3306 Quiz ?s

What is the second step of physical assessment when assessing the abdominal? Palpation Percussion Auscultation Inspection

auscultation

Peripheral vision is evaluated by the nurse using the A. cover test B. confrontation test C. cardinal fields of gaze test D. corneal light test

b. confrontation test

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. A. Temporal B. Frontal C. Parietal D. Occipital

b. frontal

Temporary heart pain, resolving in less than 20 minutes, aggravated by physical activity and stress is known at what? A. Crushing B. Gastrointestinal C. Angina D. Musculoskeletal

c. angina

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands? A. Subcutaneous layer B. Connective layer C. Dermis D. Epidermis

c. dermis

A nursing diagnosis appropriate for a patient with ear problems is a.sensory perception, gustatory. b. olfactory sensory perception. c. disturbed sensory perception. d. kinesthetic disturbed perception.

c. disturbed sensory perception

What tool does the nurse use to auscultate the client's abdomen? A. None B. Fetoscope C. Stethoscope D. Sonoscope

c. stethoscope

A nurse performs a comprehensive assessment on a client. Which is included only in a comprehensive assessment? A. Complete health history B. Circulatory assessment C. Assessment of the airway D. Disability assessment

complete health history

The nurse is assessing balance. Which test would the nurse plan on omitting from the exam? A. Hop on one foot B. Romberg C. Walking heel-to-toe D. Achilles reflexes

d. achilles reflexes

A nurse is preparing to assess a client's cerebellar function. Which of the following would the nurse expect to test? A. Remote memory B. Sensation C. Mental status exam D. Balance

d. balance

When assessing cranial nerves IX and X, which of the following would the nurse consider as an abnormal finding? A. Asymmetrical tongue movement. B. Contraction of the pharyngeal muscle. C. Upward movement of the palate. D. Impaired swallowing.

d. impaired swallowing

A client tells a nurse about a raised lesion on the client's leg. What is the nurse's first nursing action? A. Move to the next body system B. Palpate the area C. Document the statement D. Inspect the area

d. inspect the area

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? Increasing formula intake to meet caloric needs Setting up gates around stairs Team sport precautions Wearing helmets when bike riding

Setting up gates around stairs

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

murphy sign

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? You are having preterm labor. Go to the emergency room right away." "These pains are caused by the stretching of ligaments as your uterus grows. They are nothing to worry about.' "These are called Braxton Hicks contractions. They are a kind of 'practice' for when the baby is born." "You are having growing pains. There is nothing to worry about."

"These pains are caused by the stretching of ligaments as your uterus grows. They are nothing to worry about.'

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 2 6 8

4

When caring for an older adult, the nurse would know that wound healing rate reduces normally with aging by 30% 20% 40% 50%

50%

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? A. "You have conductive hearing loss." B. "You have a high frequency hearing loss." C. "You have nerve damage in your ears." D. "You have a unilateral hearing loss."

A. "You have conductive hearing loss."

Which principle should guide the nurse's approach when conducting a general survey on an older adult client? A. Allow the client time to answer questions B. Speak louder than normal to the client C. Read all written instructions for the client D. Direct questions to family whenever possible

A. Allow the client time to answer questions

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? A. Chronic obstructive pulmonary disease B. System lupus erythematosus C. Heart failure D. Diabetes mellitus

A. Chronic obstructive pulmonary disease

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? A. Ensure a patent airway B. Obtain a throat culture C. Correct clients dehydration D. Begin antibiotics immediately

A. Ensure a patent airway

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. A. Heat Intolerance B. Cold Intolerance C. Headache D. Anxiety E. Palpitations

A. Heat Intolerance D. Anxiety E. Palpitations

A client comes to the clinic reporting pain in her legs while walking. the client states the pain is goes away when resting. The nurse suspects the client is experiencing what? A. Intermittent claudication B. Varicose veins C. Deep vein thrombosis D. Pulmonary embolism

A. Intermittent claudication

the six Ps of arterial occlusion include which of the following? Select all that apply. A. Pulselessness B. Pilonidal C. Paresthesia D. Pilocarpine E. Pallor F. Pain

A. Pulselessness C. Paresthesia E. Pallor F. Pain

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? A. Systolic pressure 201 mm Hg B. Apical pulse 70 beats/minute C. Respirations 12 breaths/minute D. Oxygen saturation 95% on room air

A. Systolic pressure 201 mm Hg

When educating a client about healthy habits relating to cardiovascular health, it is important to include which of the following? Select all that apply. A. Undergo regular cholesterol screening B. Undergo regular screening for diabetes C. Eat a low-fiber diet D. Quit or do not start smoking E. Exercise regularly

A. Undergo regular cholesterol screening B. Undergo regular screening for diabetes D. Quit or do not start smoking E. Exercise regularly

During the assessment, the nurse identifies warm thick skin that is reddish-blue. The nurse also notes an ulcer at the ankle that The client describes pain at the ulcer site as achy. The nurse suspects the client may have what? A. Venous insufficiency B. Intermittent claudication C. Arterial insufficiency D. Hypertrophic changes

A. Venous insufficiency

According to the guidelines from the Centers for Disease Control and Prevention (CDC), why are nurses supposed to wear gloves? (Select all that apply.) A. reduce the risk of infecting health care personnel B. reduce the number of bacteria in the health care environment C. reduce transient contamination of the hands D. prevent the transmission of bacteria from nurses to clients E. help maintain a sterile environment

A. reduce the risk of infecting health care personnel C. reduce transient contamination of the hands D. prevent the transmission of bacteria from nurses to clients

How does the nurse use critical thinking when accurately assessing vital signs? A. Evaluating assessment techniques B. Developing nursing diagnoses C. Monitoring evaluations D. Planning assessment techniques

B. Developing nursing diagnoses

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?" Provide breast-feeding support Educate the client about nutrition and overeating, exercise, and stress management techniques Assess the structure, resources, and coping abilities of the family Help the client move toward an enriching lifestyle

Assess the structure, resources, and coping abilities of the family

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? A. Tenting indicates malnutrition B. Tenting indicates dehydration C. Tenting indicates vitamin B12 deficiency D. Tenting indicates dramatic weight loss

B. Tenting indicates dehydration

While performing an assessment, the nurse presses the tissue on the legs and there is increased pitting with a 6-mm depression. How would the nurse document this? A. 4+ pitting edema B. 3+ pitting edema C. 1+ pitting edema D. 2+ pitting edema

B. 3+ pitting edema

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? A. Breast abscess B. Gynecomastia C. Cysts D. Fibroadenoma

B. Gynecomastia

The nurse is caring for a client with a sudden onset of chest pain. Which assessment is highest priority? A. Auscultate heart sounds B. Obtain pulse and blood pressure C. Percuss the left border D. Inspect the precordium

B. Obtain pulse and blood pressure

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: A. Ataxia. B. Positive Romberg sign. C. A normal finding. D. Lack of coordination.

B. Positive Romberg sign.

The nurse palpates a fine, round, mobile, nontender nodule and suspects that it is A. a cyst B. a fibroadenoma C. breast cancer D. a fibrocystic breast change

B. a fibroadenoma

When assessing the lower extremities, it is critical that the examiner A. starts at the feet. B. compares side to side. C. evaluates the venous system and then the arterial system. D. starts at the femoral area.

B. compares side to side.

The nurse recognizes that the 60-year-old patient may have difficulty reading fine print because of A. asthenopia B. the loss of accommodation C. the unequal size of the pupils D. amblyopia

B. the loss of accommodation

Which client-satisfaction related intervention of staff nurses may lead to improved client outcomes? Leaving client room doors open Daily client rounds Bedside hand-off reports Request that visitors remain in waiting room

Bedside hand-off reports

What techniques can be performed when palpating the breasts? Select all that apply. A. Rectangular pattern B. Side to side pattern C. Circular pattern D. Wedge pattern E. Vertical pattern

C. Circular pattern D. Wedge pattern E. Vertical pattern

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? A. The client's background B. Information that the nurse obtains from the family C. Complete and accurate assessment findings D. Data in old medical records

C. Complete and accurate assessment findings

A client reports to the ER complaining of pain in their left calf. Upon assessment a nurse notes the reported area is edematous, red, and warm to the touch. The nurse suspects the client may have what? A. Varicose veins B. Pulmonary embolism (PE) C. Deep vein thrombosis (DVT) D. Lymphedema

C. Deep vein thrombosis (DVT)

A client in the ED tells a nurse that she feels short of breath. What term would the nurse use in documenting this finding? A. Orthopnea B. Tachypnea C. Dyspnea D. Anxiety

C. Dyspnea

Which of the following would the nurse consider objective data? A. Smoking history B. Reported palpitations C. Evaluating the jugular pulse D. Chest pain

C. Evaluating the jugular pulse

Which of the following assessment findings would lead the nurse to suspect that a client has Bell's palsy? A. Inability to detect sharp and dull stimuli B. Closure of the affected eye from swelling C. Inability to wrinkle the forehead D. Muscle spasm of the lower face on the affected side

C. Inability to wrinkle the forehead

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. A. An abundant lymph supply B. Deep cervical and retropharyngeal nodes C. Patency of the sinus ostia D. Normal cilia function E. Normal quality and quantity of the mucous

C. Patency of the sinus ostia D. Normal cilia function E. Normal quality and quantity of the mucous

A high-pitched crowing sound from the upper airway results fro tracheal or laryngeal spasm and is called what? A. Wheezes B. Rales C. Stridor D. Crackles

C. Stridor

The nurse assessing a clients skin identifies an ulcer. What would indicate to the nurse it is an arterial ulcer? A. The extremity has a pulse B. The borders are irregular C. The ulcer is necrotic D. The ulcer is superficial and pale

C. The ulcer is necrotic

Which formula will the nurse use to calculate cardiac output A. heart rate x preload B. preload x afterload C. heart rate x stroke volume D. systolic x diastolic

C. heart rate x stroke volume

HIPAA gives clients greater control over their medical records. What else does HIPAA provide? A. Copying of medical records B. Education of lay people about medical records C. Client recourse if privacy protections are violated D. Legal use of medical records

C. Client recourse if privacy protections are violated

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? A The evaluation of financial reimbursement B. The evaluation of client nutrition C. The evaluation of care for continual improvement D. The evaluation of timely documentation of pain

C. The evaluation of care for continual improvement

To make a legal entry into the medical record, the nurse must document what? A. Laboratory tests ordered B. Attending physician C. Time of the assessment D. Nature of the assessment

C. Time of the assessment

A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment? A. To establish rapport with the client and family. B. To quantify the degree of pain a client may be experiencing. C. To establish a database against which subsequent assessments can be measured. D. To gather information for specialists to whom the client might be referred.

C. To establish a database against which subsequent assessments can be measured.

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.) Choking prevention Suffocation prevention Reading to the baby Bundling the baby Sleep positioning

Choking prevention Suffocation prevention Sleep positioning

The point of maximum impulse is most often found where? A. 2nd intercostal space (ICS), left midclavicular line (MCL) B. 5th intercostal space (ICS), right midclavicular line (MCL) C. 2nd intercostal space (ICS), right midclavicular line (MCL) D. 5th intercostal space (ICS), left midclavicular line (MCL)

D. 5th intercostal space (ICS), left midclavicular line (MCL

Moving a part of the body away from the mid line is called? A. Flexion B. Adduction C. Extension D. Abduction

D. Abduction

A respiratory pattern that gradually becomes faster and deeper than normal, then slower, alternating with periods of apnea is known as which respiratory pattern? A. Tachypnea B. Kussmaul's C. Eupnea D. Cheyne-Stokes

D. Cheyne-Stokes

Which of the following tests would be most appropriate for the nurse to use when assessing motor function of the trigeminal nerve? A. Have the client smile, frown, and wrinkle the forehead B. Ask the client to differentiate sharp and dull sensations on the face C. Assess dilatation of pupils with direct light D. Palpate the temporal and masseter muscles while the client clenches teeth

D. Palpate the temporal and masseter muscles while the client clenches teeth

What pulse is located in the groove between the medial malleolus and the Achilles tendon? A. Dorsalis pedis B. Femoral C. Popliteal D. Posterior tibial

D. Posterior tibial

The sternal angle at the right 2nd rib space is also known as what? A. The tricuspid area B. The mitral area C. The pulmonic area D. The aortic area

D. The aortic area

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? Count respirations. Check for pupil reaction. Assess blood pressure. Ensure a patent airway.

Ensure a patent airway.

The nurse should recognize that which acute change in heart rate requires urgent attention and intervention in an adult hospitalized client? Decrease to 54 beats/minute Increase to 90 beats/minute Decrease to 44 beats/minute Increase to 112 beats/minute

Decrease to 44 beats/minute

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? Inspection with indirect lighting Iliopsoas muscle sign Indirect percussion of CVA tenderness Blumberg sign

Indirect percussion of CVA tenderness

When conducting a focused health assessment, the nurse asks questions specifically targeting what? The client's gender Issues and symptoms specific to the client The client's sexual orientation The client's culture

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? Scan the barcode on the client's chart, then administer the medications. Leave the room to obtain another armband for the client. Ask the client for name and birth date, then administer the medications. Confirm the client's identity with visitors who are present.

Leave the room to obtain another armband for the client.

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: Sticks out the tongue midline without tremors or deviation. Moves the head and shoulders against resistance with equal strength. Follows an object with his or her eyes without nystagmus or strabismus. Demonstrates the ability to hear normal conversation.

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? Small tonsils and adenoids Lack of deciduous teeth Poor pupillary reflex Mucus in the nasal passages

Mucus in the nasal passages

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. Tell the client he/she can not have anymore pain medication. Administer another dose of Morphine early. Document the pain assessment findings and reassess in 30 minutes.

Notify the healthcare provider.

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? Stroke the abdomen to elicit the abdominal reflex Auscultate for lymph nodes Percuss the abdomen for shifting dullness Listen for a fluid wave

Percuss the abdomen for shifting dullness

The RN working on a surgical unit should question which of these orders before completing it? Change a central line dressing Reapply a staple in an incision Administer a narcotic infusion Check intracranial pressure

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? Turn up the client's hearing aid Speak in a louder than normal voice Make sure the door is not blocked Reduce or eliminate background noise

Reduce or eliminate background noise

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? Abdominal aorta Right iliac artery Right renal artery Right femoral artery

Right iliac artery

A patient reports changes in bowel pattern. Which is the best question to determine normal bowel habits? Is there a family history of irritable bowel syndrome? How often do you have a bowel movement? Have any of your parents or siblings had cancer of the colon? What was your bowel pattern before you noticed the change?

What was your bowel pattern before you noticed the change?

Nursing students are learning about different methods of charting in clinical. What method is the model for improving communication between and among clinicians? A. SBAR B. CBE C. SOAP D. PIE

a. SBAR

Decreasing the angle between bones is called A. Flexion B. Inversion C. Eversion D. Extension

a. flexion

Which type of vessels filter pathogens from the body and drain the fluid that has moved outside of the circulation back into the vessels? A. Lymphatic B. Aortic C. Veins D. Arteries

a. lymphatic

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? A. Size B. Pallor C. Symmetry of the chest D. Nipple size

a. 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. A. Swishing B. Humming C. S3 & S4 D. S1 & S2

a. swishing

the RN may delegate which care component to a nursing assistant? Evaluating vital signs Ambulation assistance Check client's pain level Wound care and assessment

ambulation assistance

A patient is reporting pain after palpation of the right lower quadrant. What condition does the nurse expect? Nephrolithiasis Appendicitis Irritable bowel syndrome Gastroenteritis

appendicitis

When documenting a finding over the stomach, the nurse most accurately identifies the region as which of the following? hypogastric epigastric RUQ LUQ

epigastric

t/f If S4 is present, it will be heard following S1 and sounds like "lub-lub dub."

false

t/f The Right Middle Lobe can best be assessed posteriorly.

false

t/f The nurse assesses the response of the eye to light and documents normal findings as PERLLA

false

t/f One extremity cooler than the other indicates venous insufficiency.

false arterial insufficiency

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? A. Comprehensive B. Functional C. Head to toe D. Body systems

functional

When caring for clients in any health care environment, what is the most important technique for preventing infection? A. Sterile technique B. Standard precautions C. Hand hygiene D. Use of gloves

hand hygiene

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? Focused Shift Comprehensive Immediate

immediate

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 Bleeding time Potassium level Iron level

lead level

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 White blood cells and albumin Glucose and white blood cells Protein and albumin

protein and glucose

t/f Maintaining fluid balance is one function of the lymphatic system.

true

t/f S1 results from closure of the mitral and tricuspid valves.

true

t/f When auscultating the thorax for adventitious breath sounds it is important to listen at each site for at least one complete respiratory cycl

true

t/f 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

What percussion sound is heard over most of the abdomen? Dullness Tympany Hyperresonance Resonance

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: Tinnitus Syncope Dizziness Vertigo

vertigo

A client has just been diagnosed with osteopenia. To help prevent progression to osteoporosis, the nurse would teach this client about what? Vitamin B12 supplements Vitamin A supplements Vitamin D supplements Vitamin E supplements

vit D