NUR 205 Final
what tools are needed for cardiac assessment?
stethoscope clock penlight
A patient that is ________________ will open his eyes in response to deep pain.
stuporous
normal respiratory rate
12-20
normal pulse rate
60-100
A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?
Prior to percussing the abdomen
What is objective data?
What you observe and can assess
what is the last indicator of orientation to disappear?
a patient loses awareness of self
Which location does a nurse select when palpating a patient's liver? a. A (right lower quadrant) b. B (right upper quadrant) c. C (left upper quadrant) d. D (left lower quadrant)
b. B (right upper quadrant)
How does the nurse accurately assess bowel sounds? a. Press the diaphragm of the stethoscope firmly against the abdomen in each quadrant. b. Hold the diaphragm of the stethoscope lightly against the abdomen in each quadrant. c. Press the bell of the stethoscope firmly against the abdomen in each quadrant. d. Hold the bell of the stethoscope lightly against the abdomen in each quadrant.
b. Hold the diaphragm of the stethoscope lightly against the abdomen in each quadrant.
pulses that are included in cardiac assessment
carotid brachial radial dorsalis pedis (all of the above)
In what position should a female genitourinary system be assessed?
client should lie in supine position with knees bent and feet placed on the bed
What is atelectasis?
collapsed lung, causing decreased breath sounds
A patient reports a change in the usual pattern of urination. What question does the nurse ask to determine if incontinence is the reason for these symptoms? a. "Do you have the feeling that you cannot wait to urinate?" b. "Are you urinating a large amount each time you go to the bathroom?" c. "Has the color of your urine changed lately?" d. "Have you noticed any swelling in your ankles at the end of the day?"
do you have the feeling that you cannot wait to urinate
Order to take off PPE
gloves, gown, goggles, mask
Order to put on PPE
gown, mask, goggles, gloves
what condition is associated with jugular venous distention?
heart failure
The nurse recognizes which clinical finding as expected 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
inability to palpate the spleen
hyperesthesia
increased sensation
what is hypoxia?
lack of oxygen
What testicle hangs lower?
left, due to longer length of the left spermatic cord
What term describes an individual who is drowsy but will awaken in response to stimulation?
lethargic
anesthesia
loss of sensation
what are small bumps on surface of areola called?
montgomery glands
A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?
nausea
where does a nurse expect to hear Broncho vesicular lung sounds?
near the sternal border
which tools are used in an assessment of the head and neck ?
penlight examination gloves
What is subjective data?
the clients opinion (feeling pain)
The family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling. Which of the following factors should the nurse identify as a likely explanation for the client's behavior?
the person is confused
A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse?
top left side of the chest
a mucoid discharge and bright red nasal mucosa is associated with an ____
upper respiratory infection
which of the following questions should you ask the client when assessing for an orientation deficit? what is the date? what is your birthday? do you know why you are here? who is the president? what time is it? where are you?
what is your birthday? do you know why you are here? who is the president? where are you?
which of the following statements should you include in a teaching about health promotion screening for adults? you should have your vision checked every 2 years. you only need your hearing checked if you think you have a problem. you should have a dental exam every other year. you can decrease the frequency of screenings after the age of 60.
you should have your vision checked every 2 years.
reflexes grade scale
+1 low normal +2 normal +3 more brisk +4 brisk, hyperactive
What rating should you assign to a bounding carotid pulse?
+4
When inspecting a patient's abdomen, which finding does the nurse note as normal? a. Engorgement of veins around the umbilicus b. Sudden bulge at the umbilicus when coughing c. Visible peristalsis in all quadrants d. Silver-white striae extending from the umbilicus
Silver-white striae extending from the umbilicus
What is hypospadias?
Urethral opening located behind the glands of the penis or on the ventral surface of the penile shaft (back)
Where is the hard palate located?
anterior roof of mouth (whitish in color)
What is epispadias?
meatus located on dorsal side of glands