275 final

How does the nurse differentiate a pleural friction rub from a pericardial friction rub?1.Have the client hold his or her breath; if the rub persists, it is pericardial 2.Turn the client on the right side; if the rub persists, it is pericardial 3.Auscultate the upper back; if a rub is present, it is pleural 4.Auscultate the base of the heart; if a rub is present, it is pericardial

1

The nurse percusses the lungs and determines that there is an area of hyperresonance. This finding is consistent with which of the following conditions?1. Pneumonia 2. Atelectasis 3. Pneumothorax 4. Pleural effusion

3

The nurse is percussing the anterior chest of an elderly client. Which of the following would the nurse expect to find in this client?1. Flatness 2. Dullness 3. Tympany 4. Hyperresonance

4

The nurse is assessing the function of the client's cranial nerves. The nurse finds that the client is unable to demonstrate the ability to chew. The nurse suspects that which of the following cranial nerves is not functioning properly?

5

A patient is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the patient?

Airway

A 55 year old client is being evaluated for a suspected hearing impairment. Which of the nurse's health interview questions is most likely to yield relevant data?

Are you having difficulty hearing high frequency sounds?

A nurse has identified a goal of developing his critical thinking skills. In order to facilitate this goal, what action should the nurse prioritize? A) Applying quick decision-making B) Seeking new experiences C) Maintaining an open mind D) Maintaining a stable and static knowledge base

C) Maintaining an open mind

A respiratory pattern that gradually becomes faster and deeper than normal, then slower, alternating with periods of apnea is known as which respiratory pattern?

Cheyne-Stokes

Upon inspection of a client's chest, a nurse observes an increase in the anterior posterior diameter. The nurse recognizes this as a finding in which disease process?

Chronic obstructive pulmonary disease

During the Romberg test, a client is unable to stand with the feet together and demonstrates a wide-based, staggering, unsteady gait. The nurse would interpret this finding as suggestive of which of the following? A) Spastic hemiparesis B) Parkinsonian gait C) Scissors gait D) Cerebellar ataxia

D

For which client should a nurse perform a focused assessment?

Four-day history of sore throat and fever with enlarged lymph nodes

When testing the range of motion of the cervical spine, the nurse notes impaired range of motion and neck pain. A review of the client's history reveals fever, chills, and headache. Which of the following would the nurse suspect?

Meningitis

The nurse is reviewing a client's health history and physical examination. Which of the following would the nurse identify as subjective data? Select all that apply.

My father died of a heart attack" "I feel so tired sometimes" Client complains of a headache

A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation?

Observe for the use of accessory muscles

A nurse cares for a client with lung cancer who presents with rust-colored sputum and a fever. The nurse performs frequent auscultation of the lung sounds to determine any changes from the baseline. What type of assessment is the nurse performing?

Ongoing

An adult client is brought to the ED by ambulance and is anxious and very short of breath. While the nurse is completing the emergency assessment, the client stops breathing. What is the first action of the nurse?

Open the client's airway

What is the most important physical sign of acute pericarditis?

Pericardial friction rub

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?

Psoriasis

A young adult client has just had X-rays and computed tomography scanning of the head and neck following a mountain bicycling accident. All results are negative. What should the nurse assess for next?

Range of motion of the neck

When percussing the posterior lung fields, which of the following findings is expected?

Resonance over all lung fields

The nurse is caring for a client who has been experiencing dysphagia secondary to a stroke. What risk nursing diagnosis should the nurse associate with the health problem?

Risk for aspiration related to decreased swallowing ability

When palpating the female breast for masses, the nurse distinguishes which of the following characteristics as a potentially cancerous mass?

Single, firm, fixed nodule

A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what

Stridor

A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve?

XII

You utilize the braden scale during the admission assessment of an older client. What assessment parameter will the nurse evaluate when using the scale?

ability to change position

tacchycardia

above 100

The nurse is assessing CN V (trigeminal nerve) in a newly admitted client. What instruction should the nurse provide to the client during this phase of assessment?

clench teeth together tightly

performing romberg- what finding would show positive romberg

client moves feet apart to prevent moving

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed

comprehensive.

A nurse is going to complete a comprehensive assessment on a client. When collecting objective data, which of the following would the nurse do first? A) Assess the client's vital signs B) Take body measurements C) Assess mental status D) Observe the overall appearance

d

When assessing cranial nerves IX and X, which of the following would the nurse consider as a normal finding? A) Stationary soft palate on phonation B) Deviation of uvula when client says "ah" C) Asymmetrical soft palate D) Uvula and soft palate rising bilaterally

d

After having a client perform a Romberg test, which of the following would indicate to the nurse that the test is negative?

maintains position

A nurse is preparing to form a rhinne's test on a client the nurse should place the tuning fork at which location first?

mastoid process

When assessing the client's ear, which finding should the nurse identify as indicating a need for further assessment and possible treatment?

tendered tragus

The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. Which of the following would be most appropriate for the nurse to include?

thoroughly chew small amounts of food

A client has presented with signs and symptoms that are suggested of Bell's Palsy. What assessment finding is most consistent with this diagnosis?

unable to wrinkle forehead

graphostegia

writing numbers on hands

The nurse is assessing cranial nerve XI (spinal accessory). Which of the following statements would the nurse say to the client?1. "Shrug your shoulders and turn your head against my hand."2. "Stick out your tongue and move it from side to side."3. "Taste these foods and decide which is sweet and which is sour."4. "Smell these items and identify what they are."

1

The nurse is assessing the client's pupillary responses. The client is found to have no consensual response. The finding indicates which of the following to the nurse?1. Cranial nerve III may not be functioning appropriately. 2. This is a normal finding.3. This is evidence of increased intracranial pressure. 4. This is evidence of optic nerve damage.

1

The nurse is performing a neurological assessment and needs to test cranial nerves. The nurse asks the client to close both eyes and report when a touch with a wisp of cotton is felt. The nurse is assessing the function of which of the following cranial nerves? 1. Trigeminal nerve (cranial nerve V) 2. Abducens nerve (cranial nerve VI) 3. Facial nerve (cranial nerve VII) 4. Optic nerve (cranial nerve II)

1

The nurse is performing an assessment of the client's head and neck. The client requests information about the assessment of her lymph nodes. Which of the following is the best response? 1. "Sometimes, enlarged lymph nodes indicate an infection." 2. "All of your lymph nodes should be easily palpable." 3. "The lymph system makes antibiotics to treat infection." 4. "When one lymph node is identified as being enlarged, this is always an abnormal finding."

1

While percussing a client's lung area the nurse notes a flat tone. This tone would indicate:1. The nurse is percussing over a bone. 2. A normal finding.3. The lungs are solidified. 4. Air is trapped in the lungs.

1

The student nurse is reviewing the cranial nerves. The student recognizes some of the nerves are exclusively sensory nerves. Which of the following cranial nerves belong to this group? Select all that apply. 1. Olfactory nerve (cranial nerve I) 2. Optic nerve (cranial nerve II) 3. Trochlear nerve (cranial nerve IV) 4. Trigeminal nerve (cranial nerve V 5. Facial nerve (cranial nerve VII)

1,2

The nurse is reviewing questions to include in a focused assessment on a client who has presented to the clinic with complaints of back pain. Which of the following questions should be included in the interview? Select all that apply. 1. "How long have you been experiencing this pain?" 2. "What activities seem to increase your pain?" 3. "Do any members of your family have neurological problems?" 4. "What things do you do to relieve your pain?" 5. "Are you able to perform your employment responsibilities since the pain began?"

1,2,3,4,5

The nurse is assessing a client that experienced a head injury and assigns a Glascow Coma Scale rating of 3. The nurse would correctly note which of the following for this client? Standard Text: Select all that apply. 1. No response with eyes with commands 2. No verbal response 3. Pupil response sluggish 4. No motor movement 5. Pupils fixed and dilated

1,2,4

The nurse is preparing to auscultate a client's lungs. Which of the following breath sounds would be considered abnormal?Select all that apply.1. Crackles 2. Vesicular 3. Bronchovesicular 4. Wheezes 5. Bronchial

1,4

A nurse is assessing the respiratory rate of an elderly client. Which of the following findings in breaths per minute would indicate a normal respiratory rate in this client?

18 A respiratory rate of 18 breaths/min would be normal for this client. In older adults, the normal respiratory rate would range between 15 and 22 breaths/min. Respiratory rates of fewer than 15 breaths/min or more than 22 breaths/min would be an abnormal respiratory rate for this client.

A client with a fever is also complaining of difficulty hearing. The nurse realizes this client might be experiencing which of the following disorders?1. Sinusitis 2. Otitis media 3. Tonsillitis 4. Otitis externa

2

During chest auscultation, the nurse hears a quiet murmur immediately upon placing the stethoscope on the client's chest. The nurse interprets this as which grade?

2

In auscultating a client's heart sounds, a nurse hears a swooshing sound over the pre cordium. The nurse recognizes this sound as which of the following? 1. Ventricular gallop 2. Murmur 3. S2 4. S1

2

The nurse is palpating an adult client's neck and does not note any palpable lymph nodes. The nurse understands that this is:1. probably due to an infection. 2. a normal finding in adults.3. reason for referral to an ear, nose, and throat specialist. 4. cause to inspect for further malformations.

2

The nurse is performing the Romberg test and asks the client to stand with the feet together and eyes closed. The nurse notes the findings are normal. Which of the following client responses occurred in this situation? The client: 1. Swayed from side to side. 2. Had minimal swaying. 3. Felt moderately dizzy. 4. Had complete loss of balance.

2

The client is experiencing the effects of a recent cerebrovascular accident. The client is unable to hear out of the left ear. Which of the following cranial nerves was most likely affected?1. Cranial nerve I 2. Cranial nerve XII 3. Cranial nerve VIII 4. Cranial nerve VII

3

The nurse assesses a client and finds that a grating sound is present when a joint is bent and straightened. The nurse would correctly document this finding as which of the following?1. Subluxation 2. Grinding 3. Crepitation 4. Joint dislocation

3

The nurse is performing a neurological assessment on a client experiencing anosmia. The nurse would suspect cranial nerve involvement in which of the following? 1. Trochlear (cranial nerve IV) 2. Trigeminal (cranial nerve V) 3. Olfactory (cranial nerve I) 4. Oculomotor (cranial nerve III)

3

The nurse is assessing the client's respiratory pattern and notes periods of deep breathing alternating with periods of apnea. Which of the following terms would the nurse use to document this finding?1. Tachypnea 2. Obstructive breathing 3. Hypoventilation 4. Cheyne-Stokes

4

The nurse is assessing the eyes of an 82-year-old client. Which of the following findings are expected by the nurse based on the client's age?1. The client is easily able to read from a paper held at close range without corrective glasses.2. There is a noticeable increase in fat within the orbit of the eye.3. The client states that she feels her tear production has increased over the years.4. The pupillary light reflex is slower bilaterally.

4

The nurse is examining a client experiencing vertigo and wants to perform the Romberg test. The nurse would correctly provide which set of instructions to the client?1. "Touch your finger to your nose, alternating hands."2. "Walk across the room by placing one foot in front of the other, heel to toes."3. "Walk on your toes, then on your heels, then on your toes again."4. "Stand with your feet together, arms at sides, and eyes open."

4

When describing the importance of documenting initial assessment data to a group of new nurses, which of the following would the nurse emphasize as the primary reason? 1. It satisfies legal standards established by health care organizations and institutions. 2. Incorrect conclusions may be made without documentation of initial data. 3. Health care institutions have established policies regarding documentation. 4. It becomes the foundation for the entire nursing process.

4

A nurse assesses the pulse rate of an athletic client during a routine checkup. The nurse should anticipate the pulse rate to be in what range of beats per minute?

45-60 The normal pulse rate of a well-conditioned athletic client is often 45-60 beats per minute because of the conditioning of the cardiovascular system. A pulse rate ranging between 60 and 100 beats/min is normal for adults. A pulse rate of more than 100 beats/min would indicate tachycardia.

When reviewing the medications currently taken by a 50-year-old client who is complaining of constipation, teaching is indicated when the nurse notes which medication? A) Vitamin supplement with iron B) Nonsteroidal anti-inflammatory drug C) Antidepressant D) Hormone replacement

A

A student nurse is learning to document an initial assessment. What would the instructor tell the student that accurate documentation of this specific assessment best provides?

A baseline for comparison with future findings

Deep palpation is used to:A) identify abdominal contents.B) evaluate surface characteristics.C) elicit deep tendon reflexes.D) determine the density of a structure.

A) identify abdominal contents.Deep palpation is used to identify abdominal contents. Light palpation is used to evaluate surface characteristics. Percussion with a reflex hammer is used to elicit deep tendon reflexes. Percussion is used to determine the density (air, fluid, or solid) of a structure by a characteristic note.

Which of the following is an example of objective data? A) Alert and OrientedB) DizzinessC) an EaracheD) Sore Throat

A)Alert and oriented

A nurse has completed gathering some basic data about a client who has multiple health problems that stem from heavy alcohol use. The nurse has then reflected on her personal feelings about the client and his circumstances. The nurse does this primarily to accomplish which of the following?

Avoid biases and judgments

A client has sought care with complaints of increasing swelling in her feet and ankles, and the nurse's assessment confirms the presence of bilateral edema. The nurse's subsequent assessments should focus on the signs and symptoms of what health problem? A) Myocardial infarction B) Heart failure C) Atherosclerosis D) Heart block

B

A nurse is working on a unit for clients with neurological conditions. Which assessment form would the nurse most likely use to document assessment data? A. Ongoing B Focused C Frequent

B

When testing muscle strength, a client has difficulty moving her right arm against resistance. Which of the following should the nurse do next?A) Move the part passively through its range of motion. B) Ask the client to move the part against gravity. C) Inspect by touch for a palpable contraction of the muscle. D) Percuss the client's shoulder joint

B

A nurse palpates a client's ear and finds that the tragus is exquisitely tender. The nurse should suspect which of the following health problems? A) Otitis media B) Otitis externa C) Ruptured tympanic membrane D) Mastoiditis

B) Otitis externa

An adult patient's pulse is 46 beats per minute. The term used to describe this rate is:A) tachycardia.B) bradycardia.C) weak and thready.D) sinus arrhythmia.

B) bradycardia.A heart rate of less than 50 beats per minute in an adult is bradycardia. A heart rate of greater than 90 beats per minute in an adult is tachycardia. Weak and thready describes the force of the pulse reflecting a decreased stroke volume. Sinus arrhythmia is a pulse that is irregular; the heart rate varies with the respiratory cycle.

The examiner should use handwashing instead of an alcohol-based hand rub: A) if the patient has an infection with Mycobacterium tuberculosis.B) if the patient has an infection with Clostridium difficile.C) if the patient has an infection with hepatitis B virus.D) if the patient is HIV positive.

B) if the patient has an infection with Clostridium difficile.The examiner should use the mechanical action of soap-and-water handwashing when hands are visibly soiled and when patients are infected with spore-forming organisms (e.g., C. difficile or Bacillus anthracis). An alcohol-based hand rub would be effective against M. tuberculosis. An alcohol-based hand rub would be effective against hepatitis B virus. An alcohol-based hand rub would be effective against HIV.

When performing percussion, the examiner:A) strikes the flank area with the palm of the hand.B) strikes the stationary finger at the distal interphalangeal joint.C) strikes the stationary finger at the proximal interphalangeal joint.D) taps fingertips over bony processes.

B) strikes the stationary finger at the distal interphalangeal joint.To perform percussion, the examiner strikes the stationary finger at the distal interphalangeal joint (just behind the nail bed).

During a health history, a 62-year-old male client reveals that he occasionally sees spots before his eyes. The nurse interprets this finding as the result of which of the following? A) Increased ocular pressure B) Vitamin A deficiency C) Normal findings for client's age D) Vascular spasm

C) Normal findings for client's age

The nurse is using the mnemonic "COLDSPA" to assess a client's complaint of lower abdominal pain. The nurse asks the client to rate the pain on a scale of 0 to 10. The nurse is assessing which aspect of the complaint? A) Character B) Onset C) Severity D) Pattern

C) Severity

When assessing the client's ear, which finding should the nurse identify as indicating a need for further assessment and possible treatment? A) Darwin tubercle B) Red, flaky cerumen C) Tender tragus D) Pearly gray tympanic membrane

C) Tender tragus

A review of a client's history reveals cranial nerve IV paralysis. Which of the following findings would the nurse expect to assess? A) The eye cannot look to the outside side. B) Ptosis will be evident. C) The eye cannot look down when turned inward. D) The eye will look straight ahead.

C) The eye cannot look down when turned inward.

The CAGE test is a screening questionnaire that helps to identify:A) unhealthy lifestyle behaviors.B) personal response to stress.C) excessive or uncontrollable drinking.D) depression.

C) excessive or uncontrollable drinking.CAGE is a screening questionnaire to identify excessive or uncontrolled drinking (C = Cut down; A = Annoyed; G = Guilty; E = Eye opener). The health history assesses lifestyle, including factors such as exercise, diet, risk reduction, and health promotion behaviors. Coping and stress management are assessed during the functional assessment of the complete health history. Depression is assessed during the review of systems and during the mental status assessment (mood and affect). The Geriatric Depression Scale, Short Form is an assessment instrument for use with older adults.

During your interview of a client, you notice that he is asking for a beer during your shift. What mnemonic would you use to identify any issues or past history with alcohol use?

CAGE

The nurse is caring for a post-operative patient with an order for morphine sulfate 2 mg IV push every 4 hours. The patient's pain is unrelieved 30 minutes following administration of the morphine sulfate with the pain rating increasing from 7 to 10. Which action should the nurse take?

Call the prescribing physician see about changing the pain medication. Untreated or undertreated acute pain may lead to chronic pain syndrome (CRPS). Patients who have had surgery are at increased risk for developing CRPS. The nurse works diligently to find acceptable strategies to address a patient's pain, while observing the rights of medication administration. The nurse may need to contact the physician for adjustments in dosing, frequency of dosing, or acquiring an order for another pain medication to obtain optimal pain management for the patient. The other three options do not address the patient's pain.

The three meats lowest in cholesterol are _________, _________ and __________. Do plant foods contain any cholesterol? Animal products contain most cholesterol milk, egg and cheese do have some but are low

Chicken, pork, mutton NO

A 62-year-old construction worker presents to the clinic reporting almost a chronic cough and occasional shortness of breath that have lasted for almost 1 year. Although symptoms have occasionally worsened with a cold, they have stayed about the same. The cough has occasional mucus drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married with two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. Examination reveals a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his symptoms?

Chronic obstructive pulmonary disease (COPD)

A client presents to the health care facility with reports of new onset of chest pain of three days duration. Vital signs are stable and the chest pain has subsided since the client entered the exam room. Which type of assessment is most appropriate for a nurse perform for this client?

Comprehensive

A male client with a history of a back injury 2 months ago has been taking daily doses of narcotic pain medication. He is currently hospitalized with a leg fracture after falling down the stairs. He complains of 10/10 pain in his back and leg after taking pain medication one hour ago. What is the nurse's best action?

Consult with the healthcare provider about increasing the dose of medication.

What type of assessment is most appropriate for an individual who is admitted to a long-term care facility?A) EpisodicB) Follow-up C) Emergency D) Complete

D

during an assessment the nurse uses the CAGE test. The patient answers yes to two of the questions. what could this be indicating? a. the pt is an alcoholic b. the pt is annoyed at the questions c. the pt should be thoroughly examined for possible alcohol withdrawl D. the nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment.

D

A nurse on a post-surgical unit is admitting a client following the client's cholecystectomy (gall bladder removal). What is the overall purpose of assessment for this client? a. Collecting accurate data b. Assisting the primary care provider c. Validating previous data d. Making clinical judgments

D) Making clinical judgments

38. The nurse is using the Verbal Descriptor Scale to assess a client's pain. The nurse will prioritize which of the following data? A) The client's facial expressions B) The client's report on a 0 to 10 numeric scale C) The client's rating on a 0 to 10 visual analog scale D) The client's explanation of how her pain feels

D) The client's explanation of how her pain feels

The nurse is preparing to perform a physical examination on a female client who has been transferred to the medical unit from the emergency department. The nurse should begin the collection of objective data with which of the following examinations? A) Head and neck examination B) Palpation of lymph nodes C) Breast examination D) Vital signs

D) Vital signs

Nonverbal communication is a very important aspect in nurse-client relationships. What can the nurse do to help gain trust in clients? Select all that apply.

Do not use facial expressions such as rolling the eyes or looking bored or disgusted Make sure that dress and appearance are professional Use gestures intentionally to illustrate points, especially for clients who cannot communicate

While examining a client, the nurse observes the client's chest to be barrel shaped. The nurse would interpret this as indicating which of the following?

Emphysema

During a health history, a client reports drinking bloody Mary's several mornings a week before going to work. In which part of the CAGE questionnaire should the nurse document this information?

Eye-openers

A nurse works at a dermatologist's office and is assessing a client for skin conditions. Which of the following forms should the nurse use?

Focused

The nurse is using a Wood's light for a client who has complaints of itching, burning, and peeling of the skin between his toes. The nurse is assessing for what etiology of the client's symptoms?

Fungal infection

The nurse is preparing for a physical examination of a client. What should the nurse do first?

Hand hygiene

Which finding should a nurse recognize as normal when assessing the ears of an elderly client?

High-tone frequency loss

The student nurse is caring for a patient with emphysema. What sound would the student nurse expect to hear when percussing the patient's lungs?

Hyperresonant

A nurse cares for a client who suffered a myocardial infarction two (2) days ago. A high pitched, scratchy, scraping sound is heard that increase with exhalation and when the client leans forward. The nurse recognizes this sound as a result of what process occurring within the pericardium?

Inflammation of the pericardial sac

Which subjective finding in a client with tuberculosis should a nurse recognize as an indication of the onset of pleurisy?

Knife-like pain that worsens on inspiration

A 43-year-old store clerk comes to the office upset because she has found an enlarged lymph node under her left arm. She states she found it yesterday when she was feeling pain under her arm during movement. She states the lymph node is about an inch long and is very painful. She checks her breasts monthly and gets a yearly mammogram (her last was 2 months ago); until now everything has been normal. She states she is so upset because her mother died in her 50s of breast cancer. The client does not smoke, drink, or use illegal drugs. Her father is in good health. Examination shows a tense woman appearing her stated age. Visual inspection of her left axilla reveals a tense red area with no surrounding scarring. On palpation, the examiner feels a 2-cm tender movable lymph node underlying hot skin. Other shoddy nodes are also in the area. Visualization of both breasts is normal. Palpation of her right axilla and both breasts is unremarkable. Examination of the left arm reveals a scabbed-over superficial laceration over her left hand. Upon questioning, the client remembers that she cut her hand gardening last week. What disorder of the axilla is most likely responsible for her symptoms?

Lymphadenopathy of infectious origin

Which action should a nurse implement when assessing a non-native client to facilitate collection of subjective data?

Maintain a professional distance during assessment

An instructor is describing a comprehensive nursing health assessment to a group of students. The instructor determines that the teaching was successful when the students identify which of the following as the overall purpose?

Make a clinical judgment

The nurse is conducting a physical assessment of a new patient. What data does the nurse collect that are measurable?

Objective

Which would the nurse recognize as a barrier to assessing pain in the older adult? Select all that apply. Older adults with pain may fear becoming dependent on others. The unavailability of pain assessment tools for the older adult. Treatment of pain can lead to greater quality of life. Older adults may not display an outward reaction to pain. The belief that pain is a normal part of the aging process.

Older adults with pain may fear becoming dependent on others. Older adults may not display an outward reaction to pain. The belief that pain is a normal part of the aging process. Barriers to assessing pain in the older adult include the belief that pain is a normal part of the aging process, the lack of an outward reaction to pain by the older adult, and fear of the older adult becoming dependent on others. Pain assessment tools appropriate for use with the older adult exist and treatment of pain can lead to greater quality of life for the older adult.

A nurse cares for a client with lung cancer who presents with rust-colored sputum and a fever. The nurse performs frequent auscultation of the lung sounds to determine any changes from the baseline. What type of assessment is the nurse performing? Comprehensive Ongoing Focused Emergency

Ongoing

An adult client is brought to the ED by ambulance and is anxious and very short of breath. While the nurse is completing the emergency assessment, the client stops breathing. What is the first action of the nurse? If the client is injured, protect the cervical spine Ensure that the client is safe Begin CPR Open the client's airway

Open the client's airway

A nurse palpates a client's ear and finds that the tragus is exquisitely tender. The nurse should suspect what health problem?

Otitis externa A tender tragus is associated with otitis externa. Tenderness behind the ear would suggest otitis media. A ruptured tympanic membrane would be associated with ear pain and a popping sensation. Tenderness over the mastoid process would suggest mastoiditis.

You are a pediatric nurse caring for a child who has been brought to the clinic with otitis externa. What assessment finding is characteristic of otitis externa?

Pain on manipulation of the auricle Tophi are deposits of uric acid crystals and are generally painless; they are a common physical assessment finding in clients diagnosed with gout. Cerumen is a normal finding during assessment of the ear canal. Its presence does not necessarily indicate that inflammation is present. Pain when the nurse pulls gently on the auricle in preparation for an otoscopic examination of the ear canal is a characteristic finding in clients with otitis externa. Air bubbles in the middle ear may be visualized with the otoscope; however, these do not indicate a problem involving the ear canal. Aural tenderness or pain is not usually associated with middle ear disorders.

Which of the following test would be most appropriate for the nurse to use when assessing motor function of a client's trigeminal nerve?

Palpate temporal and masseter muscles while client clenches the teeth

A 73-year-old woman comes to the office for evaluation of new onset of tremors. She is not taking any medications, herbs, or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow, shuffling steps. She has decreased facial mobility with a blunt expression without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the client's symptoms?

Parkinson's disease

A nurse observes the gait of an elderly client admitted for surgery. The client's gait is stiff with rigid movements. The nurse should ask this client questions about which disease? Lordosis of the cervical spine Chronic obstructive pulmonary disease (COPD) Parkinson's disease Multiple sclerosis

Parkinson's disease

While auscultating the heart at the third intercostal space, left sternal border, the nurse notes a high-pitched, scratchy sound that increases with exhalation with the client leaning forward. The nurse would document which of the following?

Pericardial friction rub

Which of these clinical manifestations are physiologic responses to pain? Select all that apply. Perspiration Increased heart rate Sleeplessness Increased insulin Increased intestinal motility

Perspiration Increased heart rate Sleeplessness explanation Sleeplessness, perspiration, and increased heart rate are physiologic responses to pain. Pain elicits a stress response in the human body triggering the sympathetic nervous system. Decreased, not increased, intestinal motility and insulin are physiologic responses to pain.

While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse documents this finding as which of the following?

Petechiae

The nurse is assessing the hearing of an older adult. Which type of hearing problem might the nurse expect to find in the older adult?

Presbycusis

Which terms refers to the progressive hearing loss associated with aging?

Presbycusis Both middle and inner ear age-related changes result in hearing loss. Exostoses refers to small, hard, bony protrusions in the lower posterior bony portion of the ear canal. Otalgia refers to a sensation of fullness or pain in the ear. Sensorineural hearing loss is loss of hearing related to damage of the end organ for hearing and/or cranial nerve VIII.

A 66-year-old client states that he has increasing difficulty hearing high-pitched sounds. The patient's statement most likely suggests that he has what diagnosis?

Presbycusis Presbycusis, a gradual hearing loss that often begins with a loss of the ability to hear high-frequency sounds, is common after age 50. Vertigo refers to a true spinning motion. Otalgia refers to ear pain. Tinnitus refers to ringing in the ears.

The nurse is percussing the area over the lungs and hears a loud, low pitched, hollow sound. The nurse documents this finding as which of the following?

Resonance

A client presents at the clinic complaining of a loss of balance. What test should the nurse expect the physician to carry out on a client with a loss of balance?

Romberg test The Romberg test is used to evaluate a person's ability to sustain balance. The Audiometric test measures the hearing acuity precisely, while the Rinne test and the Weber test identify the types of hearing loss

The nurse notes that an older client has white spots on the tympanic membrane of the left ear. What should this finding indicate to the nurse?

Scars from previous ear infections White spots on the tympanic membrane are scars from previous ear infections. A red bulging eardrum is an indication of acute otitis media. Yellowish bulging membrane is associated with serous otitis media. A perforated ear drum indicates trauma from a current infection.

A client comes to the clinic for a follow-up evaluation of his blood pressure. On two previous visits his values were 140/88 mmHg and 144/92 mmHg. Today, the client's blood pressure is 146/94 mmHg. The nurse would categorize this client's blood pressure as which of the following?

Stage 1 hypertension The client's blood pressure readings meet the criteria for stage 1 hypertension (systolic of 140-159 mmHg; diastolic of 90-99 mmHg). The client would be considered prehypertensive with readings of 120 to 139 mmHg systolic and 80 to 89 mm Hg diastolic. Normal blood pressure values are less than 120 mm Hg systolic and less than 80 mmHg diastolic. Stage 2 hypertension is identified with readings of greater than or equal to 160 mmHg systolic and greater than or equal to 100 mmHg diastolic.

A nurse measures a client's blood pressure at 174/102 mm Hg. The nurse recognizes this as what classification of blood pressure measurement according to the JNC VII guidelines?

Stage 2 Hypertension The client's blood pressure falls between the ranges of 160 to 179 systolic or 100 to 109 diastolic. Therefore, the blood pressure of the client can be classified as Stage 2 Hypertension. Normal blood pressure measurement should be less than 130 systolic and less than 85 diastolic. Stage 1 Hypertension measurement should be between 140 to159 systolic and 90 to 99 diastolic. Stage 3 Hypertension measurements should be greater than or equal to180 systolic and greater than or equal to 110 diastolic.

The nurse is preparing to assess the mental status of a 90-year-old client who is being admitted to the hospital from a long-term care facility. Which of the following should the nurse assess first?

The client's sensory abilities When interviewing an older client, you must first assess hearing acuity. Assessing hearing acuity is very important when interviewing older adult clients because hearing loss normally occurs with age, and undetected hearing loss is often misinterpreted as mental slowness or confusion. This must precede the other listed assessments.

A nurse is collecting data from a client during an interview. Which of the following are subjective data that the nurse would collect? Select all that apply.

The client's weight-lifting routine The client's family history of cancer The client's occupation

Which is an example of percussion? Select all that apply.

The nurse notes dullness over the patient's liver. The nurse notes resonance over the patient's thorax. The nurse notes tympany over the patient's lower abdomen.

A 36-year-old teacher presents to your clinic, complaining of sharp, knifelike pain on the left side of her chest for the last 2 days. Breathing and lying down make the pain worse, while sitting forward helps her pain. Tylenol and ibuprofen have not helped. Her pain does not radiate to any other area. She denies any upper respiratory or gastrointestinal symptoms. Her past medical history consists of systemic lupus. She is divorced and has one child. She denies any tobacco, alcohol, or drug use. Her mother has hypothyroidism and her father has high blood pressure. On examination you find her to be distressed, leaning over and holding her left arm and hand to her left chest. Her blood pressure is 130/70, her respirations are 12, and her pulse is 90. On auscultation her lung fields have normal breath sounds with no rhonchi, wheezes, or crackles. Percussion and palpation are unremarkable. Auscultation of the heart has an S1 and S2 with no S3 or S4. A scratching noise is heard at the lower left sternal border, coincident with systole; leaning forward relieves some of her pain. She is nontender with palpation of the chest wall. What disorder of the chest best describes this disorder?

The pain from pericarditis is usually sharp and knifelike and is located over the left side of the chest. Change of position, breathing, and coughing often make the pain worse, whereas leaning forward improves the pain. Pericarditis is often seen in rheumatologic diseases such as systemic lupus and in patients with chronic kidney disease. Patients also experience this after a myocardial infarction. You can read more about Dressler's syndrome.

A nurse is interviewing a client with a different cultural background. Which nonverbal behavior should the nurse adopt to best facilitate communication during this phase of assessment?

Using a moderate amount of eye contact

After a patient describes abdominal pain to the nurse, which questions can the nurse use to help the patient provide more information about the pain? (Select all that apply.)

Where do you feel the pain?" "Where does the pain travel?" "What other symptoms do you have with the pain?" "What makes the pain less or worse?"

The nurse is planning to assess a client for graphesthesia. How will the nurse perform this phase of assessment? A) The client will close the eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object. B) The client is asked to identify the number of points felt when the nurse touches the client with the ends of two applicators at the same time. C) The nurse will simultaneously touch the client in the same area on both sides of the body, and the client will identify where the touch occurred. D) The nurse will briefly touch the client, and the client will identify where the touch occurred.

a

When assessing the legs, feet, and toes, which pulses would the nurse expect to palpate? Select all that apply. A) Femoral B) Brachial C) Temporal D) Dorsalis pedís E) Popliteal F) Posterior tibial

a d e f

After examining the client's tympanic membranes, the nurse documents "Right tympanic membrane, red and bulging with no light reflex." The nurse recognizes that these are signs of

acute otitis media. In acute otitis media there is a bulging red membrane with decreased or absent light reflex.

A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN 1. Which of the following should the nurse do?

ask the client to identify scents

The nurse is auscultating a client's heart sounds and hears what she believes to be a murmur. How should the nurse proceed with gathering further assessment data related to the suspected murmur?

auscultate in a variety of positions

The nurse is assessing a client with a cardiac condition who complains of not sleeping well and of having to get up frequently at night to urinate. The nurse should recognize what implication of this statement?A) The client may have developed a cardiac conduction problem.B) The client may be experiencing symptoms of heart failure.C) The client's cardiac problem is being adequately compensated for.D) The client may be at increased risk for myocardial infarction.

b

When performing a head-to-toe assessment, during which part would the nurse assess the motor function of cranial nerve VII? A) Mental status examination B) Head and face C) Ears D) Mouth and throat

b

An example of objective data is:A) complaints of left knee pain.B) crepitation in the left knee joint.C) left knee has been swollen and hot for the past 3 days.D) report of impaired mobility from left knee pain as evidenced by an inability to walk, swelling, and pain on passive range of motion

b Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Crepitation is assessed by palpation. Subjective data is what the person says about himself or herself during history taking.Subjective data is what the person says about himself or herself during history taking.Subjective data is what the person says about himself or herself during history taking.

While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's

bone.

A nurse is testing the range of motion of the thoracic and lumbar spine. Which of the following would the nurse document as an abnormal finding? A) Flexion of 80 degrees B) Lateral bending of 35 degrees C) Hyperextension of 15 degrees D) Rotation of 30 degrees

c

An example of subjective data is:A) decreased range of motion.B) crepitation in the left knee joint.C) left knee has been swollen and hot for the past 3 days.D) arthritis.

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

the nurse is palpating the tonsillar, submandibular, and submental lymph nodes. The nurse is most likely examining which area during a comprehensive assessment? A) Nose and sinuses B) Abdomen C) Neck D) Face

c

An obese 34 year old man is undergoing a preoperative examination prior to having bariatric surgery. The patient tells the nurse that he has a red sore in his groin area that appears to be spreading. The nurse assesses the lesion and finds a macular erythematous lesion with satellite pustules. What would the nurse suspect?

candida

A client presents with chest pain described as a pressure and squeezing sensation that is steady and severe. The nurse would suspect which system as the most likely source?

cardiac

Bells Palsy

closure of the affected eye

Which of the following clinical situations is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? A. A patient who resides in Indiana has required hospitalization during a vacation in Hawaii B. A patient has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer. C. A patient wishes to appeal her insurance company's refusal to reimburse for a diagnostic test. D. A patient has ask a nurse if he can read the documentation that his physician wrote in his chart.

d

A nurse is performing a patient assessment in an urgent care clinic. The most likely tool being used is the

focused

what should be heard over the majority of the abdomen

generalized tympany

During a health history, a male client tells the nurse that he "can't breathe well" at night when he is lying down and has trouble sleeping because he wakes up with trouble breathing. The nurse would assess this client further for which of the following?

heart failure

During a comprehensive assessment of the lungs of an adult client with a diagnosis of emphysema, the nurse anticipates that during percussion the client will exhibit

hyperresonance.

common, contagious superficial skin infection -lesion, typically on the face, that itches and burns-initial lesion is a small erythematous macule that canges into vesicle or bulla with thin roof -lesion crusts with a characteristic honey color from the exudates as the vesicles or bullae rupture -may have regional lymphadenopathy

impetigo

Which of the following is an average normal temperature in centigrade for a healthy adult? tympanic: 34.4°C oral: 37.0°C axillary: 37.5°C rectal: 36.5°C

oral 37

When describing the cardiac cycle to a group of students, the instructor correlates heart sounds with events of the cycle. Which heart sound would the instructor explain as being associated with systole?

s1

The nurse has completed a health assessment on an older adult client being seen at a neighborhood clinic. What client-specific information should the nurse identify as being a priority?

significantly impaired hearing

woods lamp

used for fungal diagnosis

A nurse is collecting both subjective and objective data in assessment of a client's mental health. Which of the following are examples of subjective data? Select all that apply •Glasgow Coma Scale score • Tone, clarity, and pace of speech • History of hospitalization for a mental health problem • History of Alzheimer's disease in a family member • Use of recreational drugs • Onset of memory lapses

• History of hospitalization for a mental health problem • History of Alzheimer's disease in a family member • Use of recreational drugs • Onset of memory lapses