Health Assessment final
A 17-year-old client has expressed concern over having a vaginal discharge just before her menses begins. What response should the nurse provide the client to best address her concerns?
"If there are no other signs or symptoms, it is likely a result of normal ovulation."
What instruction should a nurse give a client when having trouble eliciting a response from testing the patellar deep tendon reflex?
"Place your hands together, lock your fingers, and squeeze."
The nurse suspects a client's chest pain is of cardiac origin when the client states which of the following?
"The pain gets better when I rest."
The ABI is calculated by dividing the systolic BP at the dorsalis pedis by the systolic BP at the brachial artery. Which of the following values would be consistent with mild peripheral arterial disease?
0.85 RationalThe mild to moderate disease is represented by an ABI of 0.5 to 1.0. Severe disease is defined as 0.5 or less.:
A client presents with pitting edema to the left foot, which a nurse observes as a noticeably deep pit when the area is depressed and the extremity looks larger than the right. How should the nurse accurately document this amount of edema?
3+
A nurse assesses a 350-pound adult client who is 6 feet 1 inch tall. What is the estimated body mass index (BMI) for this client?
46 Rationale: The BMI is calculated by dividing weight in pounds by height in inches squared and then multiplying by 703. The body mass index calculated by the nurse should be approximately 46 for a client who is 6 feet 1 inch (73 inches) tall and 350 pounds.
The nurse is reviewing a client's cardiac output. The nurse identifies which cardiac output as being within the normal?
6 Rationale: Normal cardiac out put ranges from 5-8 L/min.
The peritoneum is a serous membrane that contains which of the following?
A parietal layer
You are using the Braden Scale to measure risk factors for pressure sores. What risk factors will you assess? Select all that apply.
Activity Nutrition moisture
A client at risk for peripheral arterial disease should be screened by which of the following tests?
Ankle-brachial index Rationale: The ABI is the primary screening tool used to detect asymptomatic or subclinical PAD.
When examining the uterus, a nurse finds that the uterus is flexed anteriorly in relation to the cervix. How should the nurse document this uterine finding?
Anteflexed
The nurse is palpating the apical impulse in a client with heart disease and finds that the amplitude is diffuse and increased. Which of the following conditions could be a potential cause of an increase in the amplitude of the impulse?
Aortic stenosis, with pressure overload of the left ventricle
A nurse assesses a newly admitted 43-year-old client and documents the vital signs as follows: temperature 98° F (36.7° C), pulse 93 beats/min regular rhythm and bounding, blood pressure 145/93 mm Hg, and respiratory rate 16 breaths/min. What is the first action of the nurse?
Ask the client if they are experiencing other symptoms.
A nurse is performing a comprehensive assessment on a client. The nurse observes excessive sweat and body odor. How should the nurse address these findings?
Ask the client if they experience periods of excessive sweating.
A client visits the health care facility with reports of lumbar back pain that radiates down the back. The nurse performs the straight leg test to determine the origin of the pain. Which techniques should the nurse use to perform this test?
Ask the client to raise the leg to the point of pain and then dorsiflex the foot
A client presents complaining of nausea, vomiting, and acute abdominal pain. What is the nurse's first action?
Ask the client when the pain began.
Which statement describes the correct technique by a nurse for use of a stethoscope to auscultate the chest for heart sounds?
Auscultate to determine the heart rate and if the rhythm is normal
The client is in a standing position. Which of the following can the nurse most effectively assess with the client in this position?
Balance
A 72-year-old male presents at a local clinic and states: "I have to urinate all the time, and I never feel like my bladder is emptied. It really bothers me at night." What condition might the nurse suspect related to this chief complaint?
Benign prostatic hyperplasia (BPH)
What intervention would be most helpful when conducting an interview with a client who has stated, "I'm a little hard of hearing"?
Closing the door may help to limit background noise.
The nurse assess for kidney tenderness at what location?
Costovertebral angle
A son brings his 80-year-old father into the clinic. The son is concerned because he feels as if his father is growing weak, losing interest in things he used to care about, and no longer coming to dinner on Sundays. The nurse would know that the father is at risk for what?
Depression
What can the nurse recommend to a young female client who is seeking to reduce her risk for breast cancer? Select all that apply.
Engage in regular, strenuous physical activity Have children before 30 years of age Breast-feed if possible
A client diagnosed with a peritonsillar abscess exhibits 4+ tonsils and is not able to eat or drink. What is the nurse's priority concern for this client?
Ensure a patent airway
The nursing student hopefuls are taking a pre-nursing anatomy and physiology class. What will they learn is the anatomical feature that equalizes air pressure in the middle ear?
Eustachian tube
During the breast examination of a client, the nurse notes firm but rubbery lesions in both breasts. The client comments that the lesions become tender just before menses. The nurse understands that these symptoms are most likely due to which breast condition?
Fibrocystic lesions
A client shares that a first-degree relative has an eye problem, but they not sure what the diagnosis is. What major eye problem will the nurse suggest screening the client for?
Glaucoma
Which strategy can the nurse use to effectively approach the older adult client during the health history?
Have the room well-lit with minimal background noise.
Which of the following should nurses teach all men, especially those who have had cryptorchidism?
How to perform a testicular self-examination.
A nurse would like to assess an elderly client's general functional status in performing daily chores. Which of the following should the nurse implement to make this assessment?
Katz Activities of Daily Living tool
When collecting a specimen from the cervix for cytology, the nurse does which of the following?
Labels glass slides and treats them immediately with fixative
Before beginning the assessment of the peripheral vascular system, a nurse should take what action to best facilitate the exam and ensure accurate results?
Make sure the temperature in the room is comfortable.
Which of the following indicates that an elderly client has been affected by polypharmacy?
Medications are used to counteract side effects of other prescribed medications.
A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms?
Migraine headache
During the abdominal examination, a nurse supports the client's right knee and ankle. The nurse flexes the client's hip and rotates the leg externally and internally. At this point, the client reports pain in the right lower quadrant. This test is positive for which sign?
Obturator Rationale: The test indicates a positive obturator sign, which is performed to assess for appendicitis. Psoas sign involves pain in the right lower quadrant on hyperextension of the client's right leg and indicates appendicitis. Murphy's sign is for assessment of cholecystitis and is elicited by pressing the fingers at the client's right costal margin and telling the client to inhale. Rovsing's sign involves pain caused by deep palpation in the left lower quadrant.
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.
At the completion of a reproductive health history, a female client tells the nurse about having pain with penetration during intercourse. What should the nurse assess at this time? (Select all that apply.)
Onset of the problem Severity of the problem What makes it better or worse
It is important for the nurse to apprise the client of what the nurse is doing and what the nurse finds as it does what?
Opens up teaching/learning moments
Which of the following unexpected findings of the testes is most likely to result in painful palpation of the testes?
Orchitis
What precaution should the nurse take when measuring a client's abdominal girth to screen for cardiovascular risk factors?
Place the tape measure behind the client and measure at the umbilicus
A nurse is assessing the mouth of an older client. Which of the following findings is common among older adults?
Receding and ischemic gums
The nurse is reviewing the functions of the ovaries, uterus, clitoris and vagina with a group of high school students. Based on this information, what would be the best response by the high school student about the function of the clitoris?
Small erectile structure that responds to sexual stimulation.
A nurse is preparing a teaching plan for a client newly diagnosed with peripheral arterial disease. To address the most modifiable risk factors, what risk factors would the nurse include? (Mark all that apply.)
Smoking Activity level High-fat diet
The client has been admitted with pneumonia. What should the nurse assess?
Sputum
A client with heart disease is concerned about the safety of engaging in sexual intercourse with his spouse. He says that he can walk a block or two without feeling any symptoms, but cannot handle any strenuous exercise. How should the nurse respond?
Suggest that he take his prescribed nitroglycerin before intercourse to prevent chest pain
A female client with HIV has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?
This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) test annually.
When would a nurse obtain a mid-arm circumference measurement?
To provide percentage of body fat and muscle tissue.
The nurse is admitting a client new to the clinic who states, "My face feels funny." When the nurse assesses the client she finds isolated facial sensory loss to pain and no neurologic deficits in his extremities. What diagnosis would the nurse expect for this client?
Trigeminal neuralgia
When beginning a height measurement on a 14-year-old, the nurse should instruct the client to stand on the scale with heels together.
True
Which action by a nurse demonstrates the correct technique to use the reflex hammer?
Use rapid wrist movement and strike the tendon
A nurse examines a client with a paralytic ileus. Which alteration in bowel sounds should the nurse expect to find with auscultation of the client's abdomen?
absent
The nurse is planning to auscultate a female adult client's carotid arteries. The nurse should plan to
ask the client to hold her breath.
The nurse is having difficulty locating a client's point of maximum impulse. What should the nurse do to facilitate this assessment?
assist the client into a left lateral decubitus position
While assessing an older adult client, the nurse detects a bruit over the carotid artery. The nurse should explain to the client that a bruit is
associated with occlusive arterial disease.
A nurse performs a focused assessment on a client who is reporting neck pain. The nurse observes the following findings: neck pain that increases with extension, fever, chills, and photophobia. The nurse suspects the client may be experiencing which of the following disorders?
bacterial meningitis
The nurse observes an orange peel appearance, or peau d'orange, of the areolae of a client's breasts. The nurse should explain to the client that this is most likely due to
blocked lymphatic drainage.
An older adult client visits the clinic complaining of urinary incontinence. The nurse should explain to the client that this is often due to
decreased urethral elasticity.
While examining a client, the nurse plans to palpate temperature of the skin by using the
dorsal surface of the hand.
The nurse is unable to palpate a client's left popliteal artery. Which artery should be assessed to determine the presence of blood flow in the left leg?
femoral
The sigmoid colon is located in this area of the abdomen: the
left lower quadrant.
While interviewing a client for the first time, the nurse is using a standardized nursing history form. The nurse should
maintain eye contact while asking the questions from the form.
An adult white client visits the clinic for the first time. During assessment of the client's skin, the nurse should assess for central cyanosis by observing the client's
oral mucosa.
The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should
position the client 609.6 cm (20 ft) away from the chart.
When assessing an older adult client, the nurse notes which age-related changes of the cardiovascular system that increase the risk for falls?
postural orthostatic hypotension
What information should a nurse give a client who reports a routine of frequent douching?
predisposes the vagina to yeast infections
The nurse is caring for a client admitted to the medical surgical unit with neck tenderness, drooling, and dysphagia. In reviewing the orders from the health care provider (see above), which order should the nurse question?
regular diet as tolerated
The cerebrospinal fluid cushions the central nervous system (CNS), provides nourishment to the CNS, and
removes wastes.
A client recovering from abdominal surgery is complaining of pain. The nurse realizes that the client is most likely experiencing which type of pain?
somatic
A client is admitted with right lower abdominal pain with rebound tenderness. The nurse suspects appendicitis and documents this type of pain as which of the following?
visceral
A client diagnosed with intermittent claudication wonders why the nurse wants to know where the client is experiencing cramping when walking. What would be the nurse's best answer?
"The area of cramping is close to the area of arterial occlusion." Rationale: The area of cramping in arterial disease, termed intermittent claudication, closely approximates the level of arterial occlusion. The other options are distracters to the question.
A nurse performs a two-point discrimination test on a client who was in an automobile accident to assess for the presence of a lesion of the sensory cortex. The nurse touches the client's body at various sites on his right side with the two points of EKG calipers. Which finding, stated as the distance between the two points at which the client can no longer distinguish the two points as separate, would indicate an abnormal response on the part of the client?
20 mm on the dorsal hand
A nurse assesses the peripheral vascular system of a client who is in the supine position. What further assessment should the nurse perform if unable to palpate the left popliteal pulse?
Assist the client to the prone position and palpate again
When assessing a client during the physical examination of the genitalia, the nurse palpates the scrotal contents. Which finding should the nurse recognize as an indication that an infection or cysts are present?
Beaded or thickened cord
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
Breast cancer
A 48-year-old woman has presented to her primary care provider concerned about the recent detection of a mass in her left breast. The mass is tender on palpation, and the nurse notes that it is round, well-delineated, and mobile. There is no evidence of nipple retraction on inspection. Which of the following breast masses would the nurse first suspect?
Cyst
A female client is reporting burning during urination. The client refuses to allow the nurse to perform a vaginal assessment. What is the best action of the nurse?
Explain to the client why the assessment is important and the possibility of missing important findings.
The nursing instructor explains to a group of students that what can shorten diastole?
Increased heart rate
A nurse should assist an elderly client to assume which position to facilitate the examination of the anus and rectum?
Left side-lying
A teenage male client comes to the ED with severe left testicular pain and vomiting. Elevation of his left testicle does not lessen the pain. What could these symptoms indicate for this client?
Left testicular torsion
When examining the breasts of a client, the nurse finds a collection of fatty tissue that appears as a lump. The nurse knows that this is which of the following conditions?
Lipoma
Variations in the presentation of S1 are due to alterations in which heart valve?
Mitral
The nurse is performing a cardiac examination of a client with shortness of breath and palpitations. The nurse listens to the heart with the client sitting upright, then has him change to a supine position, and finally has him turn onto his left side in the left lateral decubitus position. Which of the following valvular defects is best heard in this position?
Mitral Rationale: The left lateral decubitus position brings the left ventricle closer to the chest wall, allowing mitral valve murmurs to be better heard. If the examiner does not listen in a quiet room to the heart in this position with both the diaphragm and bell, it is possible to miss significant murmurs such as mitral stenosis.
The nurse suspects the client has increased intracranial pressure due to meningitis. What should the nurse assess?
Neck mobility
The nurse is performing an assessment of the neck and identifies tracheal deviation. What is the most appropriate response of the nurse?
Notify the health care provider
A nurse observes an unlicensed assistive personnel (UAP) taking a blood pressure reading on a client. The cuff wraps around the client's arm nearly twice. What is the best action of the nurse?
Obtain a smaller cuff for the UAP.
A client comes to the clinic and reports pain when he touches his ear. With what is this finding most consistent?
Otitis externa
The nurse is testing for Kernig's sign in a newly admitted client. What would indicate meningeal inflammation?
Pain and resistance to knee extension bilaterally
A nurse recognizes that a common complication of vascular surgery may manifest as which assessment finding?
Pain in the calf muscles
A client is admitted with leg ulcers to the health care facility. During the collection of objective data, which assessment finding should indicate to the nurse that the client's leg ulcers are due to arterial insufficiency?
Pallor of foot occurs with elevation
A 41-year-old real estate agent comes to the office saying that he feels like his face is paralyzed on the left. He states that last week he felt his left eyelid was drowsy; as the day progressed he could not close his eyelid all the way. Later he felt like his smile became affected also. He denies any recent injuries but had an upper respiratory viral infection last month. Past medical history is unremarkable. He is divorced with one child. He smokes one pack of cigarettes a day, occasionally drinks alcohol, and denies any illegal drug use. His mother has high blood pressure and his father has sarcoidosis. On examination the nurse asks the client to close his eyes. He cannot close his left eye. The nurse asks him to open his eyes and raise his eyebrows. His right forehead furrows but his left remains flat. The nurse then asks the client to give a big smile. The right corner of his mouth raises but the left side of h
Peripheral CN VII paralysis
When performing the physical assessment of a client, the nurse notes the presence of a small cyst that contains hair, which is located midline in the sacrococcygeal area and has a palpable sinus tract. How should the nurse document this finding?
Pilonidal cyst Rationale: A pilonidal cyst is a congenital disorder characterized by a small dimple or cyst/sinus that contains hair. External hemorrhoids are usually painless papules below the anorectal junction, caused by varicose veins. Anal fissures are splits in the tissue of the anal canal caused by trauma. Perianal abscess is a cavity of pus, caused by infection in the skin around the anal opening.
Mrs. Glynn is 90-years old and lives alone. She is able to bathe, dress, prepare her food, and transfer from bed to chair independently. She has children in the area who help her with her medications and transportation needs. Which of the following is considered an instrumental activity of daily living?
Preparing food
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
The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?
Reduce all environmental noise.
A nurse examines a client diagnosed with fibroadenoma. Which characteristic of the lump should the nurse expect to find in the client?
Round, firm, well-defined
A nurse is instructing a client who has recently experienced a transient ischemic attack (TIA) on warning signs of a stroke that the client should be aware of in case they occur and she needs to call 911. Which of the following should the nurse mention? Select all that apply.
Sudden confusion, trouble speaking, or understanding speech Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden severe headache with no known cause Sudden numbness or weakness of the face
A client presents at the clinic with severe scrotal pain. What is the presumptive diagnosis?
Testicular torsion
A client diagnosed with arthritis has been taking aspirin and now reports experiencing adverse effects. What adverse effect indicates that a decrease in dose may be necessary?
Tinnitus
Before calling a client back to an examination room, the nurse quickly observes the client in the waiting room from head to toe. Which of the following is the best rationale for this action?
To see the client before the client assumes a social face or behavior
A 23 year old male comes to the clinic complaining of sudden and severe pain in his scrotum. The nurse would suspect what?
Torsion of the spermatic cord
In an interview with an elderly female client, the nurse learns that the client often has involuntary loss of urine associated with an abrupt and strong desire to void. What type of incontinence should the nurse document in the client's record?
Urge
The largest arteries of the upper extremities are the
brachial arteries
The nurse palpates slightly enlarged epitrochlear nodes. The nurse should evaluate more closely which part of the body?
fingers Rationale: Enlarged epitrochlear lymph nodes may indicate an infection in the hand or forearm, or they may occur with generalized lymphadenopathy.
A client has osteoarthritis of the elbow. Which assessment approach should the nurse expect to be impacted by this health problem?
flexion
A client reports bleeding gums after brushing their teeth. On further assessment, the nurse observes red, swollen gums but no recession of the gum lines. The nurse determines these signs and symptoms are most likely indicative of which of the following disorders?
gingivitis
A school-age client has been diagnosed with genu valgum. What is the other name for this condition?
knock-kneed Rationale: Many children have a temporary period of genu valgum, but persistent knock-knee may be genetic or the result of metabolic bone disease. The client may need to swing each leg outward while walking to prevent striking the planted limb with the moving limb. The strain on the knee frequently causes anterior and medial knee pain. Physical therapy and surgical intervention may be required.
An older client cannot recall the date of a surgical procedure but the adult daughter interjects with the exact date because it occurred a week before her wedding. How should the nurse document this information?
last surgery date validated by adult daughter
A nurse obtains a client's blood pressure (BP) on admission in both arms: right arm BP is 130/75 mm Hg and left arm BP is 140/80 mm Hg. Which arm should the nurse use for subsequent blood pressure reading?
left arm
While assessing the inguinal lymph nodes in an older adult client, the nurse detects that the lymph nodes are approximately 3 cm in diameter, nontender, and fixed. The nurse should refer the client to a physician because these findings are generally associated with
malignancy
The nurse assesses an adult client's head and neck. While examining the carotid arteries, the nurse assesses each artery individually to prevent:
reduction of the blood supply to the brain.
The subacromial bursae are contained in the
shoulder joint.
During a physical examination, a nurse notes that the client has a slow, regular pulse. On the cardiac monitor the nurse notes that the QRS complexes are regular and there are normal P waves. The ventricular rate is found to be 54 beats per minute. The nurse recognizes that this client may have an abnormality in which part of the conduction system?
sinoatrial node Rationale: The client may have problem with the sinoatrial node. The cardiac monitor shows a normal P wave which indicates that the impulse originated in the sinoatrial node. The QRS complex is regular showing that the atrioventricular node and the rest of the conduction system are functioning well; and the problem lies at the higher level of the conduction system. The Bundle of His, Purkinje fibers, and atrioventricular nodes are lower to the sinoatrial node and therefore have no contribution to impulse origination in this case.
The nurse is preparing to perform the Romberg test on an adult male client. The nurse should instruct the client to
stand erect with arms at the sides and feet together.
The nurse is planning to test position sensation in an adult female client. To perform this procedure, the nurse should ask the client to close her eyes while the nurse moves the client's
toes up or down.
A client blinks when the right eye is lightly touched with a cotton wisp. Which cranial nerve should the nurse document as being intact?
trigeminal
When examining the eye, the nurse notices difficulty with downward motion. The nurse understands that which cranial nerve is involved?
trochlear rationale: The trochlear nerve controls inferomedial eye movement.
The nurse observes dimpling in an adult female client's breasts. The nurse should explain to the client that dimpling of the breast may indicate a
tumor.
The nurse documents information about a client's activity-exercise health pattern. Which information did the nurse most likely document?
unable to go to the gym since having back surgery
The nurse instructs a female client on breast self-examination. Which part of the breast should the nurse explain as being the area where most cancers occur?
upper outer
A clinic nurse has reviewed a new client's available health record and will now begin taking the client's health history. Which of the following questions should the nurse ask first when obtaining the health history?
"What is your major health concern at this time?"
The nurse has been asked to perform a stereognosis test on an adult client. Which instructions should the nurse provide to the client before performing the test?
"With your eyes closed, identify the object I place in your hand."
A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy, and the nurse is collecting subjective data prior to surgery. Which statement by the nurse could be construed as judgmental?
"You must quit smoking because it affects others, not only you."
The nurse is caring for an older adult client with a blood pressure of 186/98 mm Hg. The client asks, "What is happening to me?" Which of the following is the best response by the nurse?
"Your blood pressure is elevated, so we should talk more after I complete your assessment."
A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?
Pulse is felt with difficulty and disappears with slight pressure.
While assessing a client's arms, the nurse notes a 3-mm oval lesion located on left forearm. The lesion is primarily purple with areas of green and yellow. Which descriptive term should the nurse use to document this lesion in the client's medical record?
Purpuric
A client presents to the emergency department complaining of chest pain. The nurse conducts a pain assessment and discovers the client's chest pain has lasted more than 20 minutes and is accompanied by nausea and diaphoresis. The nurse should prepare for which treatment?
Balloon angioplasty Rationale: The client's symptoms are consistent with a myocardial infarction. Treatment includes nitroglycerin, bedrest to decreased oxygen consumption, thrombolytics, or angioplasty. Open heart surgery may be indicated, depending on the results of the angioplasty. Pain medication may be prescribed along with other treatments for myocardial infarction; but morphine alone, with only observation is not likely.
A nurse is establishing an ideal body weight for a 5' 9" healthy female. Based on the rule-of-thumb method, what would be this client's ideal weight?
145 lb Rationale: A general guideline, often called the rule-of-thumb method, determines ideal weight based on height. This formula is as follows: For adult females: 100 lb (for height of 5 ft) + 5 lb for each additional inch over 5 ft For adult males: 106 lb (for height of 5 ft) + 6 lb for each additional inch over 5 ft.
Which of the following groups has the highest incidence of prostate cancer?
African American men
Chris is a 20-year-old college student who has had abdominal pain for 3 days. It started at his umbilicus and was associated with nausea and vomiting. He was unable to find a comfortable position. Yesterday, the pain became more severe and constant. Now, he hesitates to walk, because any motion makes the pain much worse. It is localized just medial and inferior to his iliac crest on the right. Which of the following is most likely?
Appendicitis
A nurse is assessing a client who is obese, gathering subjective date. Which subjective questions regarding nutritional status are appropriate for the nurse to ask this client? Select all that apply.
Are any members of your family obese? "How do you decide your diet?" "What is your height and usual weight?"
After a physical assessment, the nurse determines that a client has full range of motion of the temporomandibular joint. Which of the following assessments did the nurse complete with the client? Select all that apply.
Asked the client to open and close the mouth Asked the client to jut the jaw forward Asked the client to rock the jaw laterally
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 the woman for hypothyroidism.
The nurse is assessing cranial nerves and should look for which sign of cranial nerve VII damage?
Asymmetrical smile
A 19-year-old woman comes to the office and reports that she has had a clear discharge from her right breasts for 2 months. She states that she noticed it when she and her boyfriend were "messing around" and he squeezed her nipple. She continues to have this discharge anytime she squeezes that nipple. She denies any trauma to her breasts. Her past medical history is unremarkable. She denies any pregnancies. Both of her parents are healthy. She denies tobacco or illegal drugs and drinks three to four beers a week. On examination her breasts are symmetrical with no skin changes. The nurse can express clear discharge from the client's right nipple. There are no discrete masses and the axillae are normal. The remainder of her heart, lung, abdominal, and pelvic examinations are unremarkable. A urine pregnancy test is negative. What cause of nipple discharge is most likely in her circumstance?
Benign breast abnormality
A nurse understands that the cardiac event that signals the beginning of systole and produces the first heart sound is what?
Closure of the mitral and tricuspid valves Rationale: The beginning of systole occurs when the pressure in the ventricles exceeds the pressure in the atrium, causing the mitral and tricuspid valves to close. This closure produces the first heart sound (S1). The ventricles contract and empty of the blood volume, which causes the pressure to drop and the aortic and pulmonic valves close. This produces the second heart sound (S2). Relaxation and contraction of the ventricles do not produce heart sounds.
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
A client with diabetes mellitus visits the health care clinic with reports of excessive thirst and excessive urination. She states that her appetite has been low for the past 3 months, and has lost 20 pounds. Which nursing diagnosis should the nurse confirm based on this data?
Imbalanced nutrition
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 the midline, a few centimeters behind the tip of the mandible
To adhere to standard precautions, the nurse should remember to do which? Select all that apply.
Perform hand hygiene before and after direct client contact. Remove any personal protective equipment (PPE) before leaving client's room.
When examining the uterus, a nurse finds that the cervix and the body of the uterus are tilted backward. How should the nurse document this uterine finding?
Retroverted
The nurse is admitting a client who is in hypertensive crisis. The doctor's notes indicate that bruits that are both systolic and diastolic have been noted and renal artery stenosis is suspected as the cause of the hypertension. Where would the nurse auscultate the client's abdomen to hear these bruits? (Select all that apply.)
Right upper quadrant Epigastrium Costovertebral angles
A 58-year-old gardener comes to the office for evaluation of a new lesion on her upper chest. The lesion appears to be "stuck on" and is oval, brown, and slightly elevated with a flat surface. It has a rough, wart-like texture on palpation. Based on this description, what diagnosis is most likely?
Seborrheic keratosis
A nurse determines that a client's ankle-brachial pressure index (ABPI) is 0.2. Which of the following conditions does this reading indicate?
Severe stenosis leading to ischemia and tissue damage Rationale: An ABPI of less than 0.3 indicates severe stenosis leading to ischemia and tissue damage. The ankle pressure in a healthy person is the same or slightly higher than the brachial pressure, resulting in an ABPI of approximately 1.00 or no arterial insufficiency. An ABPI of 0.5 to 1.0 indicates mild to moderate arterial insufficiency.
The nurse is caring for a 17-year-old girl who is 16 weeks pregnant. The client's history shows infection with multiple STIs. What should the nurse do?
Verify that prior STIs were treated according to protocol.
A client presents to the ED with pain in the upper right quadrant that worsens after eating. The client describes the pain as sharp, stabbing, and at times very intense. This is a description of which type of pain?
acute
A client reports experiencing chronic headache after a recent upper respiratory tract infection. On physical examination, the nurse notes tenderness when palpating over the sinuses. Which condition is likely?
acute bacterial sinusitis
During a lecture on pain management, the nursing instructor informs the group of nursing students that the primary treatment measure for pain is which of the following?
analgesics
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.
The prostate gland consists of two lobes separated by the
median sulcus.
Photoreceptors of the eye are located in the eye's
retina.
A client reports recent dizziness and feeling unsteady on their feet. Which of the following tests should the nurse perform?
romberg
A client is unable to externally rotate the left shoulder. What health problem should the nurse suspect is occurring with this client?
rotator cuff tear
The nurse is assessing the spine of an adult client and detects lateral curvature of the thoracic spine with an increase in convexity on the left curved side. The nurse suspects that the client is experiencing
scoliosis