Over the center of the sternum Extends down from the anterior axillary fold Runs down from the apex of the axillary Is along the center of the spine

Midsternal Line - Over the center of the sternum Anterior Axillary Line - Extends down from the anterior axillary fold Midaxillary line - Runs down from the apex of the axillary The vertebral line - Is along the center of the spine.

A nurse is preparing a presentation at a local community center about sleep hygiene. Sort the following characteristics into either rapid eye movement (REM) sleep or non-rapid eye movement (NREM) sleep.​​​​​​​ Cognitive restoration occurs Light sleep 75% of time sleeping Loss of muscle tone occurs Vivid dreaming occurs REM Sleep NREM Sleep

REM Sleep - Cognitive restoration occurs Loss of muscle tone occurs Vivid dreaming occurs NREM Sleep - Light sleep 75% of time sleeping

A nurse is discussing complementary and alternative therapies they can incorporate into their practice without the need for specialized licensing or certification with a group of newly licensed nurses. Sort the following therapies into either those that require a specialized licensed or those that do not require a specialized license. Acupuncture Chiropractic medicine Guided imagery Humor Therapeutic communication Requires specialized license Does not require specialized license

Requires specialized license - Acupuncture Chiropractic medicine Does not require a specialized license - Guided imagery Humor Therapeutic communication

A nurse is teaching a class about skin lesions. Match the following lesions with the associated skin condition. Scale Pustule Macule Nodule Vesicle Acne Warts Psoriasis Herpes Simplex Freckle

Scale - Psoriasis Pustule - Acne Macule - Freckle Nodule - Warts Vesicle - Herpes simples

A nurse is performing a peripheral vascular assessment of the lower extremities on a client who is postoperative following knee surgery. What information should the nurse include in the assessment?

The nurse should check and compare the skin color and temperature of the client's lower extremities. Pallor, cyanosis, and coolness are manifestations of inadequate circulation. The nurse should check and compare the pulses of the client's lower extremities. A decreased pulse strength indicates impaired circulation to the client's legs. The nurse should assess the client for the presence of edema. Edema is a manifestation of inadequate venous circulation and should be reported.

A nurse is caring for a client who tells the nurse that, based on religious values and mandates, a blood transfusion is not an acceptable treatment option. What actions should the nurse take?

The nurse should demonstrate culturally responsive care and show respect for the client's religious beliefs. The nurse should have the provider discuss the necessity for a blood transfusion, alternatives to the use of blood products, and allow the client to make an informed decision.

A nurse enters the room of a client who is reading from a religious book. The client begins to cry and asks to be left alone. What actions should the nurse take?

The nurse should demonstrate culturally responsive care and show respect to the client by providing time for the client to be alone. The nurse should close the door to the client's room and give the client time without interruption to pray and reflect. After giving the client quiet, uninterrupted time, the nurse can establish presence with the client by sitting, listening, showing acceptance, and supporting the client. The nurse can offer to contact a spiritual care provider to provide the client with spiritual support if needed.

A nurse is caring for a client who is scheduled for abdominal surgery. The client reports being worried. What interventions can the nurse implement to reduce the client's anxiety?​​​​​​​

The nurse should implement complementary and alternative therapies to promote relaxation and reduce the client's anxiety. The nurse should use therapeutic communication to allow the client to verbalize their fears and anxieties. The nurse can assist the client in relaxation therapies, such as guided imagery, healing intention, breath work, humor, meditation, simple touch, music or art therapies, and passive or progressive relaxation.

A nurse is administering a cleansing enema to a client who reports abdominal cramping. What actions should the nurse take?

The nurse should slow the flow of the solution by lowering the container. Slowing the flow of the enema should decrease abdominal cramping. If the client is experiencing severe abdominal cramping, stop the enema, assess the client's vital signs, and notify the provider.

A nurse in an acute care facility is caring for a client who is having difficulty sleeping at night. What actions should the nurse take to promote sleep?

The nurse should try to provide a quiet hospital environment and limit waking the client during the night to reduce interruptions in the client's sleep. A soothing back rub and assisting the client in following their regular bedtime routine, such as taking a bath in the evening, might promote relaxation and sleep in the acute care facility.

Cranial nerves just for the head and neck

V - Trigeminal - Sensory: light touch sensation to the face Motor: jaw opening, clenching, chewing VII - Facial - Sensory: Tast (salt/sweet) on anterior 2/3 of tongue Motor: Jaw opening, clenching, chewing XI - Spinal accessory - Motor: Turning head, shrugging shoulders

A nurse is teaching a class about expected changes associated with aging. What information should the nurse include?

When recognizing cues, the nurse should instruct that expected changes that can occur with aging can include reduced muscle mass, decline in speed, strength, resistance to fatigue, reaction time, and coordination, Decalcification of bones can lead to loss of bone mass and height, and an increasing risk for osteoporosis. Other changes that can occur include minimal decline in short-term memory, decreased vision, hearing, taste, smell, and touch.

A nurse is performing auditory screening for a client. Match the name of the test with the technique the nurse should use. Rinne Test ( Air Conduction) Weber's Test (Bone Conductivity) Whisper Test The nurse has the client occlude one ear and then tests the other ear to see if the client can hear sounds without seeing the nurse's mouth. The nurse places a vibrating tuning fork against the mastoid bone and asks the client to state when the sound can no longer be heard. The nurse places a vibrating tuning fork on top of the head and asks the client if the sound is best in the left or right ear.

Whisper Test - The nurse has the client occlude one ear and then tests the other ear to see if the client can hear sounds without seeing the nurse's mouth. Rinne Test (Air Conduction) - The nurse places a vibrating tuning fork against the mastoid bone and asks the client to state when the sound can no longer be heard. Weber's Test (Bone Conductivity) - The nurse places a vibrating tuning fork on top of the head and asks the client if the sound is best in the left or right ear. The nurse uses the whisper test to assess high-frequency hearing in both ears. Abnormal findings include the client asking the nurse to repeat the words and/or the client is unable to repeat the words. If the client has difficulty with the Whisper test, the nurse proceeds to the Rinne test and Weber's test. During the Rinne test, the nurse places a vibrating tuning fork against the client's mastoid bone and measures the length of time the client can hear the sound. An expected finding is that the client can hear air- conducted sounds twice as long as bone conducted sounds. During the Weber's test, the nurse places a vibrating tuning fork on the top of the client's head and asks the client if the sound is best heard in the left or the right ear. An expected finding of the Weber's test is that the client hears the sound equally in both ears. If the client has conduction deafness, the sound is heard best in the impaired ear. If the client has sensorineural, the sound is heard best in the unaffected ear.

A nurse is discussing complementary and alternative medicine with a newly licensed nurse (CAM). Match the CAM category with the therapy. Whole medical systems Botanical therapy Manipulative methods Mind-body therapy Energy therapy Meditation Homeopathy Magnet therapy Probiotics Massage

Whole medical systems - Homeopathy Botanical therapy - Probiotics Manipulative methods -Massage Mind-body therapy - Meditation Energy therapy - Magnet therapy The nurse should instruct that homeopathy is an example of whole medical systems. Other whole medical systems include traditional Chinese medicine and ayurveda. Probiotics are an example of botanical therapy. Other botanical therapies include herbal preparations and vitamins. Massage is an example of manipulative therapy. Other manipulative therapies are acupuncture and chiropractic medicine. Meditation is an example of mind-body therapy. Other mind-body therapies are biofeedback and yoga. Magnet therapy is an example of energy therapy. Other energy therapies are reiki and therapeutic touch.

The nurse is performing a cranial nerve assessment on the client. Match the assessment method to the associated cranial nerve. IX Glossopharyngeal nerve X Vagus Nerve XI Spinal accessory nerve XII Hypoglossal nerve Sticking out the tongue Checking speech for hoarseness Identifying a sour taste at the back of the tongue Shrugging shoulders

XII Hypoglossal nerve - Sticking out the tongue X Vagus Nerve - Checking speech for hoarseness XI Spinal accessory nerve - Shrugging shoulders IX Glossopharyngeal nerve - Identifying a sour taste at the back of the tongue