Saunders question HA

Ataxic respirations

totally irregular in rhythm and depth and indicate a dysfunction in the medulla

A nurse is performing an abdominal assessment and inspects the skin on the client's abdomen. Which assessment technique should the nurse perform next?

Listen to bowel sounds in all four quadrants.

The nurse in a health care clinic is preparing to test a client for accommodation. Initially, the nurse should ask the client to take which action?

Focus on a distant object.

hyperperistalsis

Loud gurgles (borborygmi)

The nurse is testing a client for astereognosis. The nurse should ask the client to close the eyes and perform which action?

Identify an object placed in the client's hand.

agraphesthesia test

Identify three numbers or letters traced in the client's palm.

The nurse is conducting a problem-based or focused assessment on a client. Which is accurate about this type of assessment?

Mostly used in a walk-in clinic or emergency department

The nurse is performing a physical examination on an assigned client. Which item should the nurse select to test the function of cranial nerve II?

Snellen chart

A nurse is preparing to check the breath sounds of a client. When auscultating for bronchovesicular breath sounds, the nurse should place the stethoscope over which area?

The major bronchi

When assessing for tactile fremitus, the nurse should:

begin palpating over the lung apices in the supraclavicular area. The nurse should compare vibrations from one side to the other as the client repeats the word ninety-nine. The nurse should avoid palpating over female breast tissue because breast tissue usually blocks the sound.

A nurse is preparing to measure the apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope over which cardiac site?

Mitral area

The nurse is performing a neurological assessment on a client who had a brain attack (stroke). The nurse checks for proprioception by which assessment technique?

Holding the sides of the client's great toe and, while moving it, asking what position it is in

The nurse assesses a client for the presence of Homans' sign. Which could be an indication that this sign is positive?

Pain with dorsiflexion of the foot

A pericardial friction rub is described as what heart sound?

a scratchy, leathery heart sound

The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time?

1 week after menstruation begins

A confrontation test is prescribed for a client seen in the eye and ear clinic. How should the nurse perform this test? Arrange the actions in the order that they should be performed. All options must be used.

1) Stands 2 to 3 feet in front of and faces the client 2) Asks the client to cover one eye 3) Examiner covers eye opposite to the eye covered by the client 4) The examiner brings in an object gradually from periphery 5) Asks the client to report when object is first noted

The clinic nurse is performing an assessment for a client who is complaining of shortness of breath. The client tells the nurse that he is a cigarette smoker and admits to smoking one pack of cigarettes per day for the past 10 years. The nurse determines that the client has a smoking history of how many pack years?

10 pack years

A nurse is making an initial home visit to a client who was recently discharged from the hospital after treatment for a myocardial infarction. The nurse should use which type of database initially to obtain information from the client?

A complete health database

The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which action to obtain the assessment data?

Ask the client to follow the flashlight through the six cardinal positions of gaze.

The nurse is conducting a neurological assessment, including a health history, on a client with a neurological disorder. The nurse observes that the client is having difficulty in answering the questions and should perform which action?

Ask the client to give permission for a family member to stay during the interview.

The nurse is teaching breast self-examination (BSE) to a client who has had a hysterectomy. The most appropriate instruction regarding when the BSE should be performed is at which time?

At a specific day of the month and on that same day every month thereafter

An emergency department nurse is performing an assessment on a child suspected of being sexually abused. Which assessment data obtained by the nurse most likely supports this suspicion?

Difficulty walking

A client experiencing "skipped heart beats" is diagnosed with benign premature ventricular contractions and is placed on metoprolol tartrate (Toprol XL). The client returns to the health care provider's office 1 month later for a checkup. The nurse should implement which type of database when performing an assessment?

Follow-up database

The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How should the nurse best determine the presence of erythema?

Palpate for increased skin temperature around the wound edges.

A nursing student is performing a respiratory assessment on a female adult client and is assessing for tactile fremitus. Which action by the nursing student indicates a need for further teaching?

Palpating over the breast tissue to assess and compare vibrations from one side to the other

The nurse in the health care clinic is preparing to perform an otoscopic examination on an adult client. What should the nurse do when performing the examination?

Pull the pinna up and back before inserting the speculum.

A client's vision is tested with a Snellen chart. The results of testing are documented as 20/40. Which statement is a correct interpretation of the client's test result?

The client can read at a distance of 20 feet what a person with normal vision can read at 40 feet.

A nurse is reviewing the findings on a physical examination that are documented in a client's record. The nurse notes which as a piece of documented objective data?

The client has a rash on the chest and arms.

The clinic nurse is preparing to perform a Romberg test on a client being seen in the clinic. The nurse would perform this test for the purpose of determining which status?

The functional status of the vestibular apparatus in the inner ear

The nurse is testing the coordinated functioning of cranial nerves III, IV, and VI. To do this correctly, what should the nurse test?

The six cardinal fields of gaze

Neurogenic hyperventilation

a regular, rapid and deep, sustained respiration that can indicate a dysfunction in the low midbrain and middle pons

Decorticate posturing

abnormal flexion and is noted when the client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.

Apneustic respirations

irregular respirations with pauses at the end of inspiration and expiration and can indicate a dysfunction in the middle or caudal pons.

Vesicular breath sounds are heard where?

over the peripheral lung fields.

The nurse notes documentation that a client has conductive hearing loss. The nurse understands that this type of hearing loss is caused by which problem?

A physical obstruction to the transmission of sound waves

Bronchial breath sounds are heard where?

over the trachea and larynx.

The nurse is performing a respiratory assessment and is auscultating the client's breath sounds. On auscultation, the nurse hears a grating and creaking type of sound. The nurse interprets this to mean that client has which type of sounds?

Pleural friction rub

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding?

Rhythmic respirations with periods of apnea/can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia

A sensorineural hearing loss occurs as a result of a pathological process where?

1) in the inner ear 2) a defect in the 8th cranial nerve 3) a defect of the sensory fibers that lead to the cerebral cortex

Kernig's sign positive response

tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended.

A nursing student is asked about the procedure used to elicit Homans' sign. Which response by the student indicates an understanding of this assessment technique?

"I will ask the client to extend her legs flat on the bed, and I will gently dorsiflex her foot forward."

A nurse is assessing a client with a history of cardiac problems. Where should the nurse place the stethoscope to hear the first heart sound (S1) the loudest?

Over the fifth intercostal space in the left midclavicular line

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. Which describes the sound of a heart murmur?

Gentle blowing or swooshing noise

The nurse has obtained a personal and family history from a client with a neurological disorder. Which factors in the client's history are associated with added risk for neurological problems? Select all that apply.

History of headaches Previous back injury History of hypertension History of diabetes mellitus

A chest x-ray report states that the client has a left apical pneumothorax. The nurse caring for the client monitors the status of breath sounds in that area by placing the stethoscope at which location?

Just under the left clavicle

The nurse is instructing a client in breast self-examination (BSE). The nurse tells the client to lie down and examine the left breast. The nurse should instruct the client that while examining the left breast she should place a pillow under which area?

Left shoulder

The nurse is assessing for the presence of pallor in a dark-skinned client. What finding should the nurse look for?

Loss of normal red tones in the skin

The nurse is examining a dark-skinned client for the presence of petechiae. The nurse will best observe these lesions in which body area?

Oral mucosa

The nurse is performing an abdominal assessment on a client. The nurse determines that which finding should be reported to the health care provider (HCP)?

Pulsation between the umbilicus and the pubis

After performing an initial abdominal assessment on a client, the nurse documents that the bowel sounds are normal. Which description best describes normal bowel sounds?

Relatively high-pitched clicks or gurgles auscultated in all four quadrants

The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which areas LEAST helpful in assessing for pallor or cyanosis?

Sclera

A home care nurse is assessing a client's activities of daily living (ADLs) after a stroke. What should the nurse include in the client's focused assessment?

Self-care needs such as toileting, feeding, and ambulating

The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse implement to test the motor function of this nerve?

Separate the client's jaw by pushing down on the chin.

The nurse conducting a health screening is performing hearing assessments on clients. Senior nursing students are assisting the nurse with the assessments. The nurse instructs the students to perform a voice test by taking which action?

Stand 1 to 2 feet away from the client and ask the client to block one external ear canal.

The nurse is preparing to perform an abdominal examination on a client. The nurse should place the client in which position for this examination?

Supine with the head raised slightly and the knees slightly flexed

A nursing student is performing an otoscopic examination in an adult client. The nursing instructor observes the student perform this procedure. Which observation by the instructor indicates that the student is using correct technique for the procedure?

Tilting the client's head slightly away and holding the otoscope upside down before inserting the speculum

The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe?

The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.

The clinic nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test?

The right eye is tested, followed by the left eye, and then both eyes are tested.

The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure?

The testicular-self examination is recommended monthly after a warm bath or shower when the scrotal skin is relaxed. The client should stand to examine the testicles. Using both hands, with fingers under the scrotum and thumbs on top, the client should gently roll the testicles, feeling for any lumps.

Decerebrate posturing

abnormal extension and occurs when the arms are fully extended, forearms pronated, wrists and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed

The most likely assessment findings in sexual abuse include:

difficulty walking or sitting; torn, stained, or bloody underclothing; pain, swelling, or itching of the genitals; and bruises, bleeding, or lacerations in the genital or anal area.

high-pitched and louder (hyperresonance) bowel sounds

when the intestines are under tension, such as in intestinal obstruction