3306 Final
ABCDEs for assessing melanoma?
asymmetrical, border, color, diameter, evolving
What is the second step of physical assessment when assessing the abdominal?
aucsultation
A nurse is preparing to assess a client's cerebellar function. Which of the following would the nurse expect to test?
balance
Which client-satisfaction related intervention of staff nurses may lead to improved client outcomes?
bedside hand-off report
cloudiness in the lens is called
cataract
Peripheral vision is evaluated by the nurse using the
confrontation test
tenting of the skin indicates what?
dehydration
Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?
dermis
Which of the following would the nurse consider objective data?
Evaluating the jugular pulse
Nursing students are learning about different methods of charting in clinical. What method is the model for improving communication between and among clinicians?
SBAR
What tool does the nurse use to auscultate the client's abdomen?
Stethoscope
A high-pitched crowing sound from the upper airway results fro tracheal or laryngeal spasm and is called what?
Stridor
Upon entering an adult client's room to begin a shift assessment, the nurse should call the rapid response team based on which assessment finding?
Systolic pressure 201 mm Hg
A woman in her second trimester of pregnancy calls the obstetrician's office and tells the nurse that she is having pains all around her umbilicus. What would be the nurse's best response?
"These pains are caused by the stretching of ligaments as your uterus grows. They are nothing to worry about."
The results of a client's Rinne test are as follows: bone conduction > air conduction. How should the nurse explain these findings to the client?
"you have conductive hearing loss"
The nursing instructor is discussing the normal functioning of the nose and sinuses with the nursing class. What would be the best description of the major factors related to the normal functioning of these structures? Select all that apply.
- Normal cilia function - Normal quality and quantity of the mucous - Patency of the sinus ostia
nursing diagnosis related to ears
- impaired sensory perception - acute pain
According to the guidelines from the Centers for Disease Control and Prevention (CDC), why are nurses supposed to wear gloves? (Select all that apply.)
- prevent the transmission of bacteria from nurses to clients - reduce transient contamination of the hands - reduce the risk of infecting health care personnel
A nurse is presenting a class to new mothers preparing for postpartum discharge from the hospital. What topics would the nurse be sure to include in teaching? (Select all that apply.)
- sleep positioning - suffocation prevention - choking prevention
When educating a client about healthy habits relating to cardiovascular health, it is important to include which of the following? Select all that apply.
- undergo regular cholesterol screening - quit or do not start smoking - exercise regularly - undergo regular screening for diabetes
What techniques can be performed when palpating the breasts? Select all that apply.
- vertical pattern - wedge pattern - circular pattern
A nurse is caring for an adult client who has just undergone surgery to remove a thyroid tumor. The nurse is assessing for signs of hyperthyroidism. What are some signs of hyperthyroidism? Select all that apply.
-anxiety -palpitations -heat intolerance
nursing diagnosis related to eyes
-impaired sensory perception - risk for injury
During the assessment of deep tendon reflexes, the nurse finds that a patient's responses are bilaterally normal. What number is used to indicate normal deep tendon reflexes when the documenting this finding? ____+
2+
How many quadrants is the abdomen divided in to during an assessment?
4
When caring for an older adult, the nurse would know that wound healing rate reduces normally with aging by
50%
The point of maximum impulse is most often found where?
5th intercostal space (ICS), left midclavicular line (MCL)
The nurse is assessing balance. Which test would the nurse plan on omitting from the exam?
Achilles reflexes
Which principle should guide the nurse's approach when conducting a general survey on an older adult client?
Allow the client time to answer questions
The RN may delegate which care component to a nursing assistant?
Ambulation assistance
A patient is reporting pain after palpation of the right lower quadrant. What condition does the nurse expect?
Appendicitis
What is the most appropriate nursing intervention when writing a care plan for a pregnant woman and using the nursing diagnosis "Readiness for enhanced family coping due to new role?"
Assess the structure, resources, and coping abilities of the family
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 entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would most likely suspect the client is compensating for what pathophysiological disorder?
Chronic obstructive pulmonary disease
HIPAA gives clients greater control over their medical records. What else does HIPAA provide?
Client recourse if privacy protections are violated
The nursing instructor is explaining SBAR documentation to students before taking them into the clinical area. The instructor explains that SBAR charting is based on?
Complete and accurate assessment findings
A nurse performs a comprehensive assessment on a client. Which is included only in a comprehensive assessment?
Complete health history
The nurse should recognize that which acute change in heart rate requires urgent attention and intervention in an adult hospitalized client?
Decrease to 44 beats/minute
How does the nurse use critical thinking when accurately assessing vital signs?
Developing nursing diagnoses
A client diagnosed with peritonsillar abscess exhibits 4+ tonsils and is not able to eat or drink. What is the nurse's priority concern for this client?
Ensure a patent airway
The nurse has entered a client's room to begin a head-to-toe assessment. The client appears anxious, is pale, and is struggling to breathe. What is the nurse's priority action?
Ensure a patent airway.
The nursing instructor is teaching about health assessment and explains to students how to assess the roles and relationships of the client. The students know that this type of information is assessed in what type of assessment?
Functional
The nurse is assessing a 15 year old male and finds soft, fatty enlargement of the breast tissue. The nurse would document this at what?
Gynecomastia
When caring for clients in any health care environment, what is the most important technique for preventing infection?
Hand hygiene
Which of the following assessment findings would lead the nurse to suspect that a client has Bell's palsy?
Inability to wrinkle the forehead
A patient with a history of kidney stones presents with complaints of pain, hematuria, and nausea with vomiting. What assessment technique will elicit kidney pain?
Indirect percussion of CVA tenderness
When conducting a focused health assessment, the nurse asks questions specifically targeting what?
Issues and symptoms specific to the client
The nurse enters a client's room to administer scheduled medications through a barcode system. The client is not wearing an armband. What is the nurse's best action?
Leave the room to obtain another armband for the client.
Which type of vessels filter pathogens from the body and drain the fluid that has moved outside of the circulation back into the vessels?
Lymphatic
The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient:
Moves the head and shoulders against resistance with equal strength.
Which assessment finding is priority for the nurse to address during an assessment of a one-week-old neonate?
Mucus in the nasal passages
A patient with a tympanic abdomen complains of pain in the RUQ. Which sign would the nurse expect to be positive?
Murphy sign
A hospitalized client complains of pain 10/10 one hour after receiving a dose of intravenous Morphine sulfate intravenously. The next dose is not due for over an hour. What is the nurse's best action?
Notify the healthcare provider.
The nurse is caring for a client with a sudden onset of chest pain. Which assessment is highest priority?
Obtain pulse and blood pressure
Which of the following tests would be most appropriate for the nurse to use when assessing motor function of the trigeminal nerve?
Palpate the temporal and masseter muscles while the client clenches teeth
A patient with a history of cirrhosis tells the nurse that his abdomen seems to be getting larger and that he has gained 9.7 kg (20 lb) in the past 6 months. How will the nurse determine whether the abdominal enlargement is from accumulation of fluid or fat from the weight gain?
Percuss the abdomen for shifting dullness
When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as:
Positive Romberg sign.
At each prenatal visit, a client provides a urine sample to the health care provider. What is this urine sample tested for at each visit?
Protein and glucose
The RN working on a surgical unit should question which of these orders before completing it?
Reapply a staple in an incision
The nurse is preparing to conduct an admission assessment on an older adult client. What would be important to do before interviewing this client?
Reduce or eliminate background noise
Students are learning about the many uses of the medical record. One of these uses is to perform an internal audit. What is the goal of an internal audit?
The evaluation of care for continual improvement
To make a legal entry into the medical record, the nurse must document what?
Time of the assessment
A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment?
To establish a database against which subsequent assessments can be measured.
A patient reports changes in bowel pattern. Which is the best question to determine normal bowel habits?
What was your bowel pattern before you noticed the change?
Moving a part of the body away from the mid line is called?
abduction
common nursing diagnosis for the head and neck include_______
activity intolerance, fatigue, chronic pain, and knowledge deficit
Temporary heart pain, resolving in less than 20 minutes, aggravated by physical activity and stress is known at what?
angina
A nursing diagnosis appropriate for a patient with ear problems is
disturbed sensory perception.
A client in the ED tells a nurse that she feels short of breath. What term would the nurse use in documenting this finding?
dyspnea
When documenting a finding over the stomach, the nurse most accurately identifies the region as which of the following?
epigastric
If S4 is present, it will be heard following S1 and sounds like "lub-lub dub."
false
The Right Middle Lobe can best be assessed posteriorly.
false
The nurse assesses the response of the eye to light and documents normal findings as PERLLA
false-- PERRLA
The nurse palpates a fine, round, mobile, nontender nodule and suspects that it is
fibroadenoma
Decreasing the angle between bones is called
flexion
The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviors is the __________ lobe.
frontal
the depth of a burn can be superficial, superficial-dermal, dermal, or ________
full thickness
common name for the extra heart sounds S3 and S4
gallop
what is an appendage of the skin?
hair
Which formula will the nurse use to calculate cardiac output?
heart rate x stroke volume
At the beginning of the shift, an older adult hospitalized for pneumonia complains of shortness of breath with an oxygen saturation of 90% on room air. Which type of assessment should the nurse perform at this time?
immediate
When assessing cranial nerves IX and X, which of the following would the nurse consider as an abnormal finding?
impaired swallowing
A client tells a nurse about a raised lesion on the client's leg. What is the nurse's first nursing action?
inspect the area
The nurse is collecting a history on a 4-year-old and discovers that the child is being cared for by his grandmother during the days while the parents are at work. The grandmother's house was built in the early 1940s. Which lab should the nurse prepare to collect from the child?
lead level
When auscultating the abdomen, the nurse hears a bruit to the right of the midline slightly below the umbilicus. The nurse documents this finding as a bruit of which of the following?
right iliac artery
The nurse is educating a new mother about safety precautions for a child who is beginning to walk. What information should the nurse include in this teaching session?
setting up gates around stairs
A client comes to the clinic with reports of a reddened, tender lump on the left breast. What would the nurse document about the lump?
size
A nurse notes a bruit when auscultating over the right carotid artery. The nurse determines the abnormal sound is a bruit because a _________ sound is heard.
swishing
An elderly client comes to the clinic for evaluation. During the skin assessment, the nurse noted considerable skin tenting. Why does this finding require further assessment?
tenting indicates dehydration
The sternal angle at the right 2nd rib space is also known as what?
the aortic area
The nurse recognizes that the 60-year-old patient may have difficulty reading fine print because of
the loss of accommodation
S1 results from closure of the mitral and tricuspid valves.
true
When auscultating the thorax for adventitious breath sounds it is important to listen at each site for at least one complete respiratory cycle.
true
When using an otoscope to assess the inner ear the nurse should hold the patient's ear at the helix, lifting up and back for best visualization.
true
a wound is assessed for location, size, color, texture, drainage, wound margins, surrounding skin, and healing status
true
neck pain may be cardiac related
true
static and kinetic confrontation tests measure peripheral vision
true
What percussion sound is heard over most of the abdomen?
tympany
During the taking of the health history, a patient tells the nurse that "it feels like the room is spinning around me." The nurse would document this finding as:
vertigo
A client has just been diagnosed with osteopenia. To help prevent progression to osteoporosis, the nurse would teach this client about what?
vitamin D supplements
