Nurse 160 Exam 4

What age do we start screening for scoliosis and how?

11-12 years old Standing behind the patient while the patient bends forward looking for any curves of the spine.

How many cranial nerves are there?

12

The nurse is assessing the muscle strength in Mr. Russels left hand and notes active motion against some resistance. How would the nurse document this finding?

4

The nurse is completing an abdominal assessment on a patient who is one day postoperative. The nurse hears no bowel sounds in the left upper quadrant. How long should the nurse auscultate to determine that bowel sounds in that quadrant are absent?

5 minutes

A nurse is inspecting a clients nipple. Which of the following findings should the nurse recognize as a cause for concern?

A recent retracted nipple that was previous everted.

Physical assessment strategies

Assessment: Inspection Palaption ROM Muscle strength

What is the earliest and most sensitive indicator of altered cerebral function?

Change in LOC

The nurse walks into a clients room and finds the client is disoriented to time and place and is awake and responsive. What term best describes the client?

Confused

Mrs. Jones presents at the ED complaining of severe pain in her abdomen. She has a history of liver transplant. What would the nurse know NOT to do ?

DO NOT!!!!! palpate the abdomen.

How is bone pain described?

Deep, dull, and boring.

A middle aged female tells the nurse that she is concerned because her breasts are not firm like they used to be and asks what might be causing this? What is an appropriate response by the nurse?

Firmness of the breasts decreases with age as estrogen levels decrease

The nurse is completing ROM on Mr. Russel. What movements would the nurse expect to complete at the elbow joint?

Flexion Extension supination pronation

Which of the following assessment tasks can you appropriately delegate to an unlicensed care provider?

Height, weight, and vital signs

When preparing an education session for a group of women who have been identified as postmenopausal the nurse should include which teaching point?

Increase intake of Vitamin D and Calcium

On inspection of a newborns breasts, the nurse notes that they are enlarges and elongated, with white liquid discharge. The infants mother is concerned about it. Which of the following should the nurse tell the mother regarding the finding?

It is due to the influence of the maternal hormones and should resolve in a few days.

The client tells the nurse that she has benign breast disease and so she is not worried about lumps or nodules in her breasts. How would the nurse best respond?

It is important to perform self examinations as there could be changes or additional lumps in your breasts that would need further examinations.

Mrs. Johnson, a transcriptionist, reports pain and burning in her right hand. What assessment procedures should the nurse perform next?

Phalen and tinel tests

To promote relaxation of the abdominal muscles, which of the following would be most appropriate for the nurse to do?

Place a pillow under both of the clients knees.

An adult male client reports hesitency when urinating. The nurse would further assess this for which complication?

Prostate enlargement

The nurse is assessing a patients bowel sounds. In which quadrant should the nurse being the assessment?

RLQ

As part of an abdominal assessment, the nurse must palpate a client's liver. In which quadrant is this organ located?

RUQ

While conducting the physical examination, which of the following assessments would require nurse to ausculate the abdomen?

To identify bowel sounds

A neurologic change associated with normal aging is?

a decrease in reaction time

When evaluating a clients risk for cerebrovascular accident, which client would the nurse identify as being at highest risk>

68 year old african american male with hypertension

An older adult patient who lives alone is hospitalized after falling and sustaining a broken arm. Which nursing action will best determine whether the patient is experiencing any cognitive dysfunctions that may have contributed to the fall?

Administer an assessment tool such as the Mini-Cog.

The nurse is palpating Mr. Hayes abdomen. Which technique would the nurse use to promote relaxation during the assessment?

Ask Mr. Hayes to take slow, deep breaths through his mouth.

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

Ask the client to identify scents

Which nursing actions are associated with conducting a Glasgow Coma Scale assessment on a patient who has fallen and sustained a possible brain injury?

Ask the patient to identify where he or she is. Request that the patient squeeze the nurse hand. Observe which stimuli cause the patient to open eyes.

The nurse is assessing a patients gait. Which factors should the nurse observe as the patient ambulates in the room?

Base of support Stride Arm swing Posture

Neurological system

Brain spinal cord and nerves

The nurse is preparing to conduct an abdominal assessment on a patient admitted to the medical surgical unit. Which question should the nurse ask the patient prior to conducting the assessment?

Can you please empty your bladder before we begin>

A man had a motor vehicular accident and fractured his right ankle. He was transferred from the emergency department to the orthopedic nursing unit for further observation and possible surgery in the next 12 hours. What is the priority nursing assessment of the admitting orthopedic nurse?

Capillary refill distal to the injury of the right ankle

The nurse is providing discharge instructions to Mr. Hayes following surgery to place an ostomy. Under what circumstances should Mr. Hayes be instructed to call the provider?

Change in color of skin around the stoma increased abdominal discomfort rash around the ostomy site stoma leaking more than usual

To assess an adult patient suspected of experiencing increased intracranial pressure (ICP), the nurse will implement which intervention?

Check pupillary activity

The nurse is assessing a patients joints. What should the nurse include in this assessment?

Color Size Symmetry

The nurse is performing a visual assessment of a patients abdominal area. What would the nurse include as part of inspection?

Coloration Contour Symmetry

Mr. Brown was playing soccer and hurt his right knee. It appears to be swollen. What is the first assessment you should make?

Compare the swollen knee with the other knee.

The nurse is educating Mr. Russel on the effects of prolonged immobility. What physiologic changes would the nurse describe to Mr. Russel?

Decreased muscle protein synthesis Increased muscle catabolism Decreased muscle mass Bone demineralization

A patient has reported dizziness that has been associated with orthostatic hypotension. What information will the nurse provide to the patient that is directly associated with this condition?

Dehydration can be a trigger for the dizziness.

The nurse is assessing a 51 year old modbidly obese client who is seeking care for the recent changes of sensation in his feet and toes. The client is complaining of intermittent burning and tingling, in his feet that radiate up his legs. For what health problems should the nurse assess?

Diabetic peripheral neuropathy

THe nurse in interviewing a patient who is reporting chronic abdominal pain. WHat questions would be appropriate for the nurse to include in the nursing health history?

Do you experience indigestion? Are you having any nausea or vomitting? Have you noticed an increase or decrease in your appetite?

The nurse is completing passive ROM excersizes and bends the patients foot so that the toes point upward. Which skeletal muscle movement has the nurse performed?

Dorsiflexion

Which nursing actions would be effective when managing an older adult patients risk for injury related to falling?

Encourage the patient to wear prescription glasses. PResent the patient with fluids regularly throughout the day. Offer to take the patient to the toilet every 2-3 hrs. Measure the patients blood pressure both when sitting and upon standing.

The nurse is assessing a patients ROM and notes a limitation in the movement of the elbow joint. Which tool would the nurse use to measure the degree of movement in the joint?

Goniometer

Muscle strenght

Grading strength scale 0-5 5 being normal Always compare side to side

During a routine visit, an older patient shares that they recently had trouble remembering things. little things like where he put his keys. Which interview question will the nurse ask to best identify a possible physical cause for the lapse of memory?

Have you ever had any kind of head injury during your lifetime?

The nurse is completing a health history on a patient reporting musculoskeletal pain. Which questions would be appropriate for the nurse to include in the interview?

Have you experienced any previous injuries to your joints? Do you exercise regularly? What type of job do you have? Have you had any recent weight gain? What medications are you currently taking?

The nurse is reviewing patient data from a neurological assessment and notes that the patients history includes several recent falls.Which nursing actions will the nurse take immediately to address the patients risk for injury?

Implement the facilities universal fall percautions

A nurse is providing client education to a group of prepubescent girls at a local elementary school. What should you include in the presentation?

Information about the stages of breast development

A group of students is preparing for their clinical experience, for which they are required to demonstrate the techniques for examining the abdomen. The students demonstrate understanding of the proper sequence when they demonstrate the techniques in which order?

Inspect, auscultate, percuss, palpate

While the nurse is performing blunt percussion at the costovertebral angle, the patient experiences a sharp pain. The nurse recognizes that this finding can be an indication of what condition?

Kidney infection

When doing an assessment of the spine of an older adult, you can expect to see which variation?

Kyphosis

The nurse is preparing to perform an abdominal assessment on Mr. Hayes. Which instruction should the nurse give to the patient prior to performing the assessment?

Lie flat on your back with your arms resting at your sides.

what is an assessment of teh trigeminal nerve?

Light touch over anterior scalp and jaw, clench teeth.

When percussing the abdomen, the nurse notes a dullness at the anterior right costal margin at the right midclavicular line. Which organ is most likely involved?

Liver

A young adult marathoner reports of right foot third metatarsal pain (6/10) and swelling for more than 4 weeks. An x-ray was ordered, and it did not show abnormal findings. Which of the following imaging might the nurse expect the physician to order?

MRI

Lifestyle can play a big part in developing risk factors for stroke. Which of the following can reduce a clients risk for stroke?

Maintaining a healthy weight regular exercise quitting smoking

Increase risk for breast cancer

Menarche before 12 Menopause after 55 First pregnancy after 30 No pregnancies/no children Family history

The nurse is assessing Mr. Russels medications. Which medications would place Mr. Russel at a higher risk for falls?

Merformin Losartan Chlorthalidone

The nurse is assessing a patients surgical incision. Which assessment finding would require an immediate call to the provider?

Moderate amount of purulent drainage on the dressing.

A patient with tympanic abdomen complains of pain in the RUQ. Which sign would the nurse expect to be positive?

Murphy sign

the nurse is completing an abdominal assessment and observes a pulsating midline mass. What would be the correct action by the nurse?

Notify the provider immediately.

What is considered a modifiable risk factor for breast cancer?

Obesity

Which cranial nerve controls eye movement?

Oculomotor

When PERRLA is normal, which cranial nerve is responsible?

Oculomotor CN III

Loss of bone density that occurs with greatest frequency in postmenopausal women is called?

Osteoporosis

Oculomotor III

PERRLA

The nurse understands that which structures are located in the left upper quadrant of the abdomen?

Pancreas (body and tail) Spleen Stomach

Mrs. Russel asks the nurse "what is the purpose of these passive ROM exercises? I can move my own arms and legs. What is the correct response by the nurse?

Passive ROM exercises will help you to maintain mobility in your joints.

Which assessment technique best confirms splenic enlargement?

Percussion along the left MAL spleen and gentle palpation

The nurse is preparing to perform the Romberg test on an adult male client. THe nurse should instruct the client to?

Stand erect with arms at the sides and feet together.

A patient undergoing a neurological assessment fears a serious diagnosis. Which action by the nurse will best ensure that the patient will comply with the assessment process?

Treat the patients concerns and fears with both sensitivity and empathy

While interviewing a client, a nurse asks the client whether she has ever noticed any lumps, swelling in the breasts. What other area associated with the possible risk for breast cancer should she ask about regarding the presence of lumps or swelling?

Underarm

What cranial nerve can cause syncope?

Vagus X

The client tells the nurse I am so glad i had a mastectomy and i will never have breast cancer again. How should the nurse best repsond?

We need to continue to perform examinations. Breast cancer can reoccur.

The chart states that a 62 yr-old woman has a stroke in the right parietal area of the brain. The nurse expects to note ...

Weakness in the left arm

A woman appears restless and is wringing her hands prior to having a clinical breast exam performed. Which statement by the nurse would be most appropriate?

You seem to be anxious. Can you tell me what you are thinking?

Moving a part of the body away from the midline is called?

abduction

Of the following changes, which is the earliest sign of progressing brain herniation that originates in the cerebral hemisphere?

altered mentation

Palapation

always compare side to side!

RLQ

appendix

The nurse is assessing an older adult client who has lost 2.27 kg since her last visit 1 year ago. The client tells the nurse that her husband died 2 months ago. The nurse should further assess the client for

appetite changes

temporal lobe

auditory

cerebellum

balance and coordination

Nerve pain

burning, stabbing, electric shock like

First sign of developing neurological problem

change in LOC

A client has sustained an injury to the cerebellum. which area should be the nurses primary assessment?

coordination

A client comes to the clinic and reports a sore knee. The nurse notes popping and cracking when the client attempts to bend the knee. The client exhibits signs of pain by facial expression. The nurse knows that the popping and cracking noises should be charted as?

crepitus

Vagus nerve affects

digestion and heart rate

Risk factors in which of the following are most readily cahnged to reduce the potential for falls?

enviromental

When documenting a finding over the stomach, the nurse most accurately identifies the region as?

epigastric

Glasgow Coma Scale

eye response verbal response motor response Highest score 15 out of 3

Which cranial nerve is being assessed when the nurse asks the patient to raise eyebrows, purse lips, and smile?

facial

Romberg test

feet together arm to the side, close eyes and observe for any swaying

What is one topic pertinent to abdominal health promotion?

food borne illness

Inappropriate lactation

galactorrhea

Which cranial nerve is being assessed when a patient is asked to swalow and the gag reflex is observed to be normal?

glossopharyngeal

Abnormal Male breast enlargement

gynecomastia

WHich technique should the nurse use to perform scoliosis screening in a school aged child?

have the child bend forward at the waist.

Assessment of the musculoskeletal system usually proceeds from general to specific and from:

head to toe

Bowel sounds

hi pitched clicks and gurgles should hear one every 5-15 seconds or 5-30 minutes

The nurse performs BP screening at the local community center. As part of the health promotion intervention, the nurse also discusses the following risk factors for stroke

high BP, diet high in fat, and smoking

The nurse is preparing to assess the abdomen of a hospitalized client 2 days after abdominal surgery. They nurse should first

inspect the abdominal area

when performing an abdominal assessment, what is the correct sequence?

inspection, auscultation, precussion, palpation

the nurse is assessing an older adult. which assessment finding would the nurse recognize finding associated with aging?

kyphosis

A 26 year old man was in a motor vehicle accident and suffered a complete spinal cord injury to L3. The nurse assesses the patient for loss of motor function in the

legs

LOC

level of conciousness

RUQ

liver, gallbladder

To correctly document the ROM in the fingers is full and active, the nurse writes that the patient can...

make a fist, spread and close fingers, and do finger thumb oppositions.

Fall risk

morse fall scale hendrich fall risk model

Babinski sign

normal in babies up to 18 months

Lifespan considerations

older adults - extra time for assessment gait speed assessment

When teaching the breast self-examination, you would inform the woman that the best time to conduct breast self-examination is:

on the 4th to 7th days of the menstrual cycle.

Osteomyelitis

open fracture, infection in bone

PERRLA stands for

pupils are equal, round, and reactive to light and accommodation

A nursery nurse is assessing neurologic status of a newborn, what area would the nurse be assessing?

reflexes

a patient in a nursing home was admitted with a diagnosis of dementia. He started a fire because he was cooking at home and forgot that he left a pan on the stove. The nursing diagnosis that is highest priority is:

risk for injury

What sense does the olfactory nerve control?

smell

Muscle pain

sore, tender, cramping pain with movement

Which cranial nerve controls movement of the trapezius and sternocleidomastoid muscles?

spinal accessory

LUQ

stomach, spleen

THe correct position in which to place the patient to palpate the breats is

supine with arm over head

hypothalamus

temperature and sleep regulation

LLQ

terminal portion of colon

gynecomastia may occur in an older male secondary to

testosterone deficiency

A 47 year old woman states she is having vertigo and some difficulty with balance. The nurse should assess:

the whisper test

lymphedema

tissue swelling due to lymphatic obstruction

The nurse is assessing a clients abdomen. Which technique is the nurse using>

two handed deep palpation

What is the only cranial nerve that travels out of the cranium?

vagus X

Which cranial nerve controls hearing and equilibrium?

vestibulocochlear/auditory

occipital lobe

vision

Frontal lobe

voluntary motor activity personality emotion intellect

enviromental factors

working conditions

Is a fracture the same as a broken bone?

yes

The nurse is assessing bowel sounds. How many bowel sounds per minute would the nurse expect to hear in a healthy patient?

5 to 30

Which of the following patients is at highest risk for osteoporosis?

A middle age woman of lower socioeconomic status who is a heavy smoker and drinks alcohol six times times a week

A patient reports that a previous right hip replacement is suddenly painful. Which hip assessment technique should you omit?

Adduction

An older patient reports feeling dizzy right before falling. Which action by the nurse indicates an understanding of how dizziness can be triggered?

Assess the patients blood pressure. Review the patients medical history for previous head injuries. Ask, "had you been taking any nonprescription medications before the fall?"

Mrs. Jacobson was prescribed raloxifene hydrochloride 18 months ago. She is concerned the dizziness she felt just before she fell is a result of the medication. How does the nurse best address her concerns?

Assure her that dizziness is not one of the recognized side effects of that medication.

Mr. Hayes asks the nurse why he can only have clear liquids. What is the appropriate repsonse by the nurse?

Because your bowels will be sluggish after surgery, this diet is easiest for you to tolerate.

The nurse is assessing flexion in Mr. Russels hip. What instructions would the nurse give to Mr. Russel to complete this assessment?

Bend you knee to you chest, and then pull it against your abdomen.

A patient with a head injury and increasing ICP is likely to have which assessment finding?

Decrease LOC and sluggish pupil

The nurse is assessing a patient for fall risk. Which factors would place the patient at a higher risk for falls?

Depression Gait or balance impairment Use of more than four prescription medications

The nurses patient, Edith Jacobson, is being monitored after a fall that resulted in a fractured hip. Her initial assessment included a Glasglow Coma Scale assessment that showed she had no observable deficiencies involving consciousness. Following the providers orders she is being monitored with the administration of the Glasgow Coma Scale every 4 hours. When the current assessment indicates that the patient has scored a 14, what will the nurses initial response be?

Document the latest Glasgow Coma Scale results as a 14.

The nurse is assessing a patient who underwent a colostomy yesterday. WHich assessment finding would require an immediate call to the surgeon?

Dusky, purple stoma

WHich nursing actions demonstrates an understanding of the components required when conducting the objective portion of a neurologic assessment?

Evaluate CN X1 function by asking the patient to shrug the shoulders. Test for tactile discrimination using a door key.

When assessing the rectum, the nurse observes what appear to be engorged areas near the opening. The nurse would most likely document this finding as which of the following?

Hemorrhoids

The nurse is using the Morse fall scale to determine Mr. Russels fall risk. What variables will the nurse assess by using this tool?

History of falls Presence of IV Secondary diagnosis

The nurse is performing deep palpation during an abdominal assessment. How would the nurse explain the purpose of this procedure to Mr. Hayes?

I am pressing deeply on your abdomen to feel your abdominal organs and detect masses.

THe nurse is performing deep palpation during an abdominal assessment. How would the nurse explain the purpose of this procedure to Mr. Hayes?

I am pressing deeply on your abdomen to feel your abdominal organs and detect masses?

An older adult patient is being assessed for risk for falls. Which statements by the patient would the nurse identify as risk factors?

I celebrated my 81st birthday last month. My cataract surgery is scheduled in 6 weeks. Im less depressed since ive moved in with my daughter. Ive started to have some trouble getting to the bathroom in time.

Which statement by a patient would cause the nurse to suspect that a pattern of falling exists?

I fell twice when i was visiting my daughter 2 months ago.

The nurse is providing education to Mr. Hayes on Diet following a colostomy. Which statement by the patient indicates the need for further teaching?

I should limit my fluid intake to minimize output.

The nurse is educating mr. russel on how to prevent falls. Which statement, if made by the patient, indicates that he understood the teaching?

I should press my call light when i want to get out of bed.

A clinical nurse is assessing a patients knowledge and understanding of bone health and maintenance. Which of the following responses of the patient indicates adequate understanding to maintain musculoskeletal health?

I will take calcium supplementation and vitamin D as prescribed.

What suggestions will the nurse include in the education materials regarding falls prevention at home for an older adult with a history of falls?

Keep floors clear of paper clutter. Keep halls and stairs well lighted. Wear rubber soled shoes. Store often used items on shelves that are at waist level.

A client calls the clinic and asks to speak to the nurse. The client tells the nurse that she has started taking morphine for advanced cancer, is constipated, and wonders what is causing it. What would the nurses best response be?

People can become constipated when taking certain medications.

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 lbs) 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

A patient who fell and hit her head and fractured her femur is scheduled for surgery in the morning. The patient has had a complete neurologic assessment and is currently in stable condition. How will the nursing staff best monitor the patients neurologic status?

Perform a neurologic check every 4 hours.

The nurse is caring for Mr. Russel, who is recovering from a stroke and has mild left-sided hemiplegia. What would the nurse include in the plan of care?

Perform passive ROM exercises Encourage the patient to set realistic, short term goals.

What behavior would the nurse document as lethargy related to Mrs. Jacobsons level of consciousness?

Remains awake only long enough to answer questions.

A patient with a history of kidney stones presents with complaints of pain, hematuria, and nausea with vomitting. The nurse documents this finding as a bruit of what?

Right iliac artery

An older adult is being prepared for discharge to her daughters home after completing rehabilitation following surgery to repair a hip fracture. What information will the nurse include in discharge teaching to best help minimize the patients risk for falls?

Sit down and rest when feeling dizzy. Use walking device to help with proper balance. Turn on lights at night when getting out of bed to go to the bathroom. Drink enough fluids to keep your urine pale and clear.

A patient undergoing a neurological assessment fears a serious diagnosis. WHich action by the nurse will best ensure that the patient will comply with the assessment process.

Treat the patients concerns and fears with both sensitivity and empathy

The nurse is preparing to palpate the breasts of a female client. Which technique would be appropriate?

Use the flat pads of three fingers

A patient reports changes in bowel pattern. What is the best question to determine normal bowel habits?

What was your bowel pattern before you noticed the change?

An older adult patient has fallen and sustained a bruise to the forehead. Although there appears to be no significant injury, the family is concerned when the provider orders a mini-cog assessment and asks, "why are you testing her memory and mental abilities?" Which explanation best meets the familys expressed needs?

Your mothers fall may have hurt the frontal lobe of her brain. That is the part that controls memory, reasoning, and judgement.

THe nurse palpates a fine, round, mobile, nontender, nodule and suspects that it is

a fibroadenoma

When examining the breast of a 75 year old woman the nurse would expect to find which of the following?

a grannular feel to the breast tissue

If the great toe extends upward and the other roes fan out in response to stroking the lateral aspect of the sole of the foot, this is documented as .....

babinski sign

You note that an adolescent has uneven shoulder height. To differentiate functional from structural scoliosis, you ask the patient to

bend forwards at the waist while you palpate the spine.

While the nurse performs formal patient assessment, assistive personnel often observe changes when obtaining vital signs or assisting patients with ADLs. When discussing care for a patient with back pain, the nurse should particularly alert the assistant to watch for....

bowel/bladder incontinence

Peau d' orange appearance is highly suggestive of what?

breast cancer

a male patient presents to the clinic with a complaint of a hard, irregular, nontender mass on his chest under the areola. Upon examination, the nurse notes that the mass is immobile and suspects

carcinoma

a 23 year old nulliparous woman is concerned that her breasts seem to change in size all month long and they are very tender around the time she has her period. The nurse should explain to her that

cyclical breast changes are normal

A patient with benign breast condition is likely to q

have it resolve after menopause.

The patient's muscle tone is hypertonic so the muscles are stiff and the movements are awkward. The nurse documents these findings as:

spasticity

What percussion sound is heard over most of the abdomen?

tympany

Use of the GCS provides relatively objective assessment of LOC, The three functions assessed are....

verbal response, eye opening, and motor response

it is important to examine the upper outer quadrant of the breast because it is

where most breast tumors develop