Study guide aa

An adult has a family history of dry aged related macular degeneration (AMD). Which statement made by the client demonstrates an understanding of relevant health education? A) "I eat a leafy green salad everyday with either lunch or dinner." B) "While smoking isn't good for me, at least it doesn't trigger AMD." C) "I wear sunglasses whenever I'm outdoors whether it's sunny or not." D) "I've switched from reading books to listening to a recording of it."

"I eat a leafy green salad everyday with either lunch or dinner."

A client diagnosed with intermittent claudication wonders why the nurse wants to know where the client is experiencing cramping when walking what would be the nurses best answer

"The area of cramping is close to the area of arterial occlusion."

How should the nurse document a normal pulse in the medical record?

+2/4

A client is being screened for acuity using the standard screen tool. How should the nurse document the client's ability to read at 60 feet what is normal read at 20 feet while wearing corrective lens? A) 60/20 B) 20/60 -40 C) 20/60 with glasses D) 60/20 with glasses

20/60 with glasses

Where is the erb point located?

3rd left rib space

A S3 gallop is considered normal in what client

A 4 year old diagnosed with autism An 18 year old woman in the third trimester A 30 year old Asian femal in good health

Identification of what nodal characteristic would be of concern to the assessing nurse? A) Absence of palpablecervical node B) a hard submandibular node C) A supraclavicular node that measures 0.5 cm D) A moveable posterior auricular node

A movable posterior auricular node

A student states that a client has palpable Russian vibration in the area of the pulmonic valve. What should the instructor explain the student is feeling

A thrill

Wheninspectingthe client'sface, the nurse notes severalpetechiae. What is the likely cause of this condition? (Select all that apply.) A) Trauma to the face B) Possible infection C) Low platelet count D)Facial rash E) Food allergy

A, B, C

Which assessment questions asked by the nurse demonstrate an understanding of the symptoms and signs of hypothyroidism in a 39 year old female? Select all that apply A ) "Have there been any changes in your menstrual period?" B) Have you experienced decrease in appetite?" C)"Have you lost weightrecently without trying?" D) Do you find yourself being cold frequently?" E) "Have you noticed your heart racing?"

A, B, D

What physical characteristics should the nurse describe when discussing the characteristics of fetal alcohol syndrome? Select all that apply. A) Microcephaly B) small eyes C) flattened upper lip D) prominent cheekbones E) microcephalic

A, B, E

When inspecting the hair, what would the nurse note? (Select all that apply.) A) Color B) condition of the hair shaft C) length of hair D) hair breakage of more than six hairs E) hair shafts are shiny

A, B, E

The nurse is performing visual acuity testing on an older adult who has fallen and fractured their femur. What finding would be considered normal for this client? (Select all that apply.) A) Arcus senilis B) Increased tear production C) Small cataract D) Decreased central vision E) Increased pupillary response

A, C, D

A nurse is preparing to perform a general assessment of an adult client who is new to the clinic. How would the nurse prepare to obtain objective data about the client's ears? (Select all that apply.) A) Have the client sit on the examination table B) Place the client in semi-Fowler position on the examination table C) Make sure the client is comfortable in a quiet room D) Perform the whisper, Weber, and Rinne tests before inspection E) Place the client's ears at the nurse's eye level

A, C, E

A nursing instructor is discussing areas of the health promotion related to the nose, sinuses, mouth, and throat. What topics would the instructor be most likely to cite? Select all that apply A) Tobacco use obstructive pulmonary disease(COPD) B)Risks for chronic C) Obstructive sleepapnea D) Alcohol use Oral health

A, C, E

A burn victim of a house fire is brought to the emergency department. The burn is classified as dermal. The nurse knows that which structures were injured by the burn? Select all that apply. A) Lymphatic vessels B) Connective tissue C) Vernix D) Blood vessels E) Sweat glands

A, D, E

Normal movement of the eye involves what cranial nerves? (Select all that apply.) A) CNII B) CNI C) CNIV D)CN V E)CN VI

A, b, c, e

The nursing instructor is discussing the eye with students. What would the instructor cite as part of the lacrimal apparatus? Select all that apply A) punctum B) lacrimal sac C) lacrimal gland D) limbus E) nasolacrimal duct

A, b, c, e

The nurse practitioner is assessing the eyes of a client with long-standing uncontrolled hypertension. What might the nurse practitioner visualize during an assessment with an ophthalmoscope? A) AV nicking B) Dilated veins C) Dilated arteries D) Brass wiring

AV nicking

Anolderadult client hospitalized with pancreatitis is having problems performing ADLs. The nurse's aide brushes the client's hair and tells the nurse that the client is losing an excessive amount of hair. The hair has the hair bulb intact. What might this indicate to the nurse? A) abnormal endocrine function B) Abnormal ovarian function C) Abnormal hepatic function D) Abnormalintegumentaryfunction

Abnormal endocrine function

A nurse is preparing an educational event for the parents of children with respiratory disorders.What would the nurse tellthe parents about allergies? A) If a parent has allergies, the child has a 25% chance of developing them as well. B) Children will outgrow their allergies. C) Allergy can affect any target organin the body. D) There are few effective treatments for allergies.

Allergy can affect any target organ in the body

When doing a shift assessment on a newly admitted client, the nurse notes lack of hair on therightlowerextremity;thickenednailsontherightlowerdigits;dry,flakyskinon the right lower extremity; and diminished tibial pulses bilaterallyand absent pedal pulses. What nursing diagnosis should be added to the plan of care?

Altered tissue perfusion arterial related to reduced blood flow

What symptom is associated with an inflammation of the nose and sinuses? A) geographic tongue B) leukoplakia C) halitosis D) anosmia

Anosmia

When reviewing ear assessment, a student nurse would learn that the cone of light should be visible where on the tympanic membrane? A) Anterior proximal quadrant B) Anterior-superior quadrant C) Anterior medial quadrant D) Anterior-inferior quadrant

Anterior inferior quadrant

An older adult has been admitted to the emergency department, reporting pain in his back and abdomen and shortness of breath. What might the nurse suspect is causing the symptoms

Aortic aneurysms

An older adult client presents at the clinic with a painful ulcer on the left big toe. The client states that the ulcer very painful and never seems to heal. An assessment of the ulcer shows a lesion with well-defined wound edges. When dependent,the base of the lesion is ruddy in appearance and exhibits signs of infection .What would the nurse suspect? A) Infected spider bite B) Infected tick bite C) Arterial ulcer D) Venous ulcer

Arterial ulcer

A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client? A)Work with medical team to evaluate possible surgery B) Discuss pharmacological interventions C) Educate the client regarding cervical spine pain D) Assess the client regarding characteristics of the pain

Assess the client regarding characteristics of the pain

The nursing instructoris discussing the function of sebaceous glands inthe body. What wouldthe teacher explain as thepurpose of sebum to the students? A ) Assistsin keeping the skinintact B) Assistsin friction protection C) Assistsin protection from infection D) Assist in keeping skin dry

Assist in friction protection

A client who works with a computer presents at the clinic with painful eyes, blurred vision, and headaches. After a generalized assessment with no abnormal findings, the nurse should use what term to document the possible cause of the symptomology? A) Presbyopia B) Asthenopia C) Myopia D) Hyperopia

Asthenopia

An older adult client has come to the clinic for a routine check up the nurse practitioner notes that the carotid artery pulse is diminished bilaterally. Any systolic brute is auscultated bilaterally. What would the nurse practitioner want to have this client assessed for by cardiologist

Atherosclerotic stenotic cartoid arteries

An older adult client presents at the office of the primary care physician with fatigue and heart palpitations. These reports support what cardiac related diagnosis.

Atrial fibrillation

What is the purpose of the tongue?(Select all thatapply.) A) Provides resonance to the voice B) Manipulates solids and liquids when eating and drinking C) Helps with the identification of sweet, sour, salty, and bitter tastes D) Assists in speech production E) Aids in the production of saliva

B, C, D

What might be indicated by multiple eccymoses in various areas of the body of an older adult? Select all that apply A) osteomyelitis B) repeated trauma C) physical abuse D) cancer E) a coagulopathy

B, C, E

When assessing the client's risk for hearing loss, it is important to ask about the history of exposure to noise. What related client teaching would be important? (Select all that apply.) A) Types of noise to avoid B) Types of protective equipment used C) Instructions for the use of protective ear equipment D) Length of time to limit protective equipment E) Effectiveness of protective equipment

B, C, E

A client presents atthe emergency room reporting "the worst headache I have ever had." What are the critical initial nursing interventions for this client? (Select all that apply.) A ) Schedule a magnetic resonance imaging (MRI) scan B) Physical examination for neurological changes ©)Schedule a computerized tomography(CT)scan gs Conduct a focused history interview D)Schedule an electroencephalography(EEG)

B, D

An older adult client is admitted to the hospital with pneumonia. While performing the admission assessment, the nurse finds a reddened area on the clients coccyx. What would the nurse include about this finding in notes? Select all that apply A) depth B) location C) other lesions on the body D) size E) texture

B, D, E

20. What risk factors should the nurse include in a discussion on the occurrenceof neck cancer? (Select all that apply.) A) Female gender B) Male gender C) Coffee drinker D) Tobacco use E) Age olderthan 50 years

B, D,E

A client presents to the emergency department after sustaining a significant blow to the area of the right ear. The client tells the nurse that something is leaking from the right ear. What should the nurse suspect? A) Nasal fracture B) Intracranial bleed C) Basilar skull fracture D) Fractured clavicle

Basilar skull fracture

What personal action should the nurse encourage when a client newly diagnosed with a cataract asks, "what can I do to help manage this problem"? A) "Keep all of your follow-up eye appointments." B)"Be sure to wear ultraviolet light blocking sunglasses." C) "It's important that you rest your eye to prevent eye strain." D)"Be sure to be tested regularly for diabetes and hypertension."

Be sure to wear ultraviolet light blocking sunglasses

A nurse is caring for a client diagnosed with chronic lymphedema in preparing a teaching plan for this client. What would be a central for the nurse to address when considering a psycho, social wellness

Body image Treatment Pathophysiology

While assessing an adult woman new to the clinic the nurse should perform subjective assessment of what risk factors

Bottle fed all three children

Which post is located at approximately the inner third of the antique fosa when the palm is held up word

Brachial

The nurse practitioner auscultates both lobes of a client's enlarged thyroid gland. Identification of what sound would tend to confirma diagnosis ofatoxic goiter? A) rush B) gurgle C) murmur D) bruit

Bruit

What characteristic of an infants head would be consistent with a diagnosis of hydrocephalus? A) Microcephaly B) Sunken fontanelles c) Bulging fontanelles D) Ossified of cranial sutures

Bulging fontanelles

The cup-disc ratio is assessed using the ophthalmoscope. What should the nurse practitioner know about the cup-disc ratio? (Select all that apply.) A) It should be 1:1. B) It occurs only in females. C) It is genetically determined. D) It is equal in both eyes. E) It is found only in older adults.

C, D

The autonomic nervous system innervates the salivary glands along with which cranial nerves? Select all that apply. A) x B) CN VIII C) CN VII D) CN IX E) CN XII

C, D, E

Which characteristics associated with the head and neck should be assessed with consideration to cultural-related difference? (Select all that apply.) A) skull B) nape of neck C) lips D) nose E) eyes

C, D, E

What components of sound does the cochlea interpret? (Select all that apply.) A) Tone B) Direction C) Amplitude D) Decibel E) Frequency

C, E

An older adult client presents at the clinic reporting otalgia in the right ear. Physical assessment reveals cerumen impacted in the client's ear. Removing this mechanical blockage may have what outcome for this client? (Select all that apply.) A) Increase the size of ear canal B) Provide less rigidity in outer ear C) Improve hearing D) Enhance socialization E) Prevent injury

C, d, e

An obese client is undergoing a per operative examination prior to having bariatric surgery. The client tells the nurse that he has a red sore in the groin area that appears to be spreading. The nurse assesses the lesion and finds a macular erythematous lesion with satellites pustules. What would the nurse suspect? A) roseola B) cándida C) pityriasis rosea D) herpes simplex

Candida

What type of respiratory pattern would the nurse consider normal in a client with severe heart failure? A) biot B) bradypnea C) kussmaul D) cheyne stokes

Cheyne stokes

Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would most likely suspect what? A) diabetes mellitus B) heart failure C) chronic obstructive pulmonary disease D) system lupus erythematous

Chronic obstructive pulmonary disease

A nurse practitioner is conducting the physical assessment of a school-aged child. The child's mother states that it seems like her childalways has a strep throat. What is the likely medical outcome for this child? A) Dentalcaries B) Pharyngitis C) Hypertrophic tonsils D) Chronic tonsillitis

Chronic tonsillitis

A client presents at the urgent care clinic with severe pain and pressure around the eyes. The nurse practitioner suspects asinus infection. What is considered thegold standard diagnostic techniquein evaluating sinus disease? A) Transillumination B) Computed tomography (CT) scanning C ) Percussion of the sinus cavities D) Magnetic resonance imaging

Computed tomography (CT) scanning

What test would the nurse perform to test for strabismus? A) Corneal light reflex B) Cover C)Allen D) Static

Corneal light reflex

When assessing an adult client experiencing diarrhea, the nurse notes a round "moon" face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What is the possible cause of these signs? A) myxedema B) Cushing syndrome C) scleroderma D) bell palsy

Cushing syndrome

What statement made by a clients adult child suggests a need for further neurological assessment related to Parkinson's disease? A) "Dad seems SO angry; that's not like him." B)"Mom has developed this hump on her back." C) "Dad seems to shuffleinstead of walkingnormally." D) "Mom'smother was diagnosed with Parkinson disease.'

Dad seems to shuffle instead of walking normally

The nurseis conducting a comprehensive health assessment of an Hispanic child. Which of the following abnormal findings would be most likely in this client? A) dental caries B) sleep disordered breathing C) cleft palate D) history of nosebleeds

Dental caries

The movie admitted client has given their health history and undergone a physical assessment. Laboratory data and diagnostic study results are on the chart. What is the nurses next stop and caring for the client

Developing a plan of care

The nurse is caring for an older adult client with a nasogastric feeding tube ordered by the physician. The nurse notes that the client is not a mouth breather and having no difficulty breathing. While inserting the feeding tube,the nurse encounters difficulty getting the tube through the nares. What should the nurse suspect? A) deviated septum B) obstructed turbinate C) swollen nasal passages D) hypertophied adenoids

Deviated septum

What assessment questionis relevant to the assessment for possible sleep apnea? A) do you feel rested in the morning B) do you experience facial pain C) do you have a deviated nasal septum D) do you have nosebleeds on a regular basis

Do you feel rested in the morning

A client is experiencing difficulty driving at night? What assessment question demonstrates the nurse's understanding of the factors that contribute to this condition? A)"Does your diet regularly include foods that contain vitamin A?" B)"Are you currently being prescribed medication for cataracts?" C)"Do you wear corrective lens for nearsightedness?" D) "Are visual floaters a problem for you?"

Does your diet regularly include foods that contain vitamin A

A client with visual acuity problem has an increased risk of injury. What intervention will best help maintain his safety while performing personal hygiene tasks? A) encourage him to use a magnifying mirror when shaving B) stress the need to have the bathroom well lighted and clutter free C) suggest a family member present during showering or bathing D) emphasize the importance of wearing corrective lens or contacts regularly

Encourage him to use a magnifying mirror when shaving

When percussing the scapula of a client which sound characteristic would the nurse expect to hear? A) resonance B) dullness C) flatness D) hyperresonance

Flatness

A nurse asks a client to say ninety-nine while palpating the posterior thorax. The nurse is demonstrating effective technique in assessing for that respiratory characteristic? A) fremitus B) egophony C) chest expansion D) bronchophony

Fremitus

What would the nurse expect to hear when auscultating the lungs of a client with pleuritis? a) Friction rub b) Stridor c) Sibilant wheeze d) Decreased breath sounds

Friction rub

A client comes to the emergency department with excruciating pain in the left ear. On assessment, the nurse notes that the client experiences extreme pain during palpation of the tragus. Which factor would the nurse suspect has triggered the pain? A) Otitis media B) Furuncle C) Foreign body D) Impacted cerumen

Furnucle

A client shares that a first degree relative has an eye problem but aren't sure what the diagnosis is. What major eye problem will the nurse suggest screening the client for? A) retinoblastoma B) strabismus C) retinitis pigmentos a D) glaucoma

Glaucoma

A client is given a nursing diagnosis of activity intolerance related to pain in collocation with ambulation. What would be an appropriate intervention for this client

Gradually increase activity

What should be the nurses initial intervention when adventitious sounds are heard during the auscultation clients lungs? A) refer the client for further medical evaluation B) auscultate for egophony C) perform bronchophony D) have the client cough and listen again

Have the client cough and listen again

An older adult, client reports I need to get up during the night to urinete what assessment would provide the most relevant information concerning the management of the patients nocturia

Have you made any lifestyle changes because of this?

During a health history, a client tells the nurse that "I can't breathe well at night when I'm lying down". The client also reports an interrupted sleep pattern caused by waking up with trouble breathing and a nagging cough. Considering the client's reports, what medical condition should the nurse's assessment be focused on? A) pneumonia related dyspnea B) tuberculosis related cough C) bronchitis related D) heart failure induced orthopnea

Heart failure induced orthopnea

The eustachian tube is a passage between the middle ear and the nasopharynx. What is the function of the eustachian tube? A) Helps to regulate pressure in the middle ear B) Protects the middle ear C) Allows for drainage of fluid from the middle ear D) Maintains fluid in the middle ear

Helps to regulate pressure in the middle ear

A nurse is preparing a teaching plan for a client newly diagnosed with peripheral arterial disease. To address the most modifiable risk factors what risk factors should the nurse include

High fat diet Smoking Activity level

When assessing the breast and lymphatics of the axils where would the nurse locate the central axilar y nodes

High in the axillae at the top of the ribs

Student nurses are spending time in the laboratory learning the proper use of an otoscope. What technique would these students learn for best visualization of the tympanic membrane in an adolescent? A) Hold the ear at the tragus and lift up and back B) Hold the ear at the pinna and pull down and back C) Hold the ear at the auricle and pull down and back D) Hold the ear at the helix and lift up and back

Hold the ear at the helix and lift up and back

When providing client teaching about the ears, what should the nurse be sure to include? A) How the client cleans the ears B) Basic anatomy and physiology of the ears C) How to use cotton-tipped applicators safely D) Potential infection from self-cleaning of ears

How the client cleans the ears

A client has a history of emphysema. The nurse percussing the client's chest expects to hear what characteristic sound? A) hyperresonanace B) dullness C) resonance D) tympany

Hyperresonance

Which statement by the client best demonstrates affective health promotion, teaching by the nurse to reduce the clients risk of developing cardiovascular disease. Select all that apply

I've joined a smoking cessation support group that means regularly. My blood pressure is managed a while by the medication I was prescribed my partner, and I have been fixing recipes from a low cholesterol cookbook. .

The nursing instructor is discussing the collection of subjective information when assessing a client with arterial, Venus, and lymphatic disorders. What would the nurse instructor tell the students to include in the subjective portion of the health assessment?

Identification of cardiovascular risk factors

A nurse is caring for a client admitted 2 days ago following a cerebral vascular accident. The nurse notes that the client is frequently coughing, has food falling from the mouth while eating, and frequently chokes. What would be the most pertinent nursing diagnosis for this client? A) Impaired dentition B) Alterationinmobility C) Altered cerebral perfusion D) Impaired swallowing

Impaired swallowing

A school-aged child is brought to the pediatric clinic by her mother, who tells the nurse practitioner that the child has a sore on her leg that"just keeps getting bigger." On examination, the nurse practitioner notes an area of vesicles and bulla, someof which have ruptured and are oozing serousfluid. A honey-colored crust covers the area. What would the nurse practitioner tell the mother the lesion is? A) Varicella B) Scabies C) Impetigo D) Rubella

Impetigo

A 67 year old client reports experiencing a tingling sensation in the upper arms. What expected age-related change will the nurse assessor initially? A ) Collapse of cervical vertebra B) ineffective lymphatic function ©) Muscle hypotrophyin theshoulders D) Arthriticchangesinthe cervical spine

Ineffective lymphatic function

When assessing the breast and axillae the nurse remembers that most lymph drains where?

Ipsilateral axilar y nodes

During a neck assessment, where would the nurse focus palpation of the thyroid isthmus? A) just above the thyroid cartilage B) between the thyroid and the criccoid cartilages C) just below the criccoid cartilage D) in front of the sternlcleidomastoid muscle

Just below the cricoid cartilage

A nurse is providing client teaching to the parents of a preschooler who experiences chronic epistaxis. What would the nurse identify as the area where most nosebleeds originate? A) Rosenmuller fossa B) Wharton ducts C) Kiesselbach plexus D) stensen duct

Kiesselbach plexus

What test would the nurse assess the boundaries of the clients peripheral vision? A) static confrontation B) Allen C) kinetic confrontation D) cover

Kinetic confrontation

An infant is born with microcephaly. The infant also has a depressed nasal bridge, low- set ears, and a protruding tongue. What nursing diagnosis would be appropriate for this client and the parents? A ) Inability to suck related to protruding tongue B) Knowledge deficit related to trisomy21 ©) Impairedhearingrelated to low-set ears D ) Altered breathing related to depressed nasal bridge

Knowledge deficit related to trisomy 21

Where would the nurse expect to find the point of maximum impulse when assessing an older client with a history of cardio Magaly with a hyper trophy left ventricle

Lateral and inferior to the fourth and fifth intercostal space, and the mid clavicular line

An objective assessment of a client's ears reveals small, painless nodules on the left helix. How would the nurse note this finding in the client's medical record? A) Left external ear abnormal; Darwin tubercle noted at the midpoint of helix B) Left external ear within normal limits C) Small nodules on the left helix indicating inflammation of the external ear D) Small, painless nodules on the left helix; further evaluation for carcinoma indicated

Left external ear within normal limits

Studentsare practicing documentationof peripheral vascularandlymphatic assessment before going into the clinical setting. A student documents the following; lower left leg cool to touch with dorsalispedis, back knee pulse,and femoralpulse palpable. How could the following charting be changed to communicate information in appropriate medicalterminology?

Left lower extremity cool to touch with femoral posterior popliteal and dorsales pedis pulses palpable

What is the visual acuity required for a diagnosis of legal blindness? A) Inability to see light B) Loss of vision in at least one eye C) Less than 20/150 in at least one eye D) Less than 20/200 bilaterally

Less than 20/200 bilaterally

When conducting a generalized assessment of a new client, what would the nurse focus upon when inspecting the neck? A) Signs of a strain B ) Indications of a vertebralinjury C)Lymph node enlargement D) Limitations in movement

Limitations in movement

Which nursing action would be most important for the nurse to implement when auscultating the thorax for adventitous breath sounds? A) listening at each site for at least one complete respiratory cycle B) having the client breathe deeply through the mouth C) being alert to the clients comfort and offer rest periods D) auscultating the base at the level of the sixth rib

Listening at each site for at least one complete respiratory cycle

Acini cells location

Lobules of the breasts

After teaching a group of students about age-related changes in the lungs, the instructor determines that the teaching was successful when the students identify which of the following as an age-related change? A) Increased resiliency B) Loss of elasticity C) Increased functional capillaries D) Loss of subcutaneous fat

Loss of elasticity

The nurse is caring for a client who has an elevated cholesterol level. To reduce the mean total blood cholesterol and low density lipoprotein cholesterol levels. What diet should the nurse discuss with the client.

Low, fat, low cholesterol meals

A client brought to the emergency department after a diving accident, tells the nurse ,"I think I hit a rock and now cannot feel my arms or my legs.' A rapid physical assessment shows no other apparent injuries.what initial nursing intervention is essential to the safety of this client care? A) Send for CT scanimmediately B) Draw a basic metabolic panel to check for infection C) Maintain immobilize of the spine until it is cleared of injury D) Log roll the client to remove backboardreducing pressureon the spine

Maintain immobilize of the spine until it is cleared of injury

What are the main functions of the lymphatic system?

Maintaining protein balance Fighting infection Maintaining fluid balance

What statement made by a client is consistent with symptoms associated with ischemic attack of the brain? A) I have this terrible neck pain and a fever." B) "This ringingin my ears just won't stop.' C) "My vision suddenly became blurred. D) I started feeling very anxious.'

My vision suddenly became blurred

When assessing the tympanic membrane, where would the nurse expect to visualize the malleus? A) In the anterior aspect B) In the area of the cone of light C) Near the center D) To the left of the cone of light

Near the center

The nurse assesses chest expansion in a young adult and finds it to be 8 CM. What phrasing should the nurse use to document this assessment finding? A) limited expansion B) normal expansion C) hypoexpansion D) hyperexpansion

Normal expansion

When assessing the lymph system of an adult client, the nurse notes that the epitrochlear node's are nonpalpable. What does this indicate?

Normal finding

A client presents to the clinic reporting a sudden visual loss in the left eye. What is the nurse's priority action? A) Assess cranial nerve function B) Notify the healthcare provider immediately C) Ask the client whether protective eyewear was worn D) Perform the Allen test and report the findings urgently

Notify the healthcare provider immediately

A female teenager comes to the clinic reporting excessive hair growth. She tells the nurse that she is teased a lot because of hair growth on her shoulders and back the client also reports that hair is growing o n h e r upper inner thighs. What would the nurse suspect? A) Endocrine disorder B) Ovarian dysfunction C) Hepatic dysfunction D) Chronic nephrosis

Ovarian dysfunction

When assessing for acute arterial occlusion, what should the nurse focus on?

Pain Paralysis Pallor Paresthesia

The nurse demonstrates appropriate technique when using what part of the hand to asses for a fremitus in a client? A) dorsal hand surface B) pads of fingers C) palmar base D) fist

Palmar base

An emergency department nurse is assessing an adult client who arrives at the ED reporting chest pain. The client states that the pain gets worse with movement. What further assessment should the nurse make?

Palpation of the costochondral junction

What is the open space between the eyelids called? A) palpebral fissure B) limbus C) lacrimal apparatus D) eyeball

Palpebral fissure

A client has been admitted to the cardiac unit and test results are available. The nurse is writing a plan of care for this client on. What would the nurse base interventions?

Patterns of subjective and objective data

9. A client tells the nurse, "It is like one eye is moving faster than the other." What equipment will the nurse need to further assess the client? A) Pen B) Penlight C) Split light D) Cotton-tipped applicator

Pen

While performing an admission assessment, the nurse, Oscar tates, a high-pitched scratching and grading sound at the left lower sternal border. The nurse should use what term to document the sound.

Pericardial friction rub

When assessing the extremities of a client reporting like cramping the nurse notes, muscle atrophy what does the nurse suspect is the cause?

Peripheral arterial disease

A pediatric nurse is doing the initial shift assessments on assigned clients. One of the clients is an older adult with pneumonia. How would the nurse asses the clients skin turgor? A) Pinch fold of skin onthe client's abdomen B) Pinch a fold of skin on the client's cheek ©) Pinch a fold ofskin on the clients inner thigh D) Pinch a fold of skin on the client's forearm

Pinch a fold of skin on the clients forearm

What color of sputum would support the diagnosis of heart failure? A) white B) yellow C) pink D) rust

Pink

Best position for venous pulses

Place head of the bed 30° to 45° Have the client turn the head away from the side being examined

The nurse practitioner is assessing the tympanic membrane of a client. Once the tympanic membrane has been visualized, the nurse practitioner uses the bulb insufflator to observe the movement of the tympanic membrane. When forcing air into the ear canal, what would the nurse practitioner expect to note? A) Negative pressure pulling the tympanic membrane B) Positive pressure pushing down the tympanic membrane C) Negative pressure pushing down the tympanic membrane D) Positive pressure pulling the tympanic membrane

Positive pressure pushing down the tympanic membrane

The nurse is performing a generalized assessment of an older adult. The nurse notes the clients skin presents with rough, scaly, discrete maculars especially on the back. The client tells the nurse that,"a spent a lot of time in the sun when I was younger." How would the nurse note these findings in the client's medical record? A) Possible basal cell lesions B) Possible lipoma C) Possible solar keratosis D) Possible lentigo

Possible solar keratosis

What course is located in the groove between the medial malleolus, and the Achilles tendon

Posterior tibial

Parents bring a child to the clinic and report a"rash" on her knee. On assessment, the nurse practitioner notes the area to be a reddish pink lesion covered with silvery scales .What would the nurse practitioner chart? A)Contact dermatitis B) Seborrhea C) Eczema D) Psoriasis

Psoriasis

A nurse is conducting an admission assessment of an older adult client with an intractable oral infection. The client tells the nurse that he cannot smell tbings as well as he once could what should the nurse do initially? A) Recognize that the sense of smell decreases with age B) Conduct olfactiontests ©) Notify thephysicianimmediately D) Verify the client's abilityto taste all flavors

Recognize that the sense of smell decreases with age

A nurse practitioner is working in a clinic with a client who reports that drainage from her ear is no better despite finishing three courses of prescribed antibiotics. After reviewing the client's records, what would be the nurse's most appropriate action? A) Prescribe a different antibiotic B) Refer the client to an otolaryngologist C) Reassess the client's ear D) Perform the Rinne test.

Refer the client to an otolaryngologist

The ICU nurse is caringfor a trauma victim whose statusis critical. On assessment, the nurse notes uremic frost along the clients hairline. What would this indicate to the nurse? A) Renal failure B) Cardiovascular failure c) Hepaticfailure D) Respiratory failure

Renal failure

The nurse performs an admission assessment on a client admitted to the ED with a myocardial infarction the nurse auscultated swishing sound over the right carotid artery what phrase should the nurse use to correctly? Document is finding.

Right carotid bruit auscultated

The nurse is assessing the various lobes of the lungs. The nurse must asses which lobe anteriorly? A) left upper lobe B) left lower lobe C) right upper lobe D) right middle lobe

Right middle lobe

A trauma client reports pain in the left lower extremity. The nurse notes that the extremity has pallor. Pedal pulses are diminished, and paresthesia Is present.What nursing diagnosis might the nurse use?

Risk for peripheral neurovascular dysfunction

A nurse practitioner is assessing the ears of a toddler who has had tympanostomy tubes in place for 6 months. What nursing diagnosis addresses a primary concern for this client? A) Pain B) Anxiety C) Risk of infection D) Altered auditory sensory perception

Risk of infection

An oncology nurse is caring for a client newly diagnosed with an occult nasopharyngeal malignancy. Where would the nurse expect this malignancy to be? A) osteomeatal complex B) rosemmüler fossa C) kiesselbach plexus D) Wharton ducts

Rosenmmüller fossa

When auscultating the heart, the nurse is most likely to hear a diastolic murmur after which heart sound

S2

Function of Montgomery glands

Secrete protective lubrican

True statements about varicose veins

Seen more in people older than 50 More common on women May be familial

Research has found that there is a dramatic increase in the indemne of peripheral arterial disease during what time period in a persons life?

Seventh and eighth decades

A client from a severe motor vehicle accident arrives in the emergency department. The nurse observes irregular respirations of varying depth and rate followed by periods of apnea. Which of the following would the nurse suspect? A) diabetic ketoacidosis B) renal failure C) narcotic overdose D) severe brain damage

Severe brain damage

The nurse in a dermatology clinic is assessing an adult who has presented at the clinic with lesion on the left inner thigh. The client tells the nurse that the lesion was discovered 1 month ago, and no changes in the color or size of the lesion have been noted. What would be the most appropriate teaching subjectfor this client? A) Skinself-examination B) Signs and symptoms of melanoma c) Recognizing different types of lesions D) Protection from sun damage

Signs and symptoms of melanoma

When assessing the apices of the lungs, the nurse would locate them at which position? A) at the level of the diaphragm B) near the level of the eight rib C) slightly above the clavicle D) at about the tenth rib

Slightly above the clavicle

When assessing whispered pectoriloquy, the nurse would instruct a client to do which of the following? A) Softly repeat the words "one-two-three." B) Say "ninety-nine." C) Cough each time the stethoscope is moved. D) Say the letter "e."

Softly repeat the words one, two, three

When preparing to examine a client's thoracic cage, the nurse would locate which landmark as most helpful in determining where to start? A) Sternum B) Suprasternal notch C) Sternal angle D) Sternal border

Sternal angle

The nurse is conducting a skin assessment on a client who suffered a burn injury. The clients wound exhibits rapid capillary refill is moist and red and is painful. What depth of burn should the nurse document? A) superficial B) superficial dermal C) dermal D) full thickness

Superficial

The nursing instructor is discussing ear problems. What would the instructor indicate is an abnormal finding? A) Tenderness of the mastoid process B) Atrophied lymph nodes C) Tenderness of the apex D) Sclerotic tympanic membrane

Tenderness of the mastoid process

A nurse is admitting a client to the hospital. When reviewing the client's medical record, the nurse notes that this client had abnormal findings during the Weber test. What would the nurse know this means? A) The client has unilateral hearing loss. B) The client has loss of high-frequency sounds. C) The client has loss of low-frequency sounds. D) The client has bilateral hearing loss.

The client has unilateral hearing loss

A client has been diagnosed with systemic lupus erythematosus. Whatis the m ost important point the nurse should make in client teaching about this disorder? A) The client may develop a butterfly rash on the face. B) The condition may interfere with the menstrual cycle. C) The client may experience photosensitivity that worsens the condition. D) the client should avoid antacids.

The client may experience photosensitivity that worsens the condition

A nurse practitioner is assessing the tympanic membrane of a client who has come to the clinic. What would the nurse practitioner expect to visualize if the client has a normal otoscopic evaluation? A) The arm of the stapes B) The short process of the malleus C) The head of the incus D) The long process of the stapes

The short process of the malleus

A student nurse is taking nursing test and is asked a question about the columella. What is the best description of the term columella? A ) The structurethat divides the nares B) The lining of the nares C) The lining of lymphatic ducts D) The mound of tissue just posterior to the eustachian tube

The structure that divides the nares

Which characteristic associated with respiratory effort should be considered when planning care for a client diagnosed with a brainstem injury? A) The client's oxygen levels in the blood will be increased. B)There is loss of involuntary respiratory control. C) The client will respond negatively to increased stimuli. D) There is an increased level of carbon dioxide in the blood.

There is a loss of involuntary respiratory control

What notation demonstrates the nurses understanding of effective documenting when the assessment findings identify thick, purulent drainage in both eyes of a client? A) Thick, purulent drainage is noted at inner corner of OD. B) Thick, purulent drainage is noted at inner corner of OS. C) Thick, purulent drainage is noted at inner corner of OU. D) Thick, purulent drainage is noted at inner corner of both eyes.

Thick purulent drainage is noted at inner corner of both eyes

A first-time mother calls the clinic to talk to the nurse. The mother is very upset,saying that her newborns fingernails dip in the middle, appearing spoon-like. What would be the nurse's best response ? A) "Take thenewborn to the emergency room to be evaluated." B)"Bring your newborn to the clinic immediately." C) "This may be normalin newborns." D) "This is a sign of a nutritional deficiency. What are you feeding your newborn?"

This may be normal in newborns

When considering the head and neck, what screening should be included as a component of a pregnant woman's regular examinations? A) b12 B) folic acid C) thyroid D) amniocentesis

Thyroid

While performing an otoscopic examination of a client's ear, the nurse finds white patches on the tympanic membrane. How would the nurse note this finding in the chart? A) Tympanic membrane visualized with areas of sclerosis noted B) Tympanic membrane abnormal; white, patchy areas noted C) Tympanic membrane scarred, indicating loss of hearing D) Tympanic membrane within normal limits

Tympanic membrane visualized with areas of sclerosis noted

Which of the following themes drains into the superior vena cava

Upper torso Head Upper extremities

Which food is most appropriate for the nurse to recommend for a client who suffers frequent nose bleeds due to hereditary hemorrhagic telangiectasia? A) Vegetable omelet B) garlic chicken C) Chocolate pudding D) salad with ginger dressing

Vegetable omelet

A group of students is reviewing the vertical reference lines of the thorax. They demonstrate understanding when they identify which line as a reference line for the posterior thorax? A) midaxillary line B) vertebral line C) right midcavicular lime D) sternal line

Vertebral line

A client reports, "I feel like the whole room is spinning around me, and it makes me nauseous sometimes." What term should the nurse use to document the client's svmptom? A) Dizziness B) Tinnitus C) Vertigo D) Otalgia

Vertigo

What is the largest chamber of the eye? A) anterior B) posterior C) corneal D) vitreous

Vitreous

A mother bringsher 6-month-old child to the clinic for a follow-up assessment after antibiotic treatment for recurring otitis media. What would the nurse expect to find while assessing the client's mouth to best confirm a complication of the treatment? A) Swollenuvula B)Red and white patches in the throat C) White patches firmly attachedto the buccalmucosa D) White coated tongue

White coated tongues

The client is known to have a bundle branch block that delays activation of the right ventricle as a result of a recent myocardial infarction. What would the nurse expect to hear when auscultating the clients Heartsounds?

Wide splitting

A newborn hasahemangioma on theface. What wouldbeimportantforthe nurse to include in client teaching? A) will need surgery to remove B) will become smaller over C) is made of epithelial cells that form caverns D) Will usually resolveby the age of 9 years

Will usually resolve by the age of 9 years

A woman and her teenager have come to the clinic. The teenager has acne lesions that are not well controlled. The mother asks the nurse what causes acne. What would be the nurses best response A) Acné is caused by the apocrine glands B) Acne is caused by decreased activity of the sebaceous glands C) acne is caused by the impedance of sebum secretion onto the skins surface D) acne is caused by enlarged apocrine glands

acne is caused by the impedance of sebum secretion onto the skins surface

which anterior neck structure is found in the depression between the trachea and the sternomastoid muscle

cartoid artery

When doing a risk assessment of the nose,sinuses, mouth, and throat what finding might indicate an allergy? A) low grade fever B) history of macular rash C) frequent childhood infection D) family history of diabetes

frequent childhood infection

What structure is found midline in the tracheal area just beneath the mandible? A) cricoid cartilage B) hyoid bone C) thyroid cartilage D) Adam apple

hyoid bone

The nurse is caring for an adult client who presents at the clinic with reports of general malaise and fatigue. Physical assessment reveals that the client's lips are dry and cracked. What might this indicate? A) heat stroke B) viral infection C) inadequate hydration D) allergy

inadequate hydration

across the life span a nurse knows what characterstic of the female heart is consistently true

it is smaller than the male heart

The nursing instructor should include what information regarding the effects of mydriatic drops on glaucoma? A) mydriatic drops do not specifically affect glaucoma B)mydriatic drops may precipitate acute angle closure glaucoma C) mydriatic drops contract the pupils in patients with glaucoma D) mydriatic drops may cause crisis in clients with open angle glaucoma

mydriatic drops may precipitate acute angle closure glaucoma

the sternal angle at the right 2nd rib space is also known as

the aortic area

The nurse is caring for a client with a nursing diagnosis of impaired skin integrity related to a stage lll pressure ulcer. What would be the most important outcome for this client? A) the client exhibits no signs or symptoms of infection B) the client changes position every 2 hours C) the client keeps the area clean and dry D) the client knows prevention measures for pressure ulcers

the client exhibits no signs or symptoms of infection