p r a c t i c e

. While assessing the nails of an older adult, the nurse observes early clubbing. The nurse should further evaluate the client for signs and symptoms of a. hypoxia. b. trauma. c. anemia. d. infection.

A

A 20-year-old comatose high school student arrives at the emergency room. His friends have accompanied him and report that they have been shooting up heroin tonight and think their friend may have had too much. The client is unconscious and cannot protect his airway so he is intubated. His heart rate is 60 and he is breathing through the ventilator. He is not posturing and he does not respond to a sternal rub. On neurological examination with a penlight, what type of pupils is the examiner likely to see in this comatose client? A.) Pinpoint B.) Large C.) Asymmetrical D.) Irregularly shaped

A

A 38-year-old woman presents with multiple small joints that are symmetrically involved with pain, swelling, and stiffness. Which of the following is the most likely explanation? A.) Rheumatoid arthritis B.) Septic arthritis C.) Gout D.) Trauma

A

A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action should the nurse perform next? a. Assess the client's blood pressure. b. Provide medication for pain relief. c. Inquire about family history of headaches. d. Review the client's medical record.

A

A client has osteoarthritis of the elbow. Which assessment approach should the nurse expect to be impacted by this health problem? A.) flexion B.) rotation C.) abduction D.) adduction

A

A client visits the clinic and tells the nurse that she has joint pain in her hands, especially in the morning. The nurse should assess the client further for signs and symptoms of: A. Arthritis B. Osteoporosis C. Carpal tunnel syndrome D. A neurologic disorder

A

A female client visits the clinic and tells the nurse that she frequently experiences severe recurring headaches that sometimes last for several days and are accompanied by nausea and vomiting. The nurse determines that the type of headache the client is describing is a a. migraine headache b. cluster headache c. tension headache d. tumor-related headache

A

An adult client visits the clinic and tells the nurse that she has had headaches recently that are intense and stabbing and often occur in the late evening. The nurse should suspect the presence of a. cluster headaches b. migraine headaches c. tension headaches d. tumor-related headaches

A

An older client visits the clinic accompanied by his daughter. The daughter tells the nurse that her father has been experiencing severe headaches that usually begin in the morning and become worse when he coughs. The client tells the nurse that he feels dizzy when he has the headaches. The nurse refers the client for further evaluation because these symptoms are characteristic of a A. tumor-related headache. B. tension headache. C. migraine headache. D. cluster headache.

A

As the nurse assesses facial symmetry, a significant finding is: A. Ptosis. B. Pseudostrabismus. C. Widow's peak. D. Candidiasis.

A

During the physical exam, the nurse notes a very tender and painful, reddened, hot, and swollen metatarsophalangeal joint of the client's great toe. Which of the following would the nurse suspect? A.) Gouty arthritis B.) Rheumatoid arthritis C.) Degenerative joint disease D.) Plantar fasciitis

A

Skeletal muscles are attached to bones by: A. Tendons B. Cartilage C. Fibrous connective tissue D. Ligaments

A

The client is complaining that his lower joints are increasingly painful as the day progresses. The nurse suspects the client is experiencing what musculoskeletal disorder? A.) Osteoarthritis B.) Rheumatoid arthritis C.) Fibromyalgia D.) Bone fracture

A

The client is facing the nurse with his forearm turned so that his palm is up. What movement is the client exhibiting? A.) Supination B.) Pronation C.) Inversion D.) Eversion

A

The decreasing of vision acuity associated with aging is called: A. Presbyopia B. Hyperopia C. Myopia D. Diplopia

A

The nurse is conducting an assessment of an adult client who describes herself as being in good health. Inspection of the client's nail beds reveals the presence of a bluish tone. The nurse should recognize that this finding is most likely attributable to what phenomenon? A. Vasoconstriction B. Cardiopulmonary insufficiency C. Hypoxemia D. Hyperglycemia

A

The nurse is going to test range of motion in a patient. To test extension of the triceps muscle, the nurse would instruct the patient to A.) straighten the elbow B.) bend the elbow C.) turn the palm up D.) turn the palm down

A

The nurse notices that a patient has a disturbed gait. To further assess this problem, which action should the nurse take? a.Measure the length of both legs. b.Perform deep palpation of the hip joints. c.Test range of motion of the lower extremities. d.Perform muscle-strength testing of the legs.

A

The nurse suspects carpal tunnel syndrome after examining a patient in the clinic. A test result that would suggest this diagnosis would be A. weak opposition of the thumb B. negative Tinel sign C. negative Phelan sign D. increased thumb abduction

A

The nurse suspects the client has increased intracranial pressure due to meningitis. What should the nurse assess? A.) Neck mobility B.) Decreased level of consciousness C.) Confusion D.) Extraocular movements

A

The only layer of the skin that undergoes cell division is the a. innermost layer of the epidermis. b. outermost layer of the epidermis. c. innermost layer of the dermis. d. outermost layer of the dermis.

A

The patient with psoriasis is admitted to a medical unit for unrelated reasons. When documenting the type of lesion represented by psoriasis, the nurse should document a a. papule b. pustule c. bulla d. wheal

A

Upon assessing the client's jaw, the nurse finds decreased range of motion and notes crepitus. What would the nurse suspect? A.) Arthritis B.) Temporomandibular Joint (TMJ) C.) Facial fractures D.) Myofascial pain syndrome

A

Upon examination of a client, the nurse finds a circumscribed elevated, palpable mass containing serous fluid. How should the nurse properly document this finding? a. vesicle b. papule c. wheal d. cyst

A

Vesicles in a unilateral dermatomal pattern are typical of: A. Herpes zoster B. Herpes simplex C. Tinea capitis D. Acne vulgaris

A

When the nurse moves a clients leg upward, the nurse is performing: A. Supination B. External rotation C. Eversion D. Internal rotation

A

Which action by a nurse is a correct method for performing Tinel's test to determine the presence of carpel tunnel syndrome? A.) Percuss lightly on the inner aspect of the wrist B.) Palpate the hollow area on the back of the wrist C.) Ask the client to bend the wrist down and back D.) Perform wrist movements against resistance

A

Which movement should the nurse instruct the client to perform to assess range of motion for the knee? A.) Flexion B.) Circumduction C.) Rotation D.) Abduction

A

Which of the following is characteristic of hypothyroidism? A. Cold intolerance B. Insomnia C. Tachycardia D. Weight loss

A

Which of the following risk factors for osteoporosis is the best predictor of low bone density? A.) Smoking B.) Low body weight C.) Estrogen deficiency D.) Prior vertebral fracture

A

Which of the following would the nurse interpret as a positive response to the Phalen test for a client suspected of having carpal tunnel syndrome? A.) Numbness B.) Atrophy of the thenar prominence C.) No tingling D.) Hard, painless Bouchard nodes

A

While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 1 cm. The nurse documents this as a a. plaque. b. macule. c. papule. d. patch.

A

While assessing the musculoskeletal system of an adult client, the nurse observes hard painless nodules over the distal interphalangeal joints. The nurse should document the presence of: A. Osteoarthritis B. Bursitis C. Tendonitis D. Rheumatoid arthritis

A

asymmetry of one side of mole compared to other

A

•The skin is recognized for performing which function? A. Temperature control B. Synthesizes vitamin K C. Excretion of excessive electrolytes D. Motor perception

A

The nurse assesses which of the following could be due to increased intracranial pressure? Select all that apply. A.) Headache that subsides after arising B.) Blurred vision C.) Ptosis D.) Headache that subsides when lying E.) Difficulty swallowing

A, B

The nurse would expect to assess which symptoms in a patient complaining of migraine headaches? Select all the apply. a. throbbing b. photophobia c. recurrent d. ptosis

A, B, C

When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? Select all that apply. A. notched border B. diameter greater than 6cm C. asymmetry D. pink color

A, B, C

The nurse is planning the care of a 77-year-old woman who has recently been diagnosed with osteoporosis. What nursing diagnoses should the nurse address in the client's plan of care? Select all that apply. A.) Risk for injury related to osteoporosis B.) Risk for infection related to osteoporosis C.) Activity intolerance related to osteoporosis D.) Impaired physical mobility related to osteoporosis E.) Disturbed sensory perception related to osteoporosis

A, C, D

.An adult white client visits the clinic for the first time. During assessment of the client's skin, the nurse should assess for central cyanosis by observing the client's a. nailbeds. b. oral mucosa. c. sclera. d. palms.

B

A client is brought to the health care facility with a sudden loss of movement on the right side of the body. Upon assessment, the nurse finds that the client has a slight flicker of contraction in the muscles on the right side. What should the nurse document as the muscle strength rating? A. 4 B. 1 C. 2 D. 3

B

A client receives physical therapy for carpal tunnel syndrome. Which action by the nurse is appropriate to assess the efficacy of the treatment? A.) Flex the wrists 90 degrees upward B.) Place the backs of both hands against each other C.) Maintain flexed wrists for 90 seconds D.) Bend the wrists down and back

B

A nurse is assessing an older adult client's risk for pressure ulcers using the Braden Scale for Predicting Pressure Sore Risk. Which aspect of the client's current health status would be reflected in her score on this scale? a. The client has a full-time caregiver. b. The client is consistently incontinent of urine. c. The client has a surgical diagnosis. d. The client adheres to a vegetarian diet.

B

A nurse notes that a client looks much older than his chronologic age. Which of the following conditions would most likely contribute to this appearance? A. Cushing syndrome B. Alcoholism C. Parkinson's disease D. Marfan syndrome

B

A patient with left knee pain is diagnosed with bursitis. The nurse will explain that bursitis is aninflammation of a. the synovial membrane that lines the joint. b. a small, fluid-filled sac found at some joints. c. the fibrocartilage that acts as a shock absorber in the knee joint. d. any connective tissue that is found supporting the joints of the body

B

An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what? A. Squamous cells B. Sebum production C. Subcutaneous tissue D. Sweat glands

B

During the morning assessment, the nurse notes jaundice in the patient where is the location that jaundice is usually first noticed? a. nail beds b. sclera and hard palate c. lips d. trunk

B

Functions of the skin include of the following except: A. Temperature control B. Synthesizes vitamin K C. Provides protection D. Sensory perception

B

The client presents at the clinic with a history of cerebral palsy. When examining the patient the nurse notes increased resistance that is rate dependent and increases with rapid movement. What would the nurse chart about this patient? A.) Patient has rigidity B.) Patient demonstrates spasticity C.) Patient has muscular atrophy D.) Patient demonstrates muscular atony

B

The client tells the nurse that he has joint stiffness that is worse in the morning but improves as the day progresses. The nurse should assess the client for what musculoskeletal disorder? A.) Gouty arthritis B.) Rheumatoid arthritis C.) Osteoarthritis D.) Osteoporosis

B

The muscle that raises the upper eyelid is innervated by: A. CN II B. CN III C. CN IV D. CN VI

B

The nurse assesses an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as a. stage I. b. stage II. c. stage III. d. stage IV

B

The nurse is preparing to assess the neck of an adult client. To inspect movement of the client's thyroid gland, the nurse should ask the client to a. inhale deeply b. swallow a small sip of water c. cough deeply d. flex the neck to each side

B

The nurse notes crackling sounds and a grating sensation with palpation of an older patients elbow. Howwill this finding be documented? a. Torticollis b. Crepitation c. Subluxation d. Epicondylitis

B

The subacromial bursa are contained in the: A. Temporomandibular joint B. Shoulder joint C. Elbow joint D. Wrist joint

B

This condition is a common cause of poor central vision among the elderly that may include either drusen or wet exudate. It is: A. Glaucoma B. Macular degeneration C. Presbyopia D. Retinal detachment

B

irregular borders especially ragged, notched, blurred

B

A nurse is caring for an adult client who has just undergone surgery to remove a thyroid tumor. The nurse is assessing for symptoms of hyperthyroidism. What are some of the symptoms of hypermetabolism? Select all that apply. A. Headache B. Diarrhea C. Tachycardia D. Anxiety

B, C, D

A patient with hypothyroidism is admitted to the medical unit. The nurse would expect to assess which signs/symptoms? Select all that apply. a. warm skin b. cool skin c. lethargy d. constipation e. lower systolic BP f. anxiety

B, C, D, E

A client complains of chronic pain and fatigue. The nurse suspects fibromyalgia. What is a diagnosis of this condition based on? A.) Lab tests B.) X-rays C.) Client's symptoms D.) Range of motion tests

C

A client complains of headaches each morning that resolve after getting out of bed. Which of the following would be most appropriate for the nurse to do? A.) Assess the client's level of consciousness. B.) Assess the client's deep tendon reflexes. C.) Refer the client for immediate medical follow-up. D.) Refer the client for physical therapy and occupational therapy.

C

A nurse is caring for a client who is recovering from a stroke. The nurse assesses the muscle strength of the client's arm and finds that the joint exhibits active motion against gravity. Which of the following should the nurse document to classify muscle strength based on this finding? A.) Poor range of motion B.) Slight weakness C.) Average weakness D.) Severe weakness

C

A nurse observes the presence of hirsutism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process? A. Iron deficiency anemia B. Lupus erythematosus C. Cushing's disease D. Basal cell carcinoma

C

An 82-year-old client is brought to the emergency department with suspected broken right hip. It is believed that she was lying between the bed and the wall for over 48 hours before she was found. As the nurse conducts an assessment he sees the following over the lower back/coccyx area. What should the nurse document related to this finding? A. Ecchymosis over the coccyx (bruising) B. Scaling lesion with exudate over the coccyx (keratotic) C. Stage 2 pressure ulcer (Loss of epidermis) D. Stage 4 pressure ulcer (loss or damage tomuscle or bone)

C

Assessment reveals that a client has slight weakness with active range of motion against some resistance. The nurse would document this as which of the following? A.) 2/5 B.) 3/5 C.) 4/5 D.) 5/5

C

During your physical examination of the patient, you gently pinch the back of her hand. The skin remains in a "tent" shape and slowly returns to its normal position. This is a sign of: A. Infection B. Overhydration C. Dehydration D. Properly hydrated

C

One of the functions of a bone is to: A. Store fat B. Produce secretions C. Produce blood cells D. Store protein

C

Scoliosis is a ________ curvature of the spine. A. Kyphotic B. Lordotic C. Lateral

C

The nurse is caring for a 74-year-old woman. What would be a normal age-related finding? a.Kyphosis b.Back pain c.Loss of height d.Spinal crepitation

C

The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's a. nodules. b. bullae. c. vesicles. d. wheals.

C

What finding should a nurse expect when performing the Phalen's test on a client with suspected carpal tunnel syndrome? A.) Inability to perform active range of motion with the involved wrist B.) Stiffness in the hands and fingers after holding and releasing a tight fist C.) Reports of tingling, numbness, and pain in the involved wrist D.) A change in the color of the fingers from red to white (pale)

C

Which joint movement is a nurse testing when asking a client to move an extremity towards the body? A.) Flexion B.) Extension C.) Adduction D.) Abduction

C

Which of the following symptoms is not characteristic of hypothyroidism? A. Hoarseness B. Intolerance to cold C. Palpitations D. Constipation

C

variation of change in color, especially black or blue

C

. To assess an adult client's skin turgor, the nurse should a. press down on the skin of the feet. b. use the dorsal surfaces of the hands on the client's arms. c. use the fingerpads to palpate the skin at the sternum. d. use two fingers to pinch the skin under the clavicle.

D

A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis? A. Cluster B. Analgesic rebound C. Migraine D. Tension

D

A client visits the clinic and tells the nurse that he is depressed because of a recent job loss. He complains of dull, aching, tight, and diffuse headaches that have lasted for several days, The nurse should recognize that these are symptoms of a. cluster headaches b. tumor-related headaches c. migraine headaches d. tension headaches

D

A female client visits the clinic and complains to the nurse that her skin feels "dry." The nurse should instruct the client that skin elasticity is related to adequate A. calcium B. vitamin D C. carbohydrates D. fluid intake

D

Connecting the skin to underlying structures is/are the a. papillae. b. sebaceous glands. c. dermis layer. d. subcutaneous tissue.

D

Hair follicles, sebaceous glands, and sweat glands originate from the A. epidermis B. eccrine glands C. keratinized tissue D. dermis

D

The nurse is assessing a middle-aged female client who is new to the clinic. The nurse observes the presence of significant facial hair that is uncharacteristic of the client's ethnicity. What assessment question should the nurse ask? a. "Has anyone in your family ever been diagnosed with skin cancer?" b. "Have you ever been assessed for diabetes?" c. "What dietary supplements do you usually take?" d. "Do you take steroid medications on a regular basis?"

D

The nurse is assessing the spine of an adult client and detects lateral curvature of the thoracic spine with an increase in convexity on the left curved size. The nurse suspects that the client is experiencing: A. Lordosis B. Arthritis C. Kyphosis D. Scoliosis

D

The nurse is examining an adult client's range of motion in the shoulders. The client is unable to shrug her shoulders against resistance. The nurse suspects that the client has a lesion of cranial nerve a. VIII. b. IX. c. X. d. XI

D

The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin A. A B. B12 C. C D. D

D

When palpating a female client's axillae, which finding would the nurse document as normal? A. Node size is 1.2 cm. B. Nodes are fixed. C. Nodes are hard. D. Nodes are discrete.

D

When the nurse moves the clients arm away from the midline of the body, the nurse is performing: A. Adduction B. External rotation C. Retraction D. Abduction

D

Which clinical manifestation should the nurse expect to find in a client with edema? a. Decreased skin turgor b. Prominent blood vessels c. Mottled skin tones d. Decreased skin mobility

D

Which nutrient deficiency should a nurse recognize as placing a client at risk for osteoporosis? A.) Protein B.) Vitamin C C.) Vitamin D D.) Calcium

D

While assessing an adult client's head and neck, the nurse observes asymmetry in front of the client's ears lobes. The nurse refers the client to the physician because the nurse suspects the clent is most likely experiencing a/an a. enlarged thyroid b. lymph node abscess c. neurologic disorder d. parotid gland enlargement

D

diameter ≥6 mm or different from others, especially if changing, itching, or bleeding

D

Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV. a. full thickness skin loss b. necrosis with damage to underlying muscle c. ulceration involving the dermis d. intact, firm skin with redness

D, C, A, B

evolving, a mole or skin lesion that looks different from the rest or is changing in size, shape, or color

E

The nurse knows that body odor is caused by ___________________ glands.

apocrine

What would the nurse expect to see in a patient with decreased central oxygenation?

cyanosis

A patient admitted with dehydration would typically have a ________________ in skin turgor.

decrease

The nurse is performing a light reaction test and shines a light in the retina of the right eye. The right eye constriction is called __________ reaction and the reaction that occurs in the opposite eye is called __________ reaction.

direct, consensual