Quizziz Questions

The nurse should respond to a client's request to "keep what I'm about to tell you a secret" with which statement?

"I have to share the information if it reveals something that could hurt you."

A full term neonate weighs 7.5lb (3kg) at birth. When he is 1 year old, approximately how much should he weigh? 16 lb (7.3 kg) 22 lb (10 kg) 28 lb (12.7 kg) 32 lb (14.5 kg)

22 lb (10 kg)

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? 2/5 3/5 4/5 5/5

4/5

When auscultating the abdomen for bowel sounds, how long should the nurse listen before concluding that bowel sounds are absent? 1 minute 5 minutes 10 minutes 15 minutes

5 minutes

While performing a newborn assessment on a male infant, you note that the urethral meatus opens on the dorsal side of the penis. This condition is referred to as: Epispadias Hypospadias Varicocele Hydrocele

Epispadias

T/F To be a culturally competent nurse, it is necessary to memorize all the differences in care that exist among various groups that you may come into contact with.

False

The nurse is assessing an adult client who reports hair loss. The client has been diagnosed with hyperthyroidism. Which of the following hair characteristics should the nurse expect to find in this client? Fine texture hair Coarse texture hair Weight gain Constipation

Fine texture hair

The nurse is caring for an adult client. When the client was admitted 2 days ago, the following were collected. HR 82bpm, RR 18/min, BP 142/84, SpO2 96% RA, T 98.9F Weight 72kg Height 67 inches. Today, the client reports feeling short of breath, and the nurse finds the following. HR 96bpm, RR 22/min, BP 152/88, SpO2 92% RA, T 98.5F Weight 74kg. For which of the following should the nurse assess? Fluid retention Hypertension Anxiety Bradypnea

Fluid retention

The nurse is assessing a client's abdomen for hernias. Which of the following would best accentuate hernias? Have the patient relax abdomen Have the patient flex leg Have the patient raise head off bed Have patient breathe slowly

Have patient raise head off bed

Which of the following should the nurse recognize as the primary concern for clients who have been diagnosed with a pterygium? Pain Interference with vision if the pterygium covers the pupil The danger of contamination of the internal structures of the eye Risk of infection from environmental contaminants

Interference with vision if the pterygium covers the pupil

While conducting a physical assessment, the nurse notes multiple raised edematous areas on the client's legs and groin. The client describes these lesions as "itchy insect bites". How should the nurse best document these lesions? Wheals Bullae Tumors Plaques

Wheals

A nurse at the local free clinic is collecting data on a 16-year-old boy who has come to the clinic. Under what component of the health history would the nurse place data on whether the teen routinely uses seat belts when in a vehicle?

Health maintenance

The nurse notes the client has very pale oral mucosal membranes. What lab values should the nurse expect to find? Hemoglobin 6g/dL (low) Hemoglobin 22g/dL (high) White blood cells 3 (low) White blood cells 22 (high)

Hemoglobin 6g/dL (low)

The nurse should be aware that which of the following factors has the greatest effect on the symptoms seen following a stroke? The area of the brain affected How long before the patient sought treatment Whether it was ischemic or hemorrhagic The patient's previous medical history

How long before the patient sought treatment

The nurse is providing education about the characteristics of melanoma to an adult client. Which of the following statements indicates a need for further education? "I should report asymmetrical moles" "I should report moles with irregular borders" "I should report moles that have multiple colors" "I should report moles that are <6mm in size"

I should report moles <6 mm in size

The nurse is evaluating a client who has been diagnosed with chronic obstructive pulmonary disease (COPD). On physical examination of the thorax, which of the following is an expected finding? Increased AP diameter Decreased AP diameter No change in the AP diameter Pectus excavatum

Increased AP diameter

During an assessment, the nurse notes the presence of nystagmus. For which of the following should the nurse assess? SATA Inner ear infection Cerebellar stroke Alcohol intoxication Glaucoma

Inner ear infection Cerebellar stroke Alcohol intoxication

A nurse has just admitted a patient who as a wound infection to the unit. After assessing the patient, what is the next step the nurse should perform?

Interpret the findings

While auscultating for mitral valvular sounds, the nurse should place the stethoscope at which of the following locations? Right of sternum, 2nd ICS Left of sternum, 2nd ICS Left mid-clavicular line, 4th ICS Left, mid-clavicular line, 5th ICS

Left, mid-clavicular line, 5th ICS

The nurse is caring for a client who was admitted with an asthma exacerbation. The initial assessment found loud wheezing. Before a treatment is provided, the nurse notices that the wheezing has become quieter. What should the nurse's next action be? Tell the patient they can go home because they are getting better Notify the provider that the patient needs to be seen immediately Initiate the Code Blue protocol Return in a few minutes with medication

Notify the provider that the patient needs to be seen immediately

The nurse is assessing an adult client's cardiovascular system. The client has a history of congestive heart failure (CHF), hypertension (HTN), and hyperlipidemia (HLD). Which of the following is an expected finding for this client? PMI in the 5th ICS, midclavicular line PMI in the 5th ICS, anterior axillary line PMI in the 3rd ICS, midclavicular line PMI in the 8th ICS, anterior axillary line

PMI in the 5th ICS, anterior axillary line

Which level of disorientation would be of greatest concern? Time Place Situation Person

Person

A client admitted to the health care facility for new onset of abdominal pain expresses to the nurse that she was treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information?

Personal health history

The nurse is caring for a client with vascular insufficiency of the lower extremities. The skin is pale, and there is no hair on the patient's legs. Pedal pulses are non-palpable. The client is reporting pain. What is the nurse's best action? Elevate the client's leg Place an ice pack on the client's leg Ambulate the client around the hospital unit 5 times Place the client's legs in a dependent position

Place a client's legs in a dependent position

When auscultating a client with COPD, which of the following may the nurse expect to hear? Stridor Prolonged expiratory phase Late inspiratory crackles Pleural rub

Prolonged expiratory phase

When performing a cardiac assessment, the nurse notes the presence of a "whooshing" sound in the patient's carotid artery. What is the priority concern for this client? Risk for stroke Assessment of pain level Risk for bradypnea Assessment of peripheral pulses

Risk for stroke

The nurse is assessing a client who has presented with a 1-day history of nausea and anorexia. He describes the pain as generalized yesterday, but today it has localized to the right lower quadrant. As the nurse palpates the LLQ, the client experiences pain in the RLQ. What is the name of this sign? Psoas sign Obtruator sign Rovsing's sign Cutaneous hyperesthesia

Rovsing's sign

While conducting a cardiovascular assessment, the nurse is aware that which of the following is produced by closure of the mitral valve? S1 S2 S3 S4

S1

The nurse is aware that which of the following is produced by closure of the aortic valve? S2 S1 S3 S4

S2

Which of the following occurs after the mitral valve opens and is related to rapid ventricular filling? S3 S2 S1 S4

S3

A client reports a large amount of stress from his job. Which suggestion is best to help the client?

Take stress management classes

The nurse is caring for a client who has a suspected head injury. When asked to administer eye drops to dilate the client's pupils for the eye exam, how should the nurse respond? Administer the drops as prescribed Tell the provider that you do not think this is an appropriate action Administer half of the prescribed dose Tell the provider that you will perform the eye exam and report the findings

Tell the provider that you do not think this is an appropriate action

An 18-year-old high school student presents to his family doctors office for evaluation of acute onset of pain in the left testicle. He has had no problems until this morning. The pain has been sharp and radiates into the left groin. On physical examination, the testicle feels swollen and is tender to palpation. HR 102bpm, BP 125/82, RR 23/min, T 98.3F, SpO2 95%. What is the most likely diagnosis? Epididymitis Testicular torsion Acute orchitis Testicular cancer

Testicular torsion

The nurse's patient asks why they need a vaginal examination and pap test every 3 years. What do you tell her? The pap detects cervical cancer The pap test detects the virus that causes cervical cancer The pap test detects uterine cancer The pap test detects the virus that causes uterine cancer

The Pap test detects cervical cancer

While assessing a client, the nurse notices that the client does not respond to verbal commands. What is a possible cause of this finding? There is a problem with CN VIII (8-Acoustic) There is a problem with CN II (2-Optic) There is a problem with CN V(5-Trigeminal) There is a problem with CN XI (11-Spinal Accessory)

There is a problem with CN VIII (8-Acoustic)

The nurse is assessing an adult client who has suffered a head injury. During the assessment, when the nurse touches the client's lips, he begins to suck. How should the nurse interpret this response? This indicates damage to the neurologic system This is an expected response in this client This indicates that the client is hungry This indicates that the client is healing appropriately

This indicates damage to the neurologic system

What is cryptorchidism? Undescended testicle Ventral displacement of the urethral meatus on the penis Tight pressure that cannot be retracted over the glans Inflammation of the glass

Undescended testicle

The nurse is caring for an older adult female client who is 5 feet 2 inches tall & weighs 100 pounds. Which of the following questions should the nurse ask to best understand the client's dietary intake? "Who prepares your meals on a daily basis?" "What are your favorite foods?" "How do you get to the grocery store each week?" "Could you describe what you eat on a typical day?"

"Could you describe what you eat on a typical day?"

When assessing the throat and mouth of a 3-year-old child, how many teeth should the nurse expect to see? 20 28 30 32

20

The nurse is caring for a client who is scheduled to have an arterial blood gas (ABG) sample taken on the right wrist. What physical examination maneuver should be used to assess the patency of the ulnar artery? Murphy's test Phelan's test Allen's test Obturator test

Allen's test

When assessing a client's heart, the nurse notices an extra sound following S2. How can the nurse determine if this is an expected finding? Ask the client to hold their breath Ask the client to turn onto their left side Ask the client to lay supine Ask the client to breathe out through their mouth while the nurse is auscultating

Ask the client to hold their breath

When testing muscle strength, a client has difficulty moving each extremity against resistance. Which of the following should the nurse do next? Move the part passively through its range of motion Ask the client to move the part against gravity Inspect by touch for a palpable contraction of the muscle Compare bilateral findings

Ask the client to move the part against gravity

The nurse is caring for a client who reports "a lot" of unintentional weight loss over the past 4 months. Current measurements show a height of 5 feet 11 inches and a weight of 170 pounds with a body mass index of 22.7. Which of the following should the nurse do next? Calculate his desirable body weight Ask, "What is your usual body weight?" - to know what he considers "a lot" Record what he ate in the last 24 hours Determine his hip-to-waist ratio

Ask, "What is your usual body weight?" - to know what he considers "a lot"

When assessing skin turgor, where is the best place for the nurse to assess? Hand Face Neck Below the clavicle

Below the clavicle

The nurse caring for a client with an upper GI bleed would expect the client's stools to be which of the following colors? Brown Red Green Black

Black

The nurse caring for a client with a suspected GI bleed should monitor which of the following most closely? Blood pressure Temperature SpO2 Pain

Blood pressure

The nurse is caring for a client who is receiving tPA (a strong fibrinolytic). What is the priority concern for this client? Blood pressure management Glucose level management Cardiac rhythm monitoring Oxygen saturation monitoring

Blood pressure management

A 19-year-old sexually active student presents for evaluation of a vaginal discharge. She denies fever or chills. She states that the discharge is thick, white, and curd like, and although there is no bad odor, she does experience some itching. Her vulva is inflamed, with a slightly red vaginal mucosa. There is no cervical motion tenderness. The uterus is normal in size without adnexal masses. Based on this information, what is the most likely diagnosis? Bacterial vaginitis Endometriosis Candida vaginitis Endometrial cancer

Candida vaginitis

The nurse is aware that which of the following is an early sign of increased ICP (intracranial pressure)? Change in mental status Dilated pupils Tachycardia Hypotension

Change in mental status

Which factor is an example of subjective data in a nursing assessment?

Client's feelings and statements about health problems

The nurse is caring for a client who has been admitted due to a CVA. Which of the following should the nurse recognize as possible signs of a CVA? SATA Lumbar pain Confusion Headache Blurred vision

Confusion Headache Blurred vision

When testing accommodation to a near object, which response would be considered normal? Dilating Constricting No reaction Movement toward the light

Constricting

The nurse is caring for a 72-year-old client who was brought to the clinic by a family member. The family member reports the client has had increasing confusion, weight gain with decreased appetite, and increased general swelling. Which of the following findings would support the diagnosis of hypothyroidism? Cool skin Hot skin Warm skin Clammy skin

Cool skin

The nurse is assessing the skin of an 80-year-old client. Which of the following would be an expected finding? Increased skin temperature Increased moisture Decreased erythema Decreased turgor

Decreased turgor

The nurse in a psychiatry ward is interviewing a newly admitted client. The client is speaking loudly & walking quickly, but randomly. The client states he is being persecuted by those around him, and there is a conspiracy to lock him up and take all of his money because he is the wealthiest man in the world. He has been diagnosed with an acute schizophrenic episode. How would the nurse best describe this client's type of thought process? Obsession Depersonalization Phobia Delusion

Delusion

The nurse is assessing a client who has been diagnosed with right-sided congestive heart failure. What should the nurse expect to see in this client? Localized edema of one leg Dependent edema, Sacral edema when supine, Increased JVP, S3 Edema in the loose subcutaneous tissues of the eyelids Pulmonary edema

Dependent edema, Sacral edema when supine, Increased JVP, S3

What is the most common mental health problem experienced by older adults? Personality disorder Psychosis Bipolar disorder Depression

Depression

Which type of assessment technique should be used to asses a client for noise tenderness? Direct percussion Indirect percussion Blunt percussion Direct inspection

Direct percussion

The nurse is assessing an adult client who has presented with shortness of breath. The client has been diagnosed with right-sided heart failure. Which of the following findings is expected in this client? Flattened jugular veinsJVP as expected Elevated JVP Decreased JVP

Elevated JVP

The nurse is caring for a client who has failed the Allen's test. Which of the following should the nurse do next? Ensure that no procedures are done on that extremity's arteries. Ensure the client's arm is elevated at all times. Ensure the client drinks 1L of fluid daily. Ensure the client's arm is in a dependent position at all times.

Ensure that no procedures are done on that extremity's arteries

The nurse is caring for a client who has a long history of type 2 diabetes mellitus (T2DM) and peripheral neuropathy. What is the priority assessment for this client? Examination of the feet for ulcers Ensuring the airway is patent Examination of the nails for clubbing Examination of the client's level of consciousness

Examination of the feet for ulcers

A pt is wearing a hospital gown & sitting on the exam table. What area should the nurse include in the general survey? Pulse Rate Breath Sounds Facial Expression Oral Lesions

Facial Expressions

When attempting to assess a client's pain, what would the nurse do first? Obtain a client self-report Observe behaviors in the client Search for possible causes of pain Ask family members about the client's pain

Obtain a client self-report

The nurse is caring for a client who had a knee replacement yesterday. The client tells the nurse that he cannot wait to take long walks again when he gets home. Which of the following responses by the nurse is most appropriate? "Yes, that will be great exercise for you" "That should be fine after a month of therapy" "You will not be able to take long walks again now that you've had this surgery" "It takes time to reach your maximum strength and endurance, from 6 months to a year"

"It takes time to reach your maximum strength and endurance, from 6 months to a year"

The nurse collects data on a client's chief complaint (a spell of numbness & tingling on the left side). Which of the following questions would be best for eliciting information related to associated factors?

"What other symptoms occurred during the spell?"

An 83-year-old client fractured a hip after a fall in his home. Because of his extensive cardiac history and chronic obstructive pulmonary disease, surgery isn't an option. The client tells a nurse he doesn't know how he's going to get better. Which response is best?

"What's your biggest concern right now?"

The nurse is caring for a client who is being seen for a lower-back injury. After providing education to the client regarding proper body mechanics for lifting and performing day-to-day activities, which statement by the client indicates a need for further instruction? "I will bend my knees when I lean forward" "When lifting heavy boxes, I will bend at the waist" "I will not lift anything above the level of my elbows" "I will avoid standing in one position for a long period of time"

"When lifting heavy boxes, I will bend at the waist"

When trying to explore a patient's perspective on his or her illness, the question that would best determine the patient's thoughts on the cause of the problem would be

"Why do you think you have (name the specific symptom)?"

In a healthy adult, what is the expected respiratory rate? 4-14 breaths per minute 14-16 breaths per minute 12-20 breaths per minute 26-40 breaths per minute

12-20 breaths per minute

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? 11 23 66 18

18

The nurse is providing education to a patient about how to perform a self-breast exam. When is the best time to perform a breast exam? 5-7 days after the onset of menstruation 6-8 days before the onset of menstruation The day menstruation starts Two weeks after the onset of menstruation

5-7 days after the onset of menstruation

When auscultating a client's lungs, which of the following findings may indicate a pneumothorax? Wheezes on the opposite side Rhonchi on the affected side Absent breath sounds on the affected side Resonance on the opposite side

Absent breath sounds on the affected side

The nurse is assessing an adult client who has presented with palpitations and shortness of breath. The client has been diagnosed with atrial fibrillation. Which of the following is the most likely finding upon auscultation of the client's heart? An irregularly irregular rhythm A rapid regular rhythm A mid-systolic click Bigeminy

An irregularly irregular rhythm

The nurse observes multiple red circular lesions with central clearing that are scattered all over the abdomen and thorax. How does the nurse document the shape and pattern of these lesions? Gyrate and linear Annular and generalized Iris and discrete Oval and clustered

Annular and generalized

A client's significant other is tearful over the client's condition and lack of improvement. He says he feels powerless and unable to help his friend. Which response by the nurse is the best?

Ask if he would like to help with some comfort measures

During an assessment, the nurse determines that a client sees more than one primary care provider and has obtained prescriptions from each provider. Which method would be most appropriate to determine a client's current medication regimen?

Ask the client to bring all the medications and supplements to an interview.

The nurse is caring for a client who has been diagnosed with atrial fibrillation. What is the most appropriate action when assessing the client's vital signs? Asses the radial pulse for 30 seconds Asses the apical pulse for 60 seconds Asses the dorsals pedis pulse for 60 seconds Asses the carotid pulse for 30 seconds

Asses the apical pulse for 60 seconds

A nurse is admitting a client to the postsurgical unit from the postanesthetic care unit. The nurse has transferred the client from the stretcher to a bed and asked the client if he is experiencing pain. The client acknowledges that he is in pain. What would the nurse do next? Ask the client to briefly explain his cultural background Asses the client's pain using a mnemonic device Asses the client's self-management skills Asses the client's pain by obtaining a set of vital signs

Asses the client's pain using a mnemonic device

The nursing assistant obtains VS & reports the monitor gave a reading of 125bpm for HR. What is the nurse's best action? Ask the nursing assistant to check for symptoms of tachycardia Document the HR as an expected finding Notify the healthcare provider immediately Asses the patient's apical pulse

Asses the patient's apical pulse

The nurse begins a client assessment by conducting a general survey that focuses on objective observations. What is the primary purpose for collecting this sort of information first? Assists the nurse in formulating appropriate subjective questioning Allows the nurse to form an effective nurse-client relationship Permits the nurse to initiate the assessment in a nonthreatening manner Demonstrates the nurse's therapeutic interest in the client

Assists the nurse in formulating appropriate subjective questioning

A client presents with the following signs: diffuse abdominal pain, and abdominal distention. What is the nurse's next action? Auscultate the client's bowel sounds Notify the physician that the client likely has appendicitis Administer 2 mg of Morphine for the client's pain as ordered Perform light palpation to determine the area of greatest pain

Auscultate the client's bowel sounds

The nurse is caring for an adult client who has symptoms of thyroid dysfunction. Which of the following assessments should be included? Auscultation of the thyroid Auscultation of the lungs Breast assessment Palpation of the lymph nodes

Auscultation of the thyroid

The nurse is caring for an adult client who has presented for evaluation of a bump on his face. The client states he believes it is getting larger. Physical examination reveals a 0.4cm nodule with a depressed center & a firm, elevated border that is flesh-colored. Which of the following conditions should the nurse suspect? Basal cell carcinoma Squamous cell carcinoma Melanoma Actinic keratosis

Basal cell carcinoma

While assessing a client, the nurse notes the absence of a gag reflex. Which cranial nerve may not be functioning properly? CN I (1-Olfactory) CN IV (4-Trochlear) CN X (10-Vagus) CN XII (12-Hypoglossal)

CN X (10-Vagus)

The nurse is caring for a client who had a recent MVA (motor vehicle accident) involving head trauma. The client has been resting comfortably and has recently requested a tissue due to a runny nose. The nurse notes clear, watery drainage from the client's nose and ear. How should the nurse proceed? Call the provider Ask the patient how long he has had a cold Test the patient for flu Bring the patient a cotton ball to place in his nose

Call the provider

Clients with increased fat around the middle of their body (central body fat) are at an increased risk for this: Cardiovascular disease Stroke Myocardial infarction Gingivitis

Cardiovascular disease

What type of drainage is considered normal in the external ear canal? No drainage Cerumen Serous Sanguineous

Cerumen

The nurse is caring for a client who has found a lump in her right breast. The client reports that it first appeared 3 months ago, it changes with her menstrual cycle, and it is tender to the touch. She denies a family history of breast cancer. Upon physical exam, the nurse finds no dimpling or retraction present, but a round, 2-cm, freely mobile, tender, circumscribed, firm, somewhat elastic mass is palpated. Which of the following is the most likely diagnosis? Fibroadenoma Cyst Breast cancer Mastitis

Cyst

The nurse auscultates a client's thorax at the first & second intercostal spaces (ICS) anteriorly and between the scapulae posteriorly. Which of the following is true about this location? It is the expected location of bronchi-vesicular breath sounds It is the location of the lower border of the lungs It is the location of the trachea bifurcation It is the location of the diaphragm

It is the expected location of broncho-vesicular breath sounds

The nurse is caring for a client who reports trouble breathing. Upon auscultation, the nurse hears crackles in the client's lungs. What condition can contribute to pulmonary edema? Right sided heart failure Left sided heart failure An acute stroke Deep Vein Thrombosis (DVT)

Left sided heart failure

The nurse is evaluating a client who was brought to the emergency department with an altered level of consciousness. The client is drowsy, but opens her eyes, looks at the nurse, responds to questions, & then falls back asleep. How would the nurse best describe this level of consciousness? Alert Lethargic Obtunded Comatose

Lethargic

What is the term for black, tarry stool? Hematemesis Steatorrhea Hematochezia Melena

Melena

A client asks why the nurse and health care provider seem to be asking the same questions and performing the same examination. What should the nurse explain as being the difference between the two assessments?

Nurses focus on the diagnosis of actual human responses to disease or life events.

The nurse is preparing to assess the respirations of an alert adult patient. How should the nurse perform this assessment? Explain to the pt that you will be counting respirations Observe for equal bilateral chest expansion of 2.54 to 5.08 cm (1 to 2 in) Count for 15 seconds & multiply the number by 4 to obtain the rate Ask the pt to lie supine, which makes counting the respirations easier

Observe for equal bilateral chest expansion of 2.54 to 5.08 cm (1 to 2 in)

In caring for a client with a right sided stroke in the cerebrum, where should the nurse anticipate alterations being found? On the right side of the body A change in their step, similar to a "hop" On the left side of the body Only in the lower extremities

On the left side of the body

The nurse is caring for a dark-skinned adult client. When assessing for skin color changes, where should the nurse conduct the assessment? Nails Oral mucosa Back of hands Lips

Oral mucosa

The nurse is performing posterior palpation of the thyroid gland. Which of the following actions by the nurse requires re-education? Asking the client to tip their head to the side Placing index fingers above the client's cricoid cartilage Palpating between the sternocleidomastoid muscle & the trachea Moving fingers laterally to palpate for thyroid lobes

Placing index fingers above the client's cricoid cartilage

The nurse is assessing a client and notices a white coating on the patient's tongue. The coating is able to be scraped off. Which of the following puts the client at risk for this condition? Recent use of antibiotics A sexually transmitted disease Oral cancer Smoking

Recent use of antibiotics

Which of the following applies to the client in the previous question? Risk for injury related to fails Imbalanced nutrition: more than body requirements Risk for aspiration Anxiety related to hospitalization

Risk for aspiration

The nurse is assessing the pain of an older adult client who is recovering from a right hip open reduction procedure. What element can influence the patient's pain perception? Family history Sleep pattern Genetic history Elimination pattern

Sleep pattern

An adult patient reports a sore above his lips that has not healed & is getting bigger. The nurse observes a red, scaly patch with an ulcerated center and sharp margins. Which of the following conditions should the nurse suspect in this client? Kaposi's sarcoma Malignant melanoma Basal cell carcinoma Squamous cell carcinoma

Squamous cell carcinoma

Which of the following should the nurse recognize as the primary concern for clients who have been diagnosed with an entropion? The conjunctiva may become irritated by friction If it is not treated, the lid muscles may lose their tone It can lead to glaucoma if it is not corrected The conjunctiva is exposed to environmental contaminants

The conjunctiva may become irritated by friction

Which describes the nurse using the technique of palpation? The nurse notes increased warmth surrounding an abdominal incision The nurse notes asymmetry of the individual's abdomen The nurse notes gurgling sounds over the individual's abdomen The nurse notes tympany over the individual's lower abdomen

The nurse notes increased warmth surrounding an abdominal incision

The nurse should be aware that which of the following are risk factors for a bowel obstruction? SATA The use of narcotic pain medication Post-surgical status Immobility Frequent ambulation

The use of narcotic pain medication Post-surgical status Immobility

The nurse should be aware that which of the following is true regarding the sternal angle anteriorly and the T4 spinous process posteriorly? This is the location of the trachea bifurcation This is the location of the lower lung border This is the location of tracheal breath sounds This is the location with the loudest vesicular breath sounds

This is the location of the trachea bifurcation

The nurse should be aware that which of the following is true regarding the 6th rib at the midclavicular line & the 8th rib at the midaxillary line? This is the location of the apex of the lungs This is the location of the trachea bifurcation This is the location, anteriorly, of the lower border of the lungs This is the point of maximal impulse (PMI)

This is the location, anteriorly, of the lower border of the lungs

The nurse should be aware that which of the following is true regarding the T10 spinous process? This is the location of broncho-vesicular breath sounds This is the location, anteriorly, of the lower border of the lung This is the location of the loudest fremitus This is the location, posteriorly, of the lower border of the lung

This is the location, posteriorly, of the lower border of the lung

Older adults are at an increased risk for this because of their higher risk for falls Stroke Traumatic Brain Injury (TBI) Diabetes Mellitus Cataracts

Traumatic Brain Injury (TBI)

T/F The first step to becoming culturally competent is self-reflection to identify personal biases.

True

When assessing a client's pupillary reaction, which of the following demonstrates a consensual response? When a light is shone in the right eye, the pupil constricts When a light is shone in the left eye, the right pupil constricts When a light is shone between the eyes, the reflection is symmetrical When an object is moved close to the patient's face, the eyes move together symmetrically

When a light is shone in the left eye, the right pupil constricts