FINAL health Assessment

. A nurse is having difficulty auscultating the heart for sounds of a client because the lung sounds are too loud. What action does the nurse take to hear the heart sounds? a. Asking the client lie in a supine position. b. Asking the client to cough to clear the airways. c. Asking the client to hold his breath for a few seconds. d. Asking the client to sit up and lean forward.

c

. When a nurse asks a client to place the right arm behind the back, so that the back of the hand is touching the lower spine, the nurse is testing for which range of motion? a. Pronation of the elbow. b. Hyperextension of the elbow. c. Internal rotation and adduction of the shoulder. d. External rotation and abduction of the shoulder.

c

43. During auscultation of breath sounds, the nurse should use the stethoscope correctly, in which of the following ways? a. Listen to at least one full respiration in each location b. Listen at the patient inhales and then go to the next site during exhalation c. Have the patient breathe in and our rapidly while the nurse listens to the breath d. If the patient is modest, listen to sounds over his or her clothing or hospital gown

A

52. The nurse is testing a patient's visual accommodation, which refers to which action? a. Pupillary constriction when looking at a near object b. Pupillary dilation when looking at a far object c. Changes in peripheral vision in response to light d. Involuntary blinking in the presence of bright light

A

55. When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should: VOLVIO A SALIR a. Consider this a normal finding or symmetric b. Refer the individual for further evaluation c. Document this as an asymmetric light reflex d. Perform the confrontation test to validate the findings

A

The nurse is auscultating the second intercostal space left of the sternal border to hear which valve? a. The pulmonic valve b. The tricuspid valve c. The mitral valve d. The aortic valve

A

. A nurse learns from a report that a client has aortic stenosis. Where does the nurse place the stethoscope to hear this stenotic valve? a. Second intercostal space, right sternal border b. Second intercostal space, left sternal border c. Fourth intercostal space, left sternal border T d. Firth intercostal space, left midclavicular line

A

1. Which is an example of data a nurse would collect during a physical examination? a. The client's lack of hair and shiny skin over both shins b. The client's stated concern about lack of money for prescriptions c. The client's complaints of tingling sensations in the feet d. The client's mother's statements that the client has been very nervous lately

A

11. In assessing a client's visual acuity using the Snellen chart, the nurse is assessing which cranial nerve? (II) VOLVIO A SALIR a. Optic cranial nerve b. Oculomotor cranial nerve c. Abducens cranial nerve d. Trochlear cranial nerve

A

13. During an eye assessment the nurse asks the client to keep the head stationary and by moving the eyes only follow the nurse's finger as it moves side to side, up and down, and obliquely. This assessment technique collects what data about the client's eyes? VOLVIO A SALIR a. Function of cranial nerves oculomotor (III), trochlear (IV), and abducens (VI) b. Visual acuity c. Peripheral vision of the uncovered d. Consensual reaction of the uncovered eye

A

36. A nurse had previously heard crackles over both lungs of a client. The client is improving, and the nurse anticipates hearing normal breath sounds, which would include: a. Vesicular breath sounds heard in peripheral lung fields b. Bronchial breath sounds heard over the bronchi c. Bronchovesicular breath sounds heard over the apices d. Bronchi heard over the main bronchi

A

37. The nurse is comparing pitch and duration of the various types of breath sounds and recognizes which as an expected finding? a. Bronchial sounds are high pitched with a duration of 1:2 inspiration-to-expiration. b. Bronchovesicular sounds have a moderate pitch and 2:1 expiratory-versus-inspiratory ratio. c. Vesicular breath sounds are high-pitched and have 1:2 inspiratory-versus-expiratory ratio. d. Wheezes are low-pitched and have a 2:5:1 inspiratory-versus-expiratory ratio.

A

30. Nurses inquire about life style behaviors in those clients with specific risks factors for cataracts. The characteristics labeled with numbers __a, b, c ____ are associated with risks factors for cataracts. (your answer should appear as numbers separated by commas and spaces (e.g. 1, 2, 3, 4) (Select all that apply) EN ESTA PREGUNTA SE ADICIONO EL ULTIMO INCISO a. Smoking more than 20 cigarettes a day b. Having parents with cataracts c. Chronic consumption of alcohol d. Having a chronic disease, such as diabetes mellitus e. Black American

A, B, D, E

40. The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply. a. Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. b. As the patient says "ninety-nine" repeatedly, the examiner hears the words "ninety-nine" clearly. c. When the patient speaks in a normal voice, the examiner can hear a sound but cannot distinguish exactly what is being said. d. As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" muffled sound. e. As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "aaaaaa" sound.

A, C,D

7. While taking a history, the nurse observes that the client's facial cranial nerve is intact based on which behaviors of the client? (VII) VOLVIO A SALIR a. The client's eyes move to the left, right up, down and obliquely during conversation b. The client moistens the lips with the tongue c. The sides of the mouth are symmetric when the client smiles d. The client's eyelids blink periodically

c

10. While using a Snellen visual acuity chart, the nurse records that the client's vision is 20/40, meaning that: (II) ARREGLADA a. A client's vision is about half what is normally expected b. A client can see the 20/40 line on chart while wearing glasses or contact lenses c. A client with normal vision can see the 20/40 line on the chart at 40 feet d. A client can see at 40 feet what a client with normal vision can see at 20 feet

c

21. A nurse suspects the client has an infection of the maxillary sinuses and will confirm this suspicion by: a. Using a flashlight to illuminate the floor of the mouth b. Pressing gently with both thumbs into the eyebrow ridges c. Applying firm pressure with the thumbs below the cheekbones d. Standing behind the client and asking him to slowly rotate his head

c

A nurse listening with the bell of the stethoscope over the epigastric area of the abdomen of a healthy client normally will hear: a. Bowel sounds b. Venous hum c. Aortic aneurysm d. No sounds

d

23. In assessing a client's mouth, a nurse observes the rising of the soft palate when the client says "Ahh." This expected finding reflects the function of which cranial nerve? (VIII) VOLVIO A SALIR a. Facial (VII) b. Acoustic (VIII) c. Glossopharyngeal (IX) d. Hypoglossal (XII)

c

31. The nurse is reading a family genogram. As she reads the genogram, the nurse detects an error in the symbols. Can you clarify what is this mistake: a. Two people who are married are connect by line that go down and across b. The husband on the right and the wife on the left (husband left wife right) c. Couples that are not married are depicted with a dotted line d. Children are drawn left to right, going from the oldest to the youngest

B

6. A nurse notices multiple lesions on a client's back that are 0.5 cm in width, elevated, circumscribed, and filled with serous fluid. The nurse documents these lesions as: a. Macules b. Patches c. Vesicles d. Bullae

c

The nurse asks the client to hold the arms straight out, perpendicular to the floor, and the nurse tries to push the client's arms down. The nurse is testing the strength of which muscles in this procedure? a. Triceps b. Biceps c. Trapezius d. Deltoid

d

37. The nurse is comparing pitch and duration of the various types of breath sounds and recognizes which as an expected finding? a. Bronchial sounds are low-pitched and have 2:1 inspiratory-versus-expiratory ratio b. Bronchovesicular breath sounds have a moderate pitch and 1:1 expiratory-versus-inspiratory ratio c. Vesicular breath sounds are high-pitched and have 1:2 inspiratory-versus-expiratory ratio d. Wheezes are low-pitched and have a 2:5:1 inspiratory-versus-expiratory ratioA

B

. The alteration that the nurse may auscultate that involve S2 is: a. Normal physiological splitting of S2 is best heard at aortic area it occurs on inspiration ("lub-T-dub, lub-dub") b. Normal physiological splitting of S2 is best heard at pulmonic area. It occurs on inspiration ("lub-T-dub, lub-dub") c. Splitting of S2 sound can occur when aortic pulmonary, tricuspid and mitral valves do not close at the same time

B

16. During an eye examination of an Asian client, a nurse notices an involuntary rhythmical, horizontal movement of the client's eyes and documents this finding as: a. An expected racial variation b. Nystagmus c. Exophthalmos d. Myopia

B

17. During the Weber test, a nurse determines that the client hears the sound of a tuning fork equally in each ear. Based on this finding the appropriate response of the nurse is to: (VIII) a. Repeat the test again using 2000 Hz tuning fork b. Tell the client that this represents a normal finding c. Refer the client for additional testing of the client's hearing abnormality d. Perform a Rinne test to confirm the findings of this Weber test

B

18. How does the nurse perform a Weber test to assess hearing function? The nurse: (VIII) VOLVIO A SALIR a. Whispers several words to the client and requests that the client repeat the words heard b. Places a vibrating tuning fork in the middle of the head and asks the client if the sound is heard the same in both ears or if it is louder in one ear than the other c. Places a set of headphones over both ears, plays several tones, and asks the client to identify the sounds d. Places a vibrating tuning fork on the mastoid process until the client no longer hears a sound, and then moves it in front of the ear until the client no longer hears a sound (RINNE TEST) NOTE: WEBER TEST (CONDUCTIVE HEANING LOSS)

B

24. When inspecting a client's posterior wall of the pharynx and tonsils, a nurse documents which finding as abnormal? a. Both tonsils have a smooth surface b. Left and right tonsils meet at the midline c. Left and right tonsils extend beyond the posterior pillars d. Both tonsils have a glistening texture

B

26. In assessing spinal accessory nerve function, the nurse requests the client to: (XI) a. Stick out the tongue and move it side to side against the resistance of a tongue blade b. Shrug the shoulders against the resistance of the nurse's hands c. Swallow while the nurse applies gentle pressure on the thyroid gland d. Move the chin to the chest and then up toward the ceiling

B

38. A nurse suspects a client has a chest wall injury and wants to collect more data about thoracic expansion. Which is the appropriate technique to use? a. Placing the palmar side of each hand against the lateral thorax at the level of the waist, asking the client to take a deep breath, and observing lateral movement of the hands b. Placing both thumbs on either side of the client's T9 to T10 spinal processes, extending fingers laterally, asking the client to take a deep breath and observing lateral movement of the thumbs c. Placing both thumbs on either side of the client's T7 to T8 spinal processes, extending fingers laterally, asking the client to exhale deeply, and observing lateral inward movement of the thumbs d. Placing the palmar side of each on the shoulders of the client, asking the client to sit up straight and take a deep breath, and observing symmetric movement of the shoulders

B

48.a) A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved? a. CN V and CN VII b. CN IX and CN VII c. CN VIII and CN V d. CN VI and CN X

B

51. A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to cranial nerve (CN) _XI__ and proceeds with the examination by _B_ VOLVIO A SALIR a. XI: palpating the anterior and posterior triangles b. XI: asking the patient to shrug her shoulders against resistance c. XII: percussing the sternomastoid and submandibular neck muscles d. XII: assessing for a positive Romberg sign

B

54. A patient's vision recorded as 15/20 when the Snellen eye chart is used. The nurse interprets these results to indicate that: VOLVIO A SALIR a. At 20 feet the patient can read the entire chart b. The patient can read at 15 feet what a person whit a normal vision can read at 20 feet c. The patient can read the chart from 15 feet in the left eye and 20 feet in the right eye d. The patient can read from 20 feet what a person with normal vision can read from 15 feet

B

67.b) Which of the following cranial nerves is classified correct: a. Olfactory (sensory), Trigeminal (motor), Facial (sensory), Vagus (both). b. Trochlear (motor), Olfactory (sensory), Abducens (motor), Oculomotor (motor). c. Abducens (both), Hypoglossal (motor), Vagus (motor), Optic (sensory). d. Vagus (sensory), Spinal accessory (motor), Olfactory (sensory), Trochlear (motor).

B

Frank's visual acuity is measured using a Snellen chart. The reading obtained is 20/80 in the right eye and 20/200 in the left eye. How should the nurse explain these finding to Frank? VOLVIO A SALIR a. "You are very far-sighted, especially in your left eye" .b "You are very near-sighted, especially in your left eye" c "You are very far-sighted, especially in your right eye" d "You are very near-sighted, especially in your right eye"

B

. The six steps of the nursing process are shown below, out of order. The correct order is: a. Planning, Assessment, Evaluation, Diagnostic, Implementation, Outcome identification. b. Assessment, Planning, Diagnosis, Outcome identification, Implementation, Evaluation. c. Assessment, Diagnosis, Outcome identification, Planning, Implementation, Evaluation. d. Assessment, Outcome identification, Diagnosis, Planning, Implementation, Evaluation.

C

The nurse asks the client to rest the left arm on a table and to move the lower arm so that the palm of the hand is up and then down. What motion is the nurse testing? a. Adduction and abduction of the wrist. b. Supination and pronation of the wrist. c. Adduction and abduction of the elbow. d. Supination and pronation of the elbow.

d

12. During an eye assessment, a nurse asks the client to cover one eye with a card as the nurse covers his or her eye directly opposite the client's covered eye. The nurse moves an object into the field of vision and asks the client to tell when the objects can be seen. This assessment technique collects what data about the client's eyes? (II) VOLVIO A SALIR a. Symmetry of extraocular muscles b. Visual acuity in the uncovered eye c. Peripheral vision of the uncovered eye d. Consensual reaction of the uncovered

C

14. How does a nurse assess the functions of cranial nerves III, VI and IV that innervate the muscles of the eye? VOLVIO A SALIR a. By assessing peripheral vision b. By noting the symmetry of the corneal light reflex c. By assessing the cardinal fields of gaze d. By performing the cover-uncover test

C

15. A nurse shines a light in the right pupil to test constriction and notices that the left pupil constricts as well. Based on these data, the nurse should: (III) VOLVIO A SALIR a. Documents this finding as an abnormal finding b. Assess the client for accommodation c. Document this finding as a consensual reaction PUPIL LIGTH REFLEX d. Assess the client's corneal light reflex

C

17.a) During a hearing assessment, the nurse finds that sound lateralizes to the client's left ear with the Weber and Rinne tests. What should the nurse conclude from this finding? The patient has: a. A conductive hearing loss in the right ear. b. Lateralization is a normal finding with the Weber test. c. Either a sensorineural or conductive hearing loss. d. The steps in assessing the patient's hearing were done incorrectly.

C

25. A nurse assess neck movement of an adult and documents that the client's neck muscles are within expected limits if the client: (XI) a. Is unable to resist the nurse's attempt to move the head upright b. Bends the head to the right and left (ear to shoulder) 15 degrees (lateral bending 45 grados) c. Flexes chin toward the chest 45 degrees (normal % 40 y 60 grados) d. Hyperextends the head 30 degrees from midline (normal is 45 to 70)

C

25.a) A nurse assesses the neck of an adult and documents that the client's neck muscles are within expected normal limits if the client: a. Has a convex contour of the posterior cervical spine. b. Bends the head to the right and left (ear to shoulder) 15 degrees. c. Is able to resist the nurse's attempt to move the head upright. d. Is able to hyperextend the head 30 degrees from midline.

C

29. A nurse who is palpating the lymph nodes in the anterior and posterior cervical chains places the pads of the fingers: a. In front of the ear (preauricular) b. Under the mandible (submandibular) c. On either side of the sternocleidomastoid muscle d. Along the angle of the jaw

C

35. A nurse inspects a client's hands and notices bilateral clubbing of the fingers. The nurse correlates this finding with what condition? a. Normal finding b. Trauma to the thorax c. Chronic hypoxia d. Hyper oxygenation

C

39. A nurse is assessing for vocal (tactile) fremitus on a client with pulmonary edema. Which is the appropriate technique to use? a. Systematically percussing the posterior chest wall following the same pattern that is used for auscultation while listening for a change in tone from resonant to dull b. Placing the pads of the fingers on the right and left thorax and palpating the texture and consistency of the skin feeling for a crackly sensation under the fingers c. Placing the palms of the hands on the right and left thorax, asking the client to say "99", and feeling for vibrations d. Placing both thumbs on either side of the client's spinal processes, extending fingers laterally, asking the client to take a deep breath, and feeling for vibrations

C

41. The nurse is assessing diaphragmatic excursion. The nurse knows that it is normal if she has the following result: a. Percuss up from the lower border to the scapular line, were resonance changes to dullness mark that point with a piece of tape, after that percuss down from the scapular line... and mark where the tone changes from dullness to resonance. The distance between the tape marks should be 3 - 6 cm. b. Percuss up from the lower border to the scapular line, were resonance changes to dullness mark that point with a piece of tape, after that percuss down from the scapular line... and mark where the tone changes from resonance to dullness. The distance between the tape marks should be 2 3 - 5 cm. c. Percuss down the scapular line to the lower border, were resonance changes to dullness mark that point with a piece of tape, after that percuss up from the first point... and mark where the tone changes from dullness to resonance. The distance between the tape marks should be 3 - 6 cm. d. Percuss down the scapular line to the lower border, were resonance changes to dullness mark that point with a piece of tape, after that percuss up from the first point... and mark where the tone changes from resonance to dullness. The distance between the tape marks should be 2 - 4 cm.

C

42. The nurse notes hyperresonant percussion tones when percussing the thorax of an infant. The nurse's best action would be to: a. Notify the physician b. Suspect a pneumothorax c. Consider this a normal finding d. Monitor the infant's respiratory rate and rhythm

C

47. Which statement by the nurse shows that the interview is client-centered? a. "I need to complete this questionnaire about your medical and family history" b. "The hospital requires me to complete this assessment as soon as possible" c. "Tell me about the symptoms you've been having" d. "I've had the same symptoms that you've described"

C

48. The nurse is reviewing the function of the cranial nerves. Which of the cranial nerves is responsible for conducting nerve impulses to the brain from the organ of Corti? SALIO DE NUEVO a. CN I b. CN III c. CN VIII d. CN XI

C

53. The nurse is preparing to assess the visual of a 16-year-old patient. How should the nurse proceed? a. Perform the confrontation test b. Ask the patient to read the print on a handheld Jaeger card c. Use the Snellen chart positioned 20 feet away from the patient d. Determine the patient's ability to read newsprint at a distance of 12 to inches\

C

68. a) Which heart sound is known as the ventricular gallop? ("lub - dub - ta") a. S1 b. S2 c. S3 d. S4

C

21. The nurse is testing the function of cranial nerve XI. Which of these best describes the response the nurse should expect if the nerve is intact? The patient: A)demonstrates ability to hear normal conversation. B)sticks tongue out midline without tremors or deviation. C)follows an object with eyes without nystagmus or strabismus. D)moves the head and shoulders against resistance with equal strength.

D

19. How does the nurse perform a Rinne test of hearing function? The nurse: (VIII) VOLVIO A SALIR a. Whispers several words to the client and requests that the client repeat the words heard b. Places a vibrating tuning fork in the middle of the head and asks the client if the sounds is head the same in both ears or if it is louder in one ear than the other c. Places a set of headphones over both ears, plays several tones, and asks the client to identify the sounds d. Places a vibrating tuning fork on the mastoid process until the client no longer hears a sound, and then moves it in front of the ear until the client no longer hears a sound

D

2. During an interview, the client answers questions quietly and appears sad. While answering questions about her marriage, she begins to cry. The appropriate response by the nurse would be to say. a. "Don't cry I'll come back when you've settled down" b. "I only have a few more questions to go, then I'll leave you alone for a while?" c. "Everyone has ups and downs in their marriage. What problems are you having?" d. "I see that you are upset, is there something you'd like discuss?"

D

49. The mother of a 2-year-old is concerned because her son has had three five ear infections in the past year. What would be an appropriate response by the nurse? a. "It is unusual for a small child to have frequent ear infections unless there is something else wrong" b. "We need to check the immune system of your son to see why he is having so many ear infections" c. "Ear infections are not uncommon in infants and toddlers because they tend to have more cerumen in the external ear" d. "Your son's eustachian tube is shorter and wider than yours because of this age, which allows for infections to develop more easily"

D

50. The nurse is preparing to do an otoscopic examination on a 2-year-old. Which of these reflects correct procedure?VOLVIO A SALIR a. Pull the pinna down b. Pull the pinna up and back c. Tilt the child's head slightly toward the examiner d. Have the child touch his chin to his chest

D

56. The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has "lazy eye" and should a. Examine the external structures of the eye. b. Assess visual acuity with the Snellen eye chart c. Assess the child's visual fields with the confrontation test d. Test for strabismus by performing the corneal light reflex test

D

57. The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse would report this as a: a. Bulla b. Wheal c. Nodule d. Papule

D

68. Which heart sound is known as the atrial gallop? a. S1 b. S2 c. S3 ventricular gallop (lub - dub - ta) d. S4 atrial gallop (ta-lub-dub)

D

69. The nurse is auscultating a patient. She knows that S1 is the "lub" of the "lub-dub", and this one is produced by: a. S1 is diminished in secund degree heart block b. The closure of aortic & pulmonic valves c. The closure of aortic and mitral valves d. The closure of tricuspid and mitral valves

D

The nurse is auscultating the second intercostal space right of the sternal border to hear which valve? a. The pulmonic valve b. The tricuspid valve c. The mitral valve d. The aortic valve

D

While listening to a client's heart sounds, the nurse understands that the first heart sound (S1) is created by the closing of the: a. Pulmonic and tricuspid valves. b. Mitral and aortic valves. c. Aortic and pulmonic valves. d. Mitral and tricuspid valves.

D

20. A client is being seen in the clinic for suspected nasal obstruction from a foreign body. The nurse recognizes which finding as most consistent with this diagnosis? (I) a. Unilateral foul-smelling drainage b. Bilateral purulent green-yellow discharge c. Bilateral bloody discharge d. Unilateral watery discharge

a

22. When inspecting a client's nasal mucous membrane, which finding does the nurse expect to see? a. Deep pink turbinates b. Red, edematous mucous membranes c. Septum that angles to the left d. Clear exudate

a

28. What instruction does a nurse give a client to facilitate palpation of the right lobe of the thyroid gland? a. "Swallow for me one time" b. "Flex your head down and to the left" c. "Rotate your head to the right for me" d. "Hold your breath for a few seconds"

a

A 78-year-old client is admitted to the Emergency Department (ED) via emergency medical service (EMS) with complains of severe diarrhea with resultant weakness and sings of dehydration. Discussion with the significant other reveals that the patient continually eats spoiled foods. Which of the following might be most directly related to this patient's behavior? a. Damage to cranial never I b. Damage to cranial never II c. Damage to cranial never III d. Damage to cranial never IV

a

A client has right lower lobe pneumonia creating a consolidation in that lung. In assessing for vocal (tactile) fremitus, the nurse found increased fremitus over the right lower lung. What finding does the nurse anticipate when assessing vocal resonance to confirm the consolidation? a. Bronchophony reveals the client's spoken "99" as clear and loud. b. No sounds are expected because sounds cannot be transmitted through consolidations. c. Egophony reveals indistinguishable sounds when the client says "e-e-e". d. Whispered pectoriloquy reveals a muffled sound when the client whispers "1-2-3".

a

After taking a brief respiratory health history, a nurse would need to complete a more focused assessment on which client? a. A 28-year-old man who works as a painter. b. A 15-year-old man who plays basketball and hockey. c. A 19-year-old woman who recently moved into a college dormitory. d. A 35-year-old man with a history of gout.

a

In percussing the abdomen, the nurse recognizes which finding as normal? a. Tympany over all quadrants. b. Resonance over the upper quadrants and tympany in the lower quadrants. c. Dull sounds over the upper quadrants and hollow sounds over the lower quadrants. d. Dull sounds over the stomach and resonant sounds over the bladder.

a

On palpation of the left upper quadrant of the abdomen of a female client, the nurse notes tenderness and recognizes this pain is associated with a disorder of the: a. Spleen b. Gallbladder c. Sigmoid colon d. Left ovary

a

The nurse assesses for hyperextension of the hip by asking the client to: a. Raise one leg at a time while lying prone. b. Raise one leg at a time while lying supine. c. Move one leg at a time laterally, away from midline, while lying prone. d. Move one leg at a time medially, toward midline, while lying supine.

a

The nurse palpates the client's jaw movement, placing two fingers in front of each ear and asking the client to slowly open and close the mouth. The nurse also asks the client to: a. Move the jaw side to side. b. Swallow. c. Smile. d. Clench the teeth together.

a

The nurse recognizes which clinical findings as normal on palpation of the abdomen? a. Inability to palpate the spleen b. Left kidney rounded at 2 cm below the costal margin c. Slight tenderness of the gallbladder on light palpation d. Bounding pulsation of the aorta over the umbilicus

a

27. What technique does a nurse use when palpating the right lobe of a client's thyroid gland using the anterior approach? The nurse: a. Pushes the cricoid process to the left with the right thumb. b. Displaces the trachea to the right with the left thumb. c. Manipulates the thyroid between the thumb and index finger. d. Moves the sternocleidomastoid muscle to the right with the left thumb.

b

After inspecting the abdomen for skin color, surface characteristics, and surface movement, the nurse's next assessment of the abdomen is to: a. Palpate lightly for tenderness and muscles tone. b. Auscultate for bowel sounds. c. Palpate deeply for masses or aortic pulsation. d. Percuss for tones

b

The nurse in the figure below is assessing function and strength of the ________ muscle. a. Sternocleidomastoid. b. Trapezius. c. Deltoid. d. Pectoralis major.

b

To accurately assess bowel sounds, the nurse uses the: a. Diaphragm of the stethoscope pressed firmly against the abdomen in each quadrant. b. Diaphragm of the stethoscope held lightly against the abdomen in each quadrant. c. Bell of the stethoscope pressed firmly against the abdomen in each quadrant. d. Bell of the stethoscope held lightly against the abdomen in each quadrant.

b

When assessing vocal resonance for lung consolidation, the nurse notices that a similar finding among the three procedures is: a. The client is asked to say "e-e-e" in all three procedures. b. The normal finding is a muffled sound in all three procedures. c. The bell of the stethoscope is used in all three procedures. d. The client normally complains of pain on inspiration in all three procedures.

b

9. In preparing to assess visual acuity with a Snellen chart, the nurse instructs the client to: (II) SALIO DE NUEVO a. Remove eyeglasses before attempting to read the lowest line b. Stand 10 feet from the chart and read the first line aloud c. Hold a white card over one eye and read the smallest possible line d. Squint if necessary to improve ability to read the largest letters

c

A nurse assesses the neck of an adult documents that the client's neck muscles are within normal limits if the client: a. Has a convex contour of the posterior cervical spine. b. Bends the head to the right and left (ear to shoulder) 15 degrees. c. Is able to resist the nurse's attempt to move the head upright. d. Is able to hyperextend the head 30 degrees from midline.

c

During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition? A)Airway obstruction B Emphysema C)Pulmonary consolidation D)Asthma

c

In assessing the joint range of motion of a client's knees, the nurse notices the flexion is less than expected in both knees. What is the next appropriate action for the nurse? a. Documenting this finding as normal for this client because it occurs in both knees and comparisons are made of one side with the other. b. Palpating the suprapatellar pouch on each side of the quadriceps for contour, tenderness, and edema. c. Using a goniometer to measure the flexion in both knees and comparing the results with the expected degree of flexion. d. Applying opposing force to the lower leg while the client tries to maintain flexion and extension.

c

The nurse is auscultating the chest in an adult. Which technique is correct? A)Instruct the patient to take deep, rapid breaths. B)Instruct the patient to breathe in and out through his or her nose. C Use the diaphragm of the stethoscope held firmly against the chest. D Use the bell of the stethoscope held lightly against the chest to avoid friction.

c

The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? They are: a.musical in quality b. usually pathological c. expected near the major airways d. similar to bronchial sounds except that they are shorter in duration

c

The nurse knows that while percute solid organs in the abdominal region, she heard the sounds: a. Tympanic b. Resonance c. Dullness d. Hyperresonant

c

The nurse reviews the technique of performing an abdominal assessment and understand that _________ should be performed second to maintain the correct order and client comfort. a. Palpation b. Inspection c. Auscultation d. Percussion

c

To correctly palpate a client's right kidney, the nurse: a. Ask the client to take a deep breath, elevates the client's eleventh and twelfth ribs with the left hand, and deeply palpates for the right kidney with the right hand. b. Ask the client to exhale, elevates the client's eleventh and twelfth ribs with the left hand, and deeply palpates for the right kidney with the right hand. c. Ask the client to take a deep breath, elevates the client's right flank with the left hand, and deeply palpates for the right kidney with the right hand. d. Ask the client to exhale, elevates the client's right flank with the left hand, and deeply palpates for the right kidney with the right hand.

c

When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse interprets that these are: A)sounds normally auscultated over the trachea. B)bronchial breath sounds and are normal in that location. C)vesicular breath sounds and are normal in that location. D)bronchovesicular breath sounds and are normal in that location.

c

When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is: A)seen in patients with kyphosis. B)indicative of pectus excavatum. C)a normal finding in a healthy adult. D)an expected finding in a patient with a barrel chest

c

. The range of normal liver span in the right midclavicular line in the adult is: a. 2 - 6 cm b. 4 - 8 cm c. 8 - 14 cm d. 6 - 12 cm

d

3. Select the example of an open-ended question from those below. a. "Have you experienced this pain before?" b. "Do you have someone to help you at home?" c. "How many times a day do you use your inhaler?" d. "What were you doing when you left the pain?"

d

4. When performing a skin assessment of an adult client, the nurse expects what finding?" a. Reddened are does not blanch when gentle pressure is applied b. Indentation of the finger in the skin after palpation c. Flaking or scaling of the skin d. Return of skin to its original position when pinched up slightly

d

5. In a report, a nurse learns that a client has a macular rash and expects to find: a. Elevated, firm, well-defined lesions less than 1 cm in diameter (papula) b. Depressed, firm, or scaly, rough lesions greater than 1 cm in diameter (vesicula) c. Elevated, fluid-filled lesions less than 1 cm in diameter d. Flat, well-defined, small lesions less than 1 cm in diameter (macula) 6. A nurse notices multiple lesions on a client's back that are 0.5 cm in width, elevated, circumscribed, and

d

A client asks, "Why is touching my toes necessary? This is a sports physical examination, not exercise class." The nurse replies: a. "This is the best way to check for symmetry of your arms". b. "I am looking at the stretch of your ham strings". c. "This allows me to see how straight your spinal column is". d. "It is considered abnormal if you can't touch your toes from this position."

d

A client reports a history of compression of the left cranial nerve XI (spinal accessory nerve) from an old sports injury. Based on this information, what technique does the nurse include in the focused assessment? a. Asking the client to rotate the head against resistance of the nurse's hand on the client's chin. b. Asking the client to flex the chin to the chest against resistance of the nurse's hand on the client's forehead. c. Asking the client to extend the head back against resistance of the nurse's hand on the back of the client head. d. Asking the client to shrug the shoulders while the nurse attempts to push then down.

d

The nurse notes that there is audible clicking sound when the client opens and closes the mouth. What is the appropriate response of the nurse at this time? a. Recording this as an abnormal finding requiring additional assessment. b. Measuring the distance between each side of the mandible and the eyes. c. Applying the distance to the maxilla and asking the client to repeat the motion. d. Noting this as a normal finding if there are no other associated signs or symptoms.

d

Using deep palpation of a client's epigastrium, a nurse feels the rhythmic pulsation of the aorta. Based on this finding, the appropriate response of the nurse is to: a. Auscultate this area using the bell of the stethoscope b. Percuss the area for tones c. Ask the client if there is pain in this area d. Document this a normal finding

d

When inspecting and palpating the sternoclavicular joint, the nurse would distinguish a normal finding as all of the following except: a. No visible bony overgrowths b. No swelling c. No redness d. Painful joints

d

When the nurse asks a client to place the right arm behind the head, the nurse is testing for which range of motion? a. Flexion of the elbow. b. Hyperextension of the shoulder. c. Internal rotation and adduction of the shoulder. d. External rotation and abduction of the shoulder.

d