Exam Two Study Questions
A nurse is interviewing a client as part of a routine examination of his ears and hearing. The nurse notes that this client has high blood pressure. Which of the following questions regarding his hearing should the nurse ask that is associated with his high blood pressure? "Are you ever concerned that you may be losing your ability to hear well?" "Do you have any ear drainage?" "Do you experience any ringing, roaring, or crackling in your ears?" "Do you have any ear pain?"
"Do you experience any ringing, roaring, or crackling in your ears?"
The nurse is preparing to perform a musculoskeletal examination on an adult client. The nurse has explained the examination procedure to the client. The nurse determines that the client needs further instructions when the client says "You'll continue with range of motion even if I have discomfort." "You'll be comparing bilateral joints." "You'll be assessing the size and strength of my joints." "You will be asking me to change positions often."
"You'll continue with range of motion even if I have discomfort."
Which vision acuity reading indicates blindness? 20/100 20/20 20/200 20/40
20/200
The nurse begins auscultating a client's heart sounds at the 2nd intercostal space right sternal border. Which location should the nurse assess next? 2nd intercostal space left sternal border 4th left intercostal space 3rd intercostal space left sternal border 5th left intercostal space midclavicular line
2nd intercostal space left sternal border
A mother of a small child calls the clinic and asks to schedule an appointment for ear tube removal. The call is transferred to the nurse. What is the nurse's best action? Ask healthcare provider about prescribing antibiotics before removal. Schedule appointment at hospital for tubes to be removed surgically. Ask the mother how long the tubes have been in place. Schedule first available office appointment.
Ask the mother how long the tubes have been in place.
A 63-year-old nurse comes to the office upset because she has found an enlarged lymph node under her right arm. She states she found it last week while taking a shower. She isn't sure if she has any breast lumps because she doesn't know how to do self-breast examinations. She states her last mammogram was 5 years ago and it was normal. Her past medical history is significant for high blood pressure and chronic obstructive pulmonary disease. She quit smoking 2 years ago after a 55-pack a year history. She denies any illegal drugs and drinks alcohol rarely. Her mother died of a heart attack and her father died of a stroke. She has no children. Examination shows an older woman appearing her stated age. Visual inspection of her right axilla reveals nothing unusual. Palpation reveals a 2-cm hard fixed lymph node. She denies any tenderness. Visualization of both breasts is normal. Palpation of her left axilla and breast is unremarkable. On palpation of the right breast, the nurse detects a nontender 1-cm lump in the tail of Spence. What disorder of the axilla is most likely responsible for her symptoms? Hidradenitis suppurativa Breast cancer Lymphadenopathy of infectious origin
Breast Cancer
When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics? Congruency, induration, size, turgor Delineation, integrity, shape, color Consistency, delineation, mobility, tenderness Configuration, discreteness, temperature, color
Consistency, delineation, mobility, tenderness
A Nurse Practitioner is examining a client who presented at the free clinic with vulvar pruritus. Which assessment factor would the practitioner look for that may indicate that the client has an infection caused by Candida albicans? Cottage cheese-like discharge Gray-white discharge Discharge with a fishy odor Yellow-green discharge
Cottage cheese-like discharge
A nurse is working with a client who has an impaired ability to move the tongue. He explains that he was in an automobile accident many years ago and suffered nerve damage that resulted in this condition. Which nerve should the nurse suspect was damaged in this client? Cranial nerve XII (hypoglossal) Cranial nerve X (vagus) Cranial nerve I (olfactory) Cranial nerve VII (facial)
Cranial nerve XII (hypoglossal)
A client complains of abdominal pain with cramping diarrhea, nausea, vomiting, weight loss, and loss of energy. The nurse should suspect which of the following as the underlying cause? Pancreatitis Gastroesophageal reflux Crohn's disease Gastric ulcer
Crohn's disease
A client visits a community clinic reporting severe allergies causing a "crackling sensation" in the ear. The physician diagnoses serous otitis media. Which of the following is a characteristic of this condition? This condition develops if acute purulent otitis media is not treated promptly. This condition is usually associated with a puncture eardrum. Fluid collects in the middle ear causing an obstruction of the auditory tube. An upper respiratory infection spreads through the auditory tube.
Fluid collects in the middle ear causing an obstruction of the auditory tube.
You are caring for a client in the outpatient clinic with suspicion of cancer due to recent weight losses for unidentifiable reasons. The client a 25-year history of smoking. You perform an assessment and ask the client about symptoms related to laryngeal cancer. What is an early symptom associated with laryngeal cancer? Alopecia Dyspnea Dysphagia Hoarseness
Hoarseness
The nurse is discussing risk factors of an aneurysm. What should be included? Select all that apply. Smoking Family history Lack of activity Hypertension Diabetes
Hypertension Smoking Family history
Upon observation, the nurse documents that a male child's urethral meatus is located on the underside of his penis. What is the term for this structural abnormality? Phimosis Epispadias Cryptorchidism Hypospadias
Hypospadias
The nurse tells a client that every woman past the age of puberty should have a complete pelvic examination, including a Pap test, every 1 to 3 years. What other information should the nurse provide to the client? It helps in the early detection of cervical cancer. Pap test is very accurate in detecting uterine cancer It is done during menstrual periods The client has to maintain knee-chest position for the test
It helps in the early detection of cervical cancer.
Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing? Blockage of a respiratory passage Decreased compliance of the lungs Fluid in the alveoli Narrowing or partial obstruction of an airway passage
Narrowing or partial obstruction of an airway passage
A nurse is performing a head and neck assessment on a client. Which area should the nurse inspect for facial symmetry? Nasolabial folds Temporomandibular joint Preauricular nodes Earlobes
Nasolabial folds
Mr. Martin is a 72-year-old smoker who comes to the clinic for a follow-up visit for hypertension. With deep palpation a pulsatile mass about 4 cm in diameter is palpable. What should the examiner do next? Refer to a vascular surgeon. Reassess by examination in 3 months. Reassess by examination in 6 months. Obtain abdominal ultrasound.
Obtain abdominal ultrasound.
Cranial Nerve I
Olfactory
A client comes to the clinic and reports pain when he touches his ear. With what is this finding most consistent? Otitis externa Otitis media Acoustic neuroma Meniere disease
Otitis externa
During a comprehensive assessment, a female client complains of intense external genital itching. The nurse should carefully assess for which condition that commonly presents with this symptom? Genital fissures Pediculosis pubis Enlarged inguinal lymph nodes Nabothian cysts
Pediculosis pubis
A nurse is describing some of the complications of sexually transmitted diseases (STDs) to a teenaged girl. Which of the following should the nurse mention? Select all that apply Breast cancer Pelvic inflammatory disease Ectopic pregnancy Scarring and adhesions on the fallopian tubes Infertility
Pelvic inflammatory disease Scarring and adhesions on the fallopian tubes Infertility Ectopic pregnancy
A client complains of recurring headaches that are worse when first waking in the morning and with coughing or sneezing. What would be the nurse's most appropriate action? Ask the doctor for an order for an MRI Perform a focused assessment Prepare the client for a spinal tap Perform a generalized assessment
Perform a focused assessment
A nurse inspects the cervix of a 33-year-old, nonpregnant client during a routine assessment. Which coloration of the cervix would indicate normal health in this client? Pale Red Blue Pink
Pink
During a physical assessment, the nurse identifies unequal chest expansion. The nurse knows this could be due to what? Select all that apply. Trauma Emphysema Pneumonia Atelectasis Pneumothorax
Pneumonia Atelectasis Trauma Pneumothorax
What pulse is located in the groove between the medial malleolus and the Achilles tendon? Dorsalis pedis Posterior tibial Femoral Popliteal
Posterior tibial
Which terms refers to the progressive hearing loss associated with aging? Otalgia Presbycusis Exostoses Sensorineural hearing loss
Presbycusis
On palpation of a client's prostate, a nurse detects hard, fixed, and irregular nodules on the prostate. Which condition should the nurse most suspect in this client? Hydrocele Prostate cancer Benign prostatic hypertrophy Acute prostatitis
Prostate cancer
A client has been diagnosed with candidiasis and prescribed fluconazole 20 mg PO now, following by 10 mg PO daily. What is the nurse's best action Assess the client's baseline renal function Assess the client's skin integrity and administer the medication as prescribed Question the provider about the prescribed dose Confirm the client's allergy status
Question the provider about the prescribed dose
The nurse is providing care for a 61-year-old female smoker who is 30 kg overweight and was diagnosed with type 2 diabetes several years prior. Which of the following teaching points regarding the prevention of peripheral artery disease (PAD) is most accurate? It's critical that you come to get screening tests twice annually. Quitting smoking and keeping good control of your blood sugar levels are important. If you develop swelling in your ankles or feet, then you should seek emergency care. I'll show you how to check your pulses at your groin, knees and feet to monitor your risk of PAD.
Quitting smoking and keeping good control of your blood sugar levels are important.
Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media? Red, bulging, with an absent light reflex Gray, translucent, with no retraction Yellowish, bulging, with fluid bubbles Pearly, translucent, with no bulging
Red, bulging, with an absent light reflex
A nurse should assist a client to assume what position to best assess the mouth, nose, and sinuses? Semi-recumbent position, with the chin lifted Tilting the head backwards, with the neck flexed Prone, with arms relaxed at the sides Sitting with the head erect and at the eye level of the nurse
Sitting with the head erect and at the eye level of the nurse
An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse? The client has COPD The client has asthma The client has chronic hypoxia The client has melanoma
The client has chronic hypoxia
A client tells the nurse that she has taken several doses of over-the-counter fluconazole to treat a "yeast infection." When assessing the client's risk for drug toxicity, what aspect of the client's health status should the nurse prioritize? The client has lost over 30 lbs. in the past four months through diet and exercise The client has type 2 diabetes and takes oral hypoglycemics The client experienced a transfusion reaction to packed red blood cells several years ago The client has decreased renal function following recent pyelonephritis
The client has decreased renal function following recent pyelonephritis
The submandibular glands open under the tongue through openings called Wharton ducts. Stensen ducts. parasinal ducts. lacrimonasal ducts.
Wharton ducts.
An adult client tells the nurse that she frequently experiences burning and itching of both eyes. The nurse should assess the client for a foreign body. blind spots. allergies. recent trauma.
allergies
The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the areola of the breast. adipose tissue. entire skin surface. soles of the feet.
areola of the breast.
The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should ask the client to breathe normally through her nose. place the bell of the stethoscope firmly on the posterior chest wall. auscultate from the base of the lungs to the apices. ask the client to breathe deeply through her mouth.
ask the client to breathe deeply through her mouth.
The middle layer of the eye is known as the retinal layer. optic layer. choroid layer. scleral layer.
choroid layer.
The lining of the trachea and bronchi, which serves to remove dust, foreign bodies, and bacteria, is termed the alveolar ducts. alveolar sacs. cilia. bronchioles.
cilia.
A client turns the head to the right after the nurse whispers the direction to do so in the client's left ear. What information should the nurse obtain from the client's response? the client understands directions cranial nerve XI is intact cranial nerve VIII is intact the client knows the difference between left and right
cranial nerve VIII is intact
The nurse has assessed a male client and determines that one of the testes is absent. The nurse should explain to the client that this condition is termed cryptorchidism. hematocele. orchitis. hypospadias.
cryptorchidism
When examining a client's musculoskeletal system, for which assessment should the client be in a seated position? hip abduction knee extension hip adduction elbow flexion
elbow flexion
The nurse observes an inward turning of the lower lid in a 77-year-old client. The nurse documents exophthalmos ptosis entropion ectropion
entropion
The outer layer of the vaginal wall is under the direct influence of androgen. aldosterone. progesterone. estrogen.
estrogen
Plantar Flexion
flexing foot down
Dorsiflexion
flexing foot up
When supine, a client's knees do not touch the examination table. On what area should the nurse focus to learn more information about this finding? flexion and extension gait abduction and adduction limb length
flexion and extension
The tongue is attached to the hyoid bone and styloid process of the temporal bone and is connected to the floor of the mouth by the mandible. frenulum. gums. soft palate.
frenulum.
Cranial Nerve IX
glossopharyngeal (swallowing)
The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the vagus. trigeminal. glossopharyngeal. hypoglossal.
glossopharyngeal.
During assessment of an adult client, which of the following lifestyle practices would indicate to the nurse that the client may be at high risk for HIV/AIDS? A client who smokes marijuana occasionally. uses a condom on a regular basis. has multiple female partners. has anal intercourse with other males.
has anal intercourse with other males.
The nurse is planning to assess a client's near vision. Which technique should be used? ask the client to move the eyes in the direction of a moving finger have the client read newspaper print held 14 inches from the eyes shine a light on the bridge of the nose have the client stand 20 feet from a wall chart and read the letters after covering one eye
have the client read newspaper print held 14 inches from the eyes
A male client has a distinctive bulge in the right inguinal area when standing. What should the nurse suspect is occurring with this client? hypospadias epidermoid cysts testicular torsion hernia
hernia
During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. The nurse should document which problem? herpes simplex angular cheilitis actinic cheilitis angioedema
herpes simplex
A client who is bedfast responds only to painful stimuli, never eats a complete meal, and moves occasionally in bed. Which term should the nurse use to describe this client's risk for skin breakdown? mild moderate negligible high
high
While assessing the nails of an older adult, the nurse observes early clubbing. The nurse should further evaluate the client for signs and symptoms of anemia. infection. hypoxia. trauma.
hypoxia.
A client has been placed on amphotericin B. The nurse caring for this client should administer this medication: intramuscularly. intravenously. subcutaneously. orally.
intravenously
In order to palpate an apical pulse when performing a cardiac assessment, where should the nurse place the fingers? right of the midclavicular line at the third intercostal space left midclavicular line at the fifth intercostal space right of midclavicular line at the fifth intercostal space left midclavicular line at the third intercostal space
left midclavicular line at the fifth intercostal space
L in COLDSPA
location
Abduction
movement away from the midline
Which situations should the nurse identify as being risk factors of the development of pressure sores? Select all that apply. restlessly changing position frequently shearing that occurs when sliding down in bed pressure that impairs capillary blood flow to the skin moisture being allowed to accumulate on the skin friction created by dragging the skin against bedlinen
pressure that impairs capillary blood flow to the skin friction created by dragging the skin against bedlinen shearing that occurs when sliding down in bed moisture being allowed to accumulate on the skin
A client who is an active outdoor swimmer recently received a diagnosis of discoid systemic lupus erythematosus. The client visits the clinic for a routine examination and tells the nurse that she continues to swim in the sunlight three times per week. She has accepted her patchy hair loss and wears a wig on occasion. A priority nursing diagnosis for the client is risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions. dry flaking skin and dull dry hair as a result of disease. ineffective individual coping related to changes in appearance. anxiety related to loss of outdoor activities and altered skin appearance.
risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions.
What task should a nurse ask a client to perform to assess the function of cranial nerve XI? walk in heel-to-toe fashion move tongue side to side shrug shoulders against resistance swallow water
shrug shoulders against resistance
The nurse completes the assessment of a client's reflexes. Which position should the nurse place the client to assess the Romberg sign? standing sitting supine prone
standing
Mrs. Ash, a client in her 50s, has told the nurse during her most recent visit to the clinic that she and her circle of friends have discontinued breast self-examination (BSE) since hearing and reading that the practice is now considered ineffective. How can the nurse best respond to Mrs. Ash? "BSE is certainly not a replacement for other screening methods, but a high proportion of breast masses are in fact detected by women themselves." "It's true that BSE doesn't really help to detect cancerous masses, but it's still a good way to be systematic about assessing your own health." "Actually, the recent statistics show that BSE plays a key role in reducing a woman's risks of death from breast cancer." "As long as you are conscientious about getting mammograms and clinical examinations regularly, there is likely no need for you to continue doing BSE."
"BSE is certainly not a replacement for other screening methods, but a high proportion of breast masses are in fact detected by women themselves."
A client presents with otalgia and yellow-green discharge from the external ear canal. Which question should the nurse ask to determine the cause of this problem? "Have you ever taken medication that is ototoxic?" "Do you hear ringing in your ears?" "Have you had any recent trauma to the inside of your ear?" "Are their times when you feel dizzy?"
"Have you had any recent trauma to the inside of your ear?"
The nurse recognizes that which client is at greatest risk for the development of skin cancer? 28-year-old Caucasian male who works in a paper mill 15-year-old female with facial freckles 55-year-old male who lived in California for 20 years 45-year-old female with 10 year history of cigarette smoking
55-year-old male who lived in California for 20 years
The nurse is caring for several clients who have fungal infections. Which client should the nurse prioritize for informing the provider? A client receiving amphotericin B whose torso appears jaundiced A client with candidiasis who has been prescribed nystatin and who requires education A client who has a dose of miconazole vaginal suppository due in 15 minutes A client who reports the new onset of a rash where terbinafine is being applied
A client receiving amphotericin B whose torso appears jaundiced
Cranial Nerve VI
Abducens (eye movement)
What do retinal abnormalities include? Horner's syndrome Argyll Robertson syndrome Age-related macular degeneration Mydriasis
Age-related macular degeneration
The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions? Wear nonslip shoes in the house. Avoid risky activities such as snowboarding Use of guns should be supervised by an adult Always use seat belts.
Always use seat belts.
When collecting a client's medical history, the nurse should ask if the client is taking which medications that most likely contribute to complaints of recurrent epistaxis? (Select all that apply.) Hormones Antihistamines Anticoagulants Herbal supplements Central nervous system agents
Anticoagulants Herbal supplements Antihistamines
A nurse is preparing to examine a client from Southeast Asia who has been experiencing chronic headaches. Which of the following should the nurse do in light of this client's cultural background? Avoid asking the client to remove her clothes for the examination Have a nurse who is the same sex as the client perform the examination Palpate the client's feet before palpating the head Ask permission before palpating the head and neck
Ask permission before palpating the head and neck
A 66-year-old woman has come to the clinic with complaints of increasing fatigue over the last several months. She claims to frequently feel lethargic and listless and states that, "I can never seem to get warm, no matter what the thermostat is set at." How should the nurse proceed with assessment? Assess for other signs and symptoms of Cushing's syndrome. Assess the woman for hypothyroidism. Order tests to rule out an overactive thyroid gland. Palpate the woman's parotid gland for enlargement.
Assess the woman for hypothyroidism.
When you enter the room of a hospitalized client, the intravenous pump is alarming. The client is restless, moaning, crying, and exhibiting guarding behavior. An uneaten meal is sitting on the over-bed table; several family members are arguing loudly. What would be your priority? Talking with family members Troubleshooting the infusion pump Assessing nutrition Assessing for pain
Assessing for pain
A in COLDSPA
Associated factors
A nurse is assessing a client for the presence of asynchronous contraction in the heart. Which of the following should the nurse do? Observe for a decrease in jugular venous pressure Auscultate for split S1 at the base and apex Assess for a difference between the apical and radial pulse Check for pulse inequality between right and left carotid arteries
Auscultate for split S1 at the base and apex
A client is explaining to the nurse how vaginal dryness has decreased her enjoyment of sexual intercourse. The nurse is aware that which of the following are the glands that produce mucus that lubricates the vagina during intercourse? Sebaceous glands Bartholin's glands Cowper's glands Eccrine glands
Bartholin's glands
Which alteration in the pattern of the cardiac pulse should a nurse expect to find on examination of a client with aortic regurgitation? Pulsus alternans Bisferiens pulse Bigeminal pulse Paradoxical pulse
Bisferiens pulse
The nurse enters a client's hospital room and the client asks the nurse to raise him up in the bed. What is the nurse's best action? Lower the head of bed and pull the client up with both arms. Place the client in Trendelenburg so the client can slide up in bed. Push the client toward the head of the bed to prevent back injury. Call for help and use the draw sheet to move the client.
Call for help and use the draw sheet to move the client.
When inspecting the mouth, the nurse focuses on lateral and vertical surfaces of the tongue and its base, because these are regions where: Sloughing of papillae begins. Cancers often occur. Lesions from loose dentures are found. Early jaundice can be detected.
Cancers often occur.
A client with a right subclavian central line develops fever of 101.0 degrees Fahrenheit. What is the nurse's best action? Discontinue the central line. Culture the tip of the central line. Flush all ports with heparin solution. Check the insertion site for redness.
Check the insertion site for redness.
A young woman comes in with brief, rapid, jerky, irregular movements. They occur at rest or during intentional movements and involve mostly her face, head, lower arms, and hands. How would you describe these movements? Chorea Dystonia Tics Athetosis
Chorea
A light is pointed at a client's pupil, which then contracts. It is also noted that the other pupil contracts as well, though it is not exposed to bright light. Which of the following terms describes this latter phenomenon? Consensual reaction Accommodation Direct reaction Near reaction
Consensual reaction
The nurse should recognize that which acute change in heart rate requires urgent attention and intervention in an adult hospitalized client? Increase to 112 beats/minute Decrease to 54 beats/minute Decrease to 44 beats/minute Increase to 90 beats/minute
Decrease to 44 beats/minute
The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions? Arrangement Type Distribution Color
Distribution
The nurse is beginning the examination of the skin of a 25-year-old teacher. She previously visited the office for evaluation of fatigue, weight gain, and hair loss. The previous clinician had a strong suspicion that the client has hypothyroidism. What is the expected moisture and texture of the skin of a client with hypothyroidism? Moist and smooth Dry and smooth Moist and rough Dry and rough
Dry and rough
A client in the ED tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding? Tachypnea Anxiety Dyspnea Shortness of breath
Dyspnea
Which of the following is an essential topic when discussing risk factors for peripheral arterial disease with a client? Exercise tolerance Significance of cardiac dysrhythmias Prevention of varicose veins Extent of tobacco use and exposure
Extent of tobacco use and exposure
Cranial Nerve VII
Facial - controls most facial expressions & secretion of tears & saliva & taste
A 54-year-old man is found to be anemic. Which of the following nursing diagnoses is most likely to be recorded in his plan of care? Fatigue Decreased activity level Altered nutrition Depression
Fatigue
What range of motion is the nurse testing by asking a client to stoop to pick an object off the floor? Abduction Flexion Extension Rotation
Flexion
What would the nurse expect to hear when auscultating the lungs of a client diagnosed with pleuritis? Sibilant wheeze Decreased breath sounds Friction rub Stridor
Friction rub
A six-month old male infant is brought to the emergency department by his parents for inconsolable crying and pulling at his right ear. When assessing this infant the nurse is aware that the tympanic membrane should be what color in a healthy ear? Yellowish-white Red Gray Bluish-white
Gray
An adolescent present at the free clinic with a collection of fluid in the tunica vaginalis of the testes. The nurse knows that the term that defines this condition is what? Prostatism Cryptorchidism Orchitis Hydrocele
Hydrocele
Cranial Nerve XII
Hypoglossal (tongue movement)
A client presents to the health care clinic with a 3-week history of pain and swelling of the right foot. A nurse inspects the foot and observes swelling and a large ulcer on the heel. The client reports the right heel is very painful and he has trouble walking. Which nursing diagnosis should the nurse confirm from these data? Risk for Skin Breakdown Fear of Loss of Extremity Impaired Skin Integrity Imbalanced Nutrition
Impaired Skin Integrity
The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes? In front of the ear In the midline, a few centimeters behind the tip of the mandible Superficial to the sternomastoid At the angle of the mandible
In the midline, a few centimeters behind the tip of the mandible
The nurse understands that when the sympathetic nervous system is stimulated what occurs? Select all that apply. Increased cardiac output Decreased cardiac output Increased blood pressure Decreased blood pressure Increased heart rate
Increased cardiac output Increased blood pressure Increased heart rate
Before the nurse begins the physical examination of a client with congestive heart failure, the client reports having to get up at night to void frequently. Which action should the nurse take in response to the client's report? Assess for thrills. Inspect for dependent edema. Ensure that the client lies flat for the examination. Palpate the carotid pulse.
Inspect for dependent edema.
IPPA stands for
Inspection Palpation Percussion Auscultation
A nurse is inspecting the abdomen of a young, fit client who has well-defined abdominal muscles. The nurse recognizes the vertical line that appears in the center of the client's abdomen as which of the following? Transverse abdominis Peritoneum Internal abdominal oblique Linea alba
Linea alba
When performing an assessment of the nervous system, it is most appropriate for a nurse to complete it in which sequence? Reflexes, sensory, motor/cerebellar, cranial nerves, mental status Motor/cerebellar, sensory, reflexes, cranial nerves, mental status Cranial nerves, motor/cerebellar, sensory, reflexes, mental status Mental status, cranial nerves, motor/cerebellar, sensory, reflexes
Mental status, cranial nerves, motor/cerebellar, sensory, reflexes
A nurse recognizes that which finding is normal upon palpation of the prostate? Swollen and tender Hard, fixed, irregular nodules Nontender and rubbery Enlarged, smooth, firm, slightly elastic
Nontender and rubbery
The nurse is unable to palpate a pedal pulse in the right leg of an adult client. What the nurse's best action? Elevate the client's right leg. Apply sequential compression devices. Obtain a Doppler to verify absent pulse. Notify the healthcare provider.
Obtain a Doppler to verify absent pulse.
Cranial Nerve III
Oculomotor - eyelid and eyeball movement
A nurse is caring for a client who uses a hearing aid for amplifying sound. During the Rinne test for checking the bone conduction of the sound, where should the nurse place the stem of the vibrating tuning fork? On the mastoid area. Center of the head. Near the ear canal. Behind the client's head.
On the mastoid area.
When auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following? One quiet full inspiration through pursed lips Two full breaths every 10 seconds through the nose Two full breaths in through the mouth and out through the nose One deep inspiration and expiration through the open mouth
One deep inspiration and expiration through the open mouth
Cranial Nerve II
Optic. Example: Visual fields and Pupillary light reflex
A client complains of difficulty sleeping, stating he has to sit up with the help of several pillows and cannot breathe when lying flat. This client has a condition known as what? Tachypnea Pneumonia Orthopnea Sleep apnea
Orthopnea
The nurse is present during a pelvic examination of a 21-year-old female client. Which action should the nurse prepare for first? Pap smear specimen collection Apply spray fixative on specimen slides Gonorrhea culture specimen collection Chlamydia culture specimen collection
Pap smear specimen collection
A 73-year-old woman comes to the office for evaluation of new onset of tremors. She is not taking any medications, herbs, or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow, shuffling steps. She has decreased facial mobility with a blunt expression without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the client's symptoms? Cushing's syndrome Myxedema Parkinson's disease Nephrotic syndrome
Parkinson's disease
A nurse is discussing breast self-examination (BSE) with a 60-year-old woman. Which of the following should the nurse recommend? Picking a set day of the month that the client will remember on which to perform BSE Discontinuing the practice, as it is no longer needed after menopause Performing BSE annually, on the client's birthday Performing BSE as soon as menstruation ceases each month
Picking a set day of the month that the client will remember on which to perform BSE
An 80-year-old woman is receiving treatment with oral fluconazole for a fungal infection Following yesterday's and today's dose, she reports an upset stomach to the charge nurse. How should the nurse at the facility best respond to the woman's report? Stop administering the fluconazole and inform the client's physician. Assess the client for signs and symptoms of an infusion reaction. Arrange for the client to receive intravenous fluconazole on an outpatient basis. Provide food along with the fluconazole when administering it in the future.
Provide food along with the fluconazole when administering it in the future.
What sequence do you follow when auscultating bowel sounds? RUQ,LLQ,LUQ,RLQ LLQ,LUQ,RUQ,RLQ RLQ,RUQ,LUQ,LLQ
RLQ,RUQ,LUQ,LLQ
A nurse inspects the cervix of a 28-year-old, nonpregnant client during a routine assessment. Which coloration of the cervix may indicate inflammation? Red Pale Blue Pink
Red
Which nursing diagnosis is most appropriate for an elderly client with poor dentition? Risk for Imbalanced Nutrition: Less Than Body Requirements Fluid volume deficit Diarrhea Constipation
Risk for Imbalanced Nutrition: Less Than Body Requirements
A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. The client states that he almost ran into a parked car yesterday because he misjudged the distance from the bumper of his own car. He works for a computer software company and has noticed he is experiencing difficulty reading the manuals that accompany the software he installs for companies. What nursing diagnosis can the nurse confirm based on this data? Disturbed Self Concept Risk for Injury Self-Care Deficit Ineffective Individual Coping
Risk for Injury
A client presents at the clinic complaining of a loss of balance. What test should the nurse expect the physician to carry out on a client with a loss of balance? Romberg test Audiometric test Weber test Rinne test
Romberg test
Internal Rotation
Rotation of a joint toward the middle of the body.
A client comes to the emergency department reporting a sudden onset of dyspnea. What finding is a manifestation of dyspnea? Painful breathing Inability to breathe Shortness of breath Rapid breathing
Shortness of breath
Cranial Nerve XI
Spinal Accessory - controls trapezius & sternocleidomastoid
The client has been admitted with pneumonia. What should the nurse assess? Heart tones Swelling Sputum Peripheral pulses
Sputum
During a shift assessment, the nurse finds the client unable to speak and her face is asymmetrical. What does the nurse suspect? Myocardial infarction Bell's palsy Sepsis Stroke
Stroke
The client is facing the nurse with his forearm turned so that his palm is up. What movement is the client exhibiting? Eversion Supination Pronation Inversion
Supination
What finding upon assessment would indicate the client is experiencing shock? Temperature 99.5 F Heart rate 100 Systolic blood pressure 50 Respiratory rate 24
Systolic blood pressure 50
Mrs. Fletcher presents to the office with chronic unilateral pain when chewing. She does not have facial or scalp tenderness. Which of the following is the most likely cause of her pain? Temporal arteritis Tumor of the mandible Trigeminal neuralgia Temporomandibular joint syndrome
Temporomandibular joint syndrome
Which of the following assessment findings would signal a pathophysiological finding to the nurse? S2 is split when the nurse asks the client to inhale deeply but is not split on exhalation. Auscultation at the client's apex reveals that S1 is louder than S2. The intensity of the client's S1 varies between beats. S1 is softer than S2 when the nurse listens at the base of the client's heart.
The intensity of the client's S1 varies between beats.
The nursing instructor is discussing the difference between sensorineural and conductive hearing loss with his class. The discussion turns to evaluation for determining what kind of hearing loss a client has. What Weber test results would indicate the presence of a sensorineural loss? The sound is heard better in the ear in which he has poorer hearing. The sound is better in the ear in which he has better hearing. The sound is heard equally in both ears. The sound is heard longer in the ear in which he has better hearing.
The sound is better in the ear in which he has better hearing.
Which observation confirms to the nurse that the client is experiencing a normal inspiration? Air can be heard moving out of the tracheobronchial tree. The diaphragm is seen relaxing. The abdominal wall is pushed inward. The thoracic cavity enlarges.
The thoracic cavity enlarges.
Cranial Nerve V
Trigeminal - chewing face & mouth touch & pain
Cranial Nerve IV
Trochlear (eye movement)
A decrease in oxyhemoglobin will result in documentation of pallor. True or False:
True
While examining the perineum of a female client, the nurse notes an enlarged knot to the right side just below the vaginal opening. The nurse will most likely note this as an enlarged Bartholin gland. False True
True
How can a nurse accurately assess the distant visual acuity of a client who is non-English speaking? Perform the confrontation test Use a Snellen E chart to perform the examination Have the client read from a Jaeger reading card Move an object through the six cardinal positions of gaze
Use a Snellen E chart to perform the examination
Cranial Nerve X
Vagus Swallowing Gag
When you enter the room of a hospitalized client, you note that the client is guarding her left leg, which is swollen and reddened. You should identify the signs and symptoms of what complication of hospitalization? Fluid imbalance Decreased mobility Venous thromboembolism Sepsis
Venous thromboembolism
Cranial Nerve VIII
Vestibulocochlear (hearing and balance)
Before beginning the examination of the genitalia of an adult male client, the nurse should ask the client to empty his bladder. tell the client that he will remain in a supine position. tell the client that he may leave his underwear in place. ask the client to leave his shirt in place.
ask the client to empty his bladder.
Flexion
bending of the joint
The nurse suspects that a male client may have a hernia. The nurse should further assess the client for urinary tract infection. bowel sounds at the bulge. bruising at the site. cysts at the spermatic cord.
bowel sounds at the bulge.
C in COLDSPA
character
D in COLDSPA
duration
When should the nurse assess a client's lymph nodes? while assessing the head and neck during the assessment of the associated body area during the assessment of the anterior chest after assessing the abdomen
during the assessment of the associated body area
Two body systems that may be logically integrated and assessed at the same time are the ear and nose exams. eye and ear exams. ear exam and cranial nerves IV, VI, and VIII. eye exam and cranial nerves II, III, IV, and VI.
eye exam and cranial nerves II, III, IV, and VI.
clubbing of nails
finding in the nails that indicates chronic hypoxia
A client visits the clinic and tells the nurse that she had a mastectomy 2 years ago. The nurse should assess the client for bruits over the radial artery. poor peripheral pulses. Raynaud disease. lymphedema.
lymphedema
While assessing an adult client's abdomen, the nurse observes that the client's umbilicus is deviated to the left. The nurse should refer the client to a physician for possible masses. kidney trauma. cachexia. gallbladder disease.
masses
Adduction
movement toward the midline
O in coldspa
onset
P in COLDSPA
pattern
While assessing the range of motion in an adult client's shoulders, the client expresses pain and exhibits limited abduction and muscle weakness. The nurse plans to refer the client to a physician for possible tendonitis. cervical disc degeneration. nerve damage. rotator cuff tear.
rotator cuff tear.
S in COLDSPA
severity
Extenstion
straightening the angle of the joint
Connecting the skin to underlying structures is/are the subcutaneous tissue. dermis layer. papillae. sebaceous glands.
subcutaneous tissue.
edema
swelling
A client visits the clinic and tells the nurse that he is depressed because of a recent job loss. He complains of dull, aching, tight, and diffuse headaches that have lasted for several days. The nurse should recognize that these are symptoms of tension headaches. migraine headaches. tumor-related headaches. cluster headaches.
tension headaches.
A client with congestive heart failure presents to the emergency department with soreness from swelling of the ankles. When conducting the physical examination of this client, the nurse would require a stethoscope for which reason? to auscultate the lungs to check the radial pulse to assess pedal pulses to assess jugular venous pressure
to auscultate the lungs
The nurse tests the six cardinal directions to test extraocular movement of the eye. True False
true
Pronate
turning down
Inversion
turning inward medially
Eversion
turning outward laterally
external rotation
turning the joint outward
Supinate
turning up
After assessing the breasts of a female client, the nurse should explain to the client that most breast tumors occur in the lower inner quadrant. upper outer quadrant. lower outer quadrant. upper inner quadrant.
upper outer quadrant.
While transilluminating the scrotal contents in a male adult client, the nurse does not detect a red glow. The nurse should refer the client to a physician for possible hydrocele. orchitis. spermatocele. varicocele.
varicocele
The rich blood supply of the nose serves to propel debris to the throat. filter large particles from the air. warm the inspired air. help propel moist air to the body.
warm the inspired air.
