Health assessment review
The nurse caring for a client who is a long-term smoker is told in shift report that the client has clubbing of the fingers. To assess for clubbing, the nurse would instruct the client to do which of the following things?
"Bring the backside of two corresponding fingers together."
The nurse is interviewing a client in the first trimester of pregnancy who reports she has not felt the baby move yet. Which of the following is the best response? "Have you lost a baby before?" "You shouldn't be concerned about something like that." "Fetal movements are usually recognized at approximately 18-20 weeks after conception." "Are you sure you are pregnant?"
"Fetal movements are usually recognized at approximately 18-20 weeks after conception."
A patient states to the nurse, "I've been feeling very short of breath, especially at night when I'm sleeping." Which question should the nurse ask the patient next?
"How many pillows do you use to sleep?"
The nurse is palpating the frontal sinuses. Which of the following statements made by the patient describes a normal finding? "I feel firm pressure." "It feels like there's a slight upward movement." "I can feel pain behind my eyes." "It hurts just a little."
"I feel firm pressure."
The nurse is performing stereognosis on a client. Which of the following instructions would the nurse provide for the client? "Identify the object in your hand with your eyes closed." "Tell me what part of your body is being touched." "Identify the number being traced in your hand with your eyes closed." "Tell me if you feel one or two objects touching you with your eyes closed."
"Identify the object in your hand with your eyes closed
Which of the following should the nurse include when teaching the patient about the Pap test?
"This test will screen for cervical cancer."
The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measure to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? We need to discourage him from wearing eyeglasses." b. "We need to place objects in his impaired field of vision." c. "We need to approach him from the impaired field of vision." "We need to remind him to turn his head to scan the lost visual field."d. "We need to remind him to turn his head to scan the lost visual field."
"We need to remind him to turn his head to scan the lost visual field."
A 52-year-old male client is seen in the primary health care provider's (PHCP's) office for a physical examination after experiencing unusual fatigue over the last several weeks. The client's height is 5 ft, 8 in (173 cm) and his weight is 220 lb (99.8 kg). Vital signs are as follows: temperature, 98.6º F (37º C) orally; pulse, 86 beats/min; and respirations, 18 breaths/min. The blood pressure reading is 184/100 mm Hg. A random blood glucose level is 122 mg/dL (6.8 mmol/L). Which question should the nurse ask the client first?
"When was the last time you had your blood pressure chec
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds? Stridor Crackles Scattered rhonchi Diminished breath sounds
"crackles at the bases"
decrease fremitus occurs with
-COPD -Air trapping -muscular or obese chest -plural effusion -bronchial obstruction due to mucus plug -pneumothorax. (CAMP BP)
Muscle strength is graded on a scale of
0 to 5
A clinic nurse notes that a client's visual acuity has been documented as 20/200. Which statement is a correct interpretation of the test result? 1. The client is legally blind. 2. The client requires the use of reading glasses. 3. The client requires the use of glasses at all times. 4. The client is partially blind and will need both contact lenses and glasses to see objects.
1. The client is legally blind. * The person can see at 20 ft what a person with normal vision can see at 200
The nurse is performing a physical assessment of a client's musculoskeletal system and notes that the client is right-handed. The nurse would document which assessment findings as normal? Select all that apply.
2.Muscle strength graded 5/5 3.Symmetrical movements bilaterally 4.Increased muscle size on the dominant arm 5.A 1-cm hypertrophy of the right upper arm
While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which?
A blowing or swooshing noise
The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client?a. A client complaining of muscles aches, a headache, and history of seizures b. A client who twisted her ankle when rollerblading and is requesting medication for pain c. A client with a minor laceration on the index finger sustained while cutting an eggplant d. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce
A client with chest pain who states that he just ate pizza that was made with a very spicy sauce
Which of the following is true of occult blood? a)The test requires a large stool sample. b)It may indicate an imperforate anus. c)The test is used to assess prostate health. d) A negative response is normal.
A negative response is normal.
The nurse notes that the health care provider has documented a diagnosis of presbycusis on a client's chart. The nurse understands that which describes this condition? 1. Tinnitus that occurs with aging 2. Nystagmus that occurs with aging 3. A conductive hearing loss that occurs with aging 4. A sensorineural hearing loss that occurs with aging
A sensorineural hearing loss that occurs with aging
A nurse who is assessing a client's eyes notes that the pupil gets larger when looking at an object in the distance and gets smaller when looking at a near object. The nurse documents this finding as which condition? 1. Myopia 2. Hyperopia 3. Photophobia 4. Accommodation
Accommodation
A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply. a. Administer stool softeners as prescribed. b. Instruct the client to limit fluid intake to avoid urinary retention. c. Encourage a high-fiber diet to promote bowel movements without straining. d. Apply cold packs to the anal-rectal area over the dressing until the packing is removed. e. Help the client to a Fowler's position to place pressure on the rectal area and decrease bleeding.
Administer stool softeners as prescribed. Encourage a high-fiber diet to promote bowel movements without straining. Apply cold packs to the anal-rectal area over the dressing until the packing is removed.
A client with glaucoma asks the nurse if complete vision will return. Which is the most appropriate response by the nurse? 1. "Your vision will never return to normal. "2. "Your vision will return as soon as the medication begins to work. "3. "Your vision loss is temporary and will return in about 3 to 4 weeks. "4. "Although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan.
Although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan.
The nurse is teaching breast self-examination (BSE) to a client who has had a hysterectomy. The appropriate instruction regarding when the BSE should be performed is at which time?
At a specific day of the month and on that same day every month thereafter If the client has had a hysterectomy or is no longer menstruating, the BSE should be performed on the same day every month. Options that recommend scheduling related to menses are inappropriate because the client who had a hysterectomy would not be menstruating. It is best not to perform the BSE at ovulation time because of the hormonal changes that occur.
A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? a. Hoarseness b. Hypocalcemia c. Audible stridor d. Edema at the surgical site
Audible stridor-is a high-pitched, wheezing sound caused by disrupted airflow.
The nurse would perform which action to assess for a pulse deficit?
Auscultate the apical heartbeat while palpating the radial artery.
The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply. 1- Auscultating lung sounds 2-Obtaining the client's temperature 3-Assessing the strength of peripheral pulses 4- Obtaining information about the client's respirations 5- Performing a musculoskeletal and neurological examination 6- Asking the client about a family history of any illness or disease
Auscultating lung sounds Obtaining the client's temperature Obtaining information about the client's respirations
a. Speak loudly but mumble or slur the words. b. Speak loudly and clearly while facing the client. c. Speak at normal tone and pitch, slowly and clearly. d. Speak loudly and directly into the client's affected ear.
Avoid sudden head movements.
The nurse is performing reflex testing on a client and uses the reflex hammer to gently strike the forearm about 5 cm (2 inches) above the wrist. The nurse is assessing which of the following reflexes? Patellar Triceps Brachioradialis
Brachioradialis
When performing an assessment of the thorax of a client, which of the following should the nurse know to be a normal sounds?
Bronchovesicular sounds heard over the major bronchi. Resonant sound heard on percussion. Respiratory rate of 16 breaths per minute AP vesus transvers 2 :1 ratio
Which of the following describes an advantage of the Jaeger card over the Snellen chart? Can be more easily administered at the bedside. The Jaeger card also tests the peripheral visual fields. The Jaeger card tests all the extraocular muscles. The Jaeger card provide a more accurate measure of far vision.
Can be more easily administered at the bedside.
A client is admitted to the emergency department with chest pain that is consistent with myocardial infarction based on elevated troponin levels. Heart sounds are normal. Over the last 45 minutes, the heart rate and respiratory rate have been steadily increasing, and blood pressure has been steadily decreasing. The nurse should alert the primary health care provider because the vital sign changes and client assessment are most consistent with which complication? Cardiogenic shock Cardiac tamponade Pulmonary embolism Dissecting thoracic aortic aneurysm
Cardiogenic shock
The nurse is examining a client with a chief complaint of numbness and tingling in the hands. The nurse asks the client to bend the wrist downward and press the backs of the hands together. The client complains of numbness and tingling in the arms during the procedure. The nurse would suspect which of the following conditions in this situation? Crepitus of the wrists Dupuytren's contracture Carpal tunnel syndrome Arthritis of the wrists
Carpal tunnel syndrome
An older client with diabetes mellitus complains of blurred vision with difficulty reading and driving at night. On the basis of the client's history, the nurse interprets that these changes most likely indicate the development of which condition? 1. Cataracts 2. Glaucoma 3. Papilledema 4. Detached retina
Cataracts
A blue coloration to the cervical mucosa is known as: Chadwick sign Syphilis Nabothian cysts
Chadwick sign
Which of the following describes is the best way to describe skin color within the normal range of findings?
Color tone is even.
The nurse is caring for a client with a diagnosis of detached retina. Which assessment finding, if present in the client, would indicate that bleeding has occurred as a result of the retinal detachment? 1. Total loss of vision 2. A reddened conjunctiva 3. A sudden sharp pain in the eye 4. Complaints of a burst of black spots or floaters
Complaints of a burst of black spots or floaters
A nurse notes that a client's eyes are reddened, and the client states that an eye infection has been diagnosed. The nurse understands that the client most likely is referring to infection of which structure, which provides a protective covering for the eye? 1. Iris 2. Lens 3. Cornea 4. Conjunctiva
Conjunctiva
The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological changes the nurse expects to note? Select all that apply. 1. Increased heart rate 2. Decline in visual acuity 3. Decreased respiratory rate 4. Decline in long-term memory 5. Increased susceptibility to urinary tract infections 6. Increased incidence of awakening after sleep onse
Decline in visual acuity Decreased respiratory rate Increased susceptibility to urinary tract infections Increased incidence of awakening after sleep onset
The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? A low respiratory rate Diminished breath sounds The presence of a barrel chest A sucking sound at the site of injury
Diminished breath sounds
The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding would indicate the presence of a pneumothorax in this client? 1. A low respiratory rate 2. Diminished breath sounds 3. The presence of a barrel chest 4. A sucking sound at the site of injury
Diminished breath sounds
The nurse is examining a third-trimester pregnant client who is complaining of lower-back pain. The nurse notes a slight lordosis and waddling gait in the client. The nurse would correctly choose which of the following actions in this situation? Ask the client if she has been doing heavy lifting Notify the physician of the findings Tell the client to go on bedrest Document the findings as normal
Document the findings as normal
A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings? Xerostamia Dysphagia Epistaxis Rhinorrhea
Dysphagia (hard time swallowing )
A nurse conducting an eye examination notes protruding of the client's eyeballs. The nurse should document this finding as which condition? 1. Ptosis 2. Nystagmus 3. Scleral icterus 4. Exophthalmos
Exophthalmos
During a routine visit to the health care provider's office, an older client complains to the nurse of vision changes. The client describes vision as foggy, complains of mild aching in the eyes, and reports the need to change eye glass prescriptions frequently. Given these symptoms, the nurse most likely suspects which condition? 1. Cataracts 2. Glaucoma 3. Papilledema 4. Detached retina
Glaucoma
A client reports to the health care clinic for an eye examination, and a diagnosis of macular degeneration is made. Which nursing assessment question will most specifically elicit information regarding the clinical manifestations associated with this disorder? 1. "Do bright lights bother you? "2. "Do you have any pain in your eye? "3. "Have you had any blurred vision? "4. "Are you having difficulty seeing things out of the sides of your eyes?"
Have you had any blurred vision? *loss of central vision
The nurse is performing a neurological assessment on a client who had a stroke (brain attack). The nurse checks for proprioception using which assessment technique?
Holding the sides of the client's great toe and, while moving it, asking what position it is in. A method of testing for proprioception is to hold the sides of the client's great toe and, while moving it, asking the client what position it is in.
The nurse is examining the genitalia of a male child and notes that the urinary meatus appears on the underside of the glans penis. The nurse would correctly document this finding as which of the following? Normal Hypospadias Paraphimosis Epispadias
Hypospadias
A client's vision is tested with a Snellen chart. The results of the test are documented as 20/60. What action should the nurse implement based on this finding?
Instruct the client that he or she may need glasses when driving
A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding?
Instruct the client that he or she may need glasses when driving. Vision that is 20/20 is normal—that is, the client is able to read from 20 feet (6 meters) what a person with normal vision can read from 20 feet (6 meters). A client with a visual acuity of 20/60 can only read at a distance of 20 feet (6 meters) what a person with normal vision can read at 60 feet (18 meters).
The nurse reviews the findings from a physical exam done on a client for ear or hearing disorders and notes documentation that the client has hyperacusis. Which would the nurse expect to note on assessment of the client?
Intolerance for sound levels that do not bother other people hyperacusis is a change in hearing for a client and the intolerance for sound levels that do not bother other people. Ringing in the ears is known as tinnitus. An excessive amount of cerumen in the ear canal is not associated with hyperacusis. Complaints of dizziness and sensations of being "off balance" are known as vertigo.
Match each organ with the anatomic location within the abdomen where it is primarily found: Liver Gallbladder stomach appendix bladder
Liver = RUQ Gallbladder = RUQ Stomach= LUQ Appendix= RLQ Bladder = midline
The nurse is inspective the spine of a client and notes the presence of an exaggerated lumbar curve. The nurse would correctly document which of the following choices? Kyphosis Lordosis Spinal list Flattened lumbar curve
Lordosis
The nurse is assessing for the presence of pallor in a dark-skinned client. What finding should the nurse look for?
Loss of normal red tones in the skin . In the black-skinned client, pallor produces an ashen-gray color.
A woman is in the clinic for an annual gynecologic examination. The nurse should plan to begin the interview with the: Sexual history, because discussing it first will build rapport. Menstrual history, because it is generally nonthreatening. Urinary system history, because problems may develop in this area as well. Obstetric history, because it includes the most important information.
Menstrual history, because it is generally nonthreatening.
The nurse is assessing muscle strength in a client and notes full range of motion against gravity with full resistance. The nurse would correctly document which of the following choices? Normal Fair Good
Normal
Immediately after cataract repair, a nurse notes that the conjunctiva and eyelids on the client's operated eye are edematous. The nurse should make which interpretation about this finding? 1. Normal and should subside within 3 days 2. Grossly abnormal and should be reported at once 3. Abnormal because only the eyelids should be affected 4. Abnormal because the conjunctiva should not be affected
Normal and should subside within 3 days
The nurse is providing care to a client admitted for coronary artery disease (CAD) and a history of tobacco use. What is the most importantelement of the nurse's focused assessment of the client's smoking history?
Number of pack-years The number of cigarettes smoked daily and the duration of the habit are used to calculate the number of pack-years, which is the standard method of documenting smoking history. The brand of cigarettes may give a general indication of tar and nicotine levels, but the information is of no immediate clinical use. Desire to quit and number of past attempts to quit smoking may be useful when the nurse develops a smoking cessation plan with the client.
The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time?
One week after menstruation begins The breast self-examination should be performed regularly, 7 days after the onset of the menstrual period. Performing the examination weekly is not recommended. At the onset of menstruation and during ovulation, hormonal changes occur that may alter breast tissue.
The nurse is examining a dark-skinned client for the presence of petechiae. The nurse will bestobserve these lesions in which body area?
Oral mucosa
The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? Slow, deep respirations Rapid, deep respirations Paradoxical respirations Pain, especially with inspiration
Pain, especially with inspiration
A nursing student is performing a respiratory assessment on a female adult client and is assessing for tactile fremitus. Which action by the nursing student indicates a need for further teaching?
Palpating over the breast tissue to assess and compare vibrations from 1 side to the other When assessing for tactile fremitus, the nurse should begin palpating over the lung apices in the supraclavicular area. The nurse should compare vibrations from 1 side to the other as the client repeats the word ninety-nine. The nurse should avoid palpating over female breast tissue because breast tissue usually blocks the sound.
A client is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to use in obtaining the client's health history?
Plan short sessions with the client to obtain data.
The nurse is interviewing a female client who reports absence of menstruation and breast tenderness. The nurse would document these as which classification of signs of pregnancy? Probable Objective Positive Presumptive
Presumptive Urine pregnancy test- probable· Chadwick sign- probable· Nausea - presumptive· Fetal heart rate - positive· Fatigue- presumptive· Breast pain- presumptive· Fetal outline- positive· A menorrhea - presumptive
When performing an assessment of the thorax of a client, which of the following should the nurse know to be an abnormal finding?
Ratio of anteroposterior to costovertebral diameter of 1:1.
A nurse is attempting to inspect the lacrimal apparatus of the client's eye. Because of the anatomical location of this structure, the nurse should take which action? 1. Retract the lower eyelid and ask the client to look up. 2. Retract the upper eyelid and ask the client to look up 3. Retract the upper eyelid and ask the client to look down 4. Retract the lower eyelid and ask the client to look down.
Retract the upper eyelid and ask the client to look down
The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which findin
Rhythmic respirations with periods of apnea
what as some characteristic of prostate gland would the nurse recognize as a normal finding while palpating the prostate gland throughout the rectum? more than on option. Nodular surface. Rubbery consistency. Nontender to palpation. palpable central grove
Rubbery consistency. Nontender to palpation. palpable central grove
The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse implement to test the motor function of this nerve?
Separate the client's jaw by pushing down on the chin. The motor function (muscles of mastication) of cranial nerve V (trigeminal nerve) is assessed by palpating the temporal and masseter muscles as the person clenches the teeth. The muscles should feel equally strong on both sides. The nurse should try to separate the client's jaws by pushing down on the chin; normally, the jaws cannot be separated. Asking the client to puff out the cheeks tests the facial nerve. Placing an object on the client's tongue tests sense of taste and the sensory function of the facial nerve. Checking for equal strength by asking the person to rotate the head forcibly against resistance applied to the side of the client's chin assesses cranial nerve XI, the spinal accessory nerve.
The nurse is preparing to perform an abdominal examination on a client. The nurse should place the client in which position for this examination?
Supine with the head raised slightly and the knees slightly flexed
A nursing assistant will be obtaining vital signs on a client who had a left-sided mastectomy two days prior. What specific instructions would the nurse provide to the nursing assistant in delegating this task?
Take blood pressure on the right arm
The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye?
Test the 6 cardinal positions of gaze. Testing the 6 cardinal positions of gaze (diagnostic positions test) is done to assess for muscle weakness in the eyes. The client is asked to hold the head steady, and then to follow movement of an object through the positions of gaze. The client should follow the object in a parallel manner with the 2 eyes.
The clinic nurse is preparing to perform a Romberg test on a client being seen in the clinic. The nurse would perform this test for the purpose of determining which status?
The Romberg test assesses the ability of the vestibular apparatus in the inner ear to help maintain standing balance. The Romberg test also assesses intactness of the cerebellum and proprioception.
The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe?
The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.
The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test?
The right eye is tested, followed by the left eye, and then both eyes are tested. Visual acuity is assessed in 1 eye at a time, and then in both eyes together, with the client comfortably standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes are then tested together. Visual acuity is measured with or without corrective lenses, and the client stands at a distantof 20 feet (6 meters) from the chart.
Which of the following best describes the most important purpose for a general survey?
This initial set of data will help to guide the physical assessment
The nurse is palpating the scrotum of a male client and detects a hardened area in the right side of the scrotal sac. The nurse would correctly choose which of the following actions? Use a light to perform transillumination Notify the physician of the finding Ask the client about voiding patterns. Ask the client about sexual practices
Use a light to perform transillumination
A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, "You don't smoke, drink, or take drugs, do you?" This question is an example of:
Using a leading question.
The nurse is interviewing a male client with a chief complain of "feels like a bag of worms in my scrotum." The nurse would correctly suspect which of the following conditions? Varicocele Orchitis Epididymitis Hernia
Varicocele
A client with myocardial infarction is developing cardiogenic shock. What condition should the nurse carefully assess the client for?
Ventricular dysrhythmias
After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should expect to note which finding?
Waves of loud gurgles auscultated in all 4 quadrants Although frequency and intensity of bowel sounds vary depending on the phase of digestion, normal bowel sounds are relatively high-pitched clicks or gurgles. Loud gurgles (borborygmi) indicate hyperperistalsis and are commonly associated with nausea and vomiting.
During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. What should be the initial nursing action? a. Call the health care provider (HCP) b. Reassure the client that this is normal c. Turn the client onto his or her operative side d. Administer the prescribed pain medication and antiemetic
a. Call the health care provider (HCP)
The nurse should educate the young adult female client that which of the following is strongly associated with increased risk of breast cancer?
alcohol consumption.
When assessing a patient with ascites, the nurse should note
an everted umbilicus
During otoscopy, the cone of light should be seen in what part of the tympanic
anteroinferior quadrant
a abdomen that is fluid field would be?
ascites
The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse should use which technique to test the client's peripheral response to pain? Sternal rub b. Nailbed pressure c. Pressure on the orbital rim d. Squeezing of the sternocleidomastoid muscle
b. Nailbed pressure Note that the question specifically asks for peripheral response to pain. At that point you just have to identify which of the options involves the periphery.
The nurse is assessing a client who has come to the clinic after having noticed a new lump in her right breast. The nurse should:
begin by assessing the left breast.
Urine that is "tea-colored" is that color because of
blood
An acute transient increase of pain for someone whose pain is otherwise well
breakthrough pain
Which of the following is described an elevated, circumscribed, superficial, fluid-filled blister of the skin that is less than 1 cm in diameter?
bulla
A pregnant woman is beginning to display a butterfly-shaped pigmentation of the face. This is: a sign of diabetes. due to rapid weight gain. a result of poor dental hygiene. also called chloasma.
chloasma (chloasma likes butterflies)
An AP-to-transverse diameter of 1:1 is seen in patients with
chronic emphysema
increased fremitus occurs with
compression or consolidation of lung tissue
The nurse is aware that one change that occurs in the GI system of an an aging adult is?
decreases gastric acid
what are some relaxation measures with voluntary guarding during palpation?
emptied the bladder room warm to avoid chilling and tensing of muscles. supine, with the head on a pillow, the knees bent or on pillow, and the arms at the sides or across the chest.
glaucoma should be suspect the patient complains of
haloes around lights
When preparing the woman for an examination of the genitourinary system, it is most helpful to: remove the patient's shoes and socks. have the client empty the bladder beforehand. explain each step in the procedure after you do it.
have the client empty the bladder beforehand.
The S3 sound is
is a ventricular filling sound
Palpating the brachial pulses:
is generally only done if arterial insufficiency is suspected.
In order to determine that a patient has absent bowel sounds, the nurse must: a)use the bell end of the stethoscope. b)listen for a full 5 minutes. c)auscultate in all four quadrants. d)ask the patient to hold their breath during auscultation.
listen for a full 5 minutes.
Increased fremitus could be a sign of:
lobar pneumonia
An important adjustment to the examination for an older adult woman is to: avoid asking about sexual activity. utilize the Tanner rating scale. ask indirect questions to avoid confrontation. lubricate instruments and the examining hand.
lubricate instruments and the examining hand. Because older women have dry vagina.
During the interview, the nurse notes that the client is confused as to day and time. This would be an indicator of the client's
orientation
What is Brudzinski's sign?
pain w/ passive neck flexion sign of meningeal irritation
Which of the following is described as a a flat, non-palpable,irregular-shaped macule of the skin that is greater than 1 cm in diameter?
patch
The nurse suspects that a patient has distended bladder. how should the nurse assess for this condition?
percuss and palpate the midlines area above the suprpubic bone *dull percussion sounds would elicited over a distended bladder and hyopastic area would seem firm
Is seen as a spot of light, when shining a penlight from one naris to the other.
perforation septum
papules can turn into ?
plaques
The normal finding for inspection and palpation of the scrotum is
presence of rug
The S-shaped structures that continues from descending colon above and joins the rectum? median sulcus. sigmoid colon. prostate. rectum
sigmoid colon.
The anterior angle and posterior angle of the neck share this muscle as a border: clavicle trapezius sternomastoid masseter
sternomastoid
Wharton's duct
submandibular
a patient comes in and states "the headache feels like a band around me head" - what type of headaches is this
tension headache
The purpose of the Ballotement test is to see whether or not
there is a large amount of fluid present in the joint
The jugular veins are a good measure of central venous pressure because:
they are attached directly to the right atrium
To test lateral bending of the neck, the nurse should ask the patient to
tilt ear towards the shoulder
The nurse places her finger on the sternal notch and slips it off to each side of the neck to assess for: dysphagia bruit lymphadenopathy tracheal shift
tracheal shift
The nurse is performing a neurological assessment on a client experiencing vertigo. The nurse wants to perform the Romberg test. The nurse would correctly provide which set of instructions to the client? "Touch your finger to your nose alternating hands." "Walk on your toes, then on your heels." "Stand with your feet together and your arms at your sides." "Walk across the room by placing one foot in front of the other heel to toes.
"Stand with your feet together and your arms at your sides."
To minimize voluntary guarding during palpation, the nurse should
use relaxation measure
The community health nurse who is conducting a teaching session about the risks of testicular cancer has reviewed a list of instructions regarding testicular self-examination (TSE) with the clients attending the session. Which statement by a client indicates a need for further instruction?
"It is best to do TSE first thing in the morning before a bath or shower."
The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply.
A hyperinflated chest noted on the chest x-ray Decreased oxygen saturation with mild exercise
The nurse is performing range of motion of the cervical spine and asks the client to touch the chest with the chin. The nurse is assessing which of the following movements? Lateral flexion Rotation Hyperextension Flexion
Flexion
The nurse is performing a vaginal examination on a pregnant client and notes the cervix is soft in texture and nontender. The nurse would correctly document which of the following conditions in this situation? Piscecek's sign Leopold sign Chadwick sign Goodell's sign
Goodell's sign * indication of preganacy
Which of the following is described as a flat discoloration of the skin that is less than 1 cm in diameter?
Macule
What is the primary reason to perform otoscope examination before the hearing test? Impacted cerumen may give an inaccurate hearing test result. The hearing test will change the otoscope examination findings. The otoscope examination usually makes the hearing test unnecessary. The otoscope examination is more important, and the patient may not want to continue after.
Impacted cerumen may give an inaccurate hearing test result.
The nurse prepares to take the blood pressure of a school-age child. To obtain an accurate measurement, how should the nurse position the blood pressure cuff?
Two thirds of the distance between the antecubital fossa and the shoulder
Which of the following should be used if the nurse is unable to detect a weak peripheral pulse?
Ultrasound
The school nurse has conducted a class on testicular self-examination (TSE) at the local high school. The nurse determines that the information was correctly interpreted if 1 of the students states that which action should be performed?
Roll the testicle between the thumb and forefinger. TSE is an excellent self-screening examination for testicular cancer, which predominantly affects men in their late teens and 20s. The examination is performed once a month. the examination should be done on the same day each month. The scrotum is held in one hand, and the testicle is rolled between the thumb and forefinger of the other hand. The examination should not be painful. It is easiest to do either during or after a warm shower (or bath), when the scrotum is relaxed.
if a person is experiencing vertigo, what test would you want to preform ?
Romberg test
A nurse conducting an eye examination notes yellowing. The nurse should document this finding as which condition? 1. Ptosis 2. Nystagmus 3. Scleral icterus 4. Exophthalmos
Scleral icterus
Which of the following is true of the lymphatic system?
The lymph ducts empty into the venous system.
When assessing the anus of a newborn, it is important to look for
a reflex
The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority? a. Blood pressure b. Airway patency c. Oxygen flow rate d. Level of consciousness
b. Airway patency
The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a completion of surgery? A negative Kernig's sign b. Absence of nuchal rigidity c. A positive Brudzinski's sign d. A Glasgow Coma Scale score of 15
c. A positive Brudzinski's sign
The S3 sound is heard:
immediately after the AV valves open.
If an infant boy's foreskin can not be retracted, that is called
phimosis
General Survey
physical appearance, body structure, mobility, behavior
The nurse is assessing the eyes of a client and notes a drooping of the left eyelid. The nurse would correctly chart which of the following conditions? ptosis strabismus diplopia nystagmus
ptosis
when a patient comes in and states that they feel a burn in their esophaguses area? dysphagia. anorexia. nausea. pyrosis
pyrosis (heartburn)
When the nurse compares a list of current medications with a previous, list, the nurse is completing the medication ________________.
reconciliation
The distal portion of the large intestine is known as the: median sulcus. sigmoid colon. prostate. rectum
rectum.
The cremaster muscle
regulates temperature of testes
The nurse is explaining the purpose of maneuvering the arms over the head and pushed onto the hips, pointing out that these maneuvers will help to detect:
retraction
when the abdomen curves inward
scaphoid
If an inguinal hernia is incarcerated, it means that
the bowel cannot be reduced
In performing a breast examination, the nurse knows that it is especially important to examine the upper outer quadrant of the breast. The reason for this is that the upper outer quadrant is:
the location of most breast tumors.
A client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the 50 to 56 beats/min range. The client is also complaining of nausea. The nurse interprets that these symptoms are because of stimulation of which cranial nerve (CN)? 1. Vagus (CN X) 2. Hypoglossal (CN XII) 3. Spinal accessory (CN XI) 4. Glossopharyngeal (CN IX)
vagus (CNX)
scaphoid is found in someone who is
very thin
The nurse is palpating the frontal sinuses. Which of the following statements made by the patient describes abnormal finding?
"It feels like there's a slight upward movement." "I can feel pain behind my eyes." "It hurts just a little."
The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam?
After a shower or bath The nurse needs to teach the client how to perform a TSE. The nurse should instruct the client to perform the exam on the same day each month. The nurse should also instruct the client that the best time to perform a TSE is after a shower or bath when the hands are warm and soapy and the scrotum is warm.
A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item? Causative factors, such as caffeine Sensation of fluttering or palpitations Blood pressure and oxygen saturation Precipitating factors, such as infection
Blood pressure and oxygen saturation
The nurse is performing a neurological assessment on a client experiencing anosmia. The nurse would suspect cranial nerve involvement in which of the following? CN III CN IV CN II CN I
CN1 - Olfactory * anosmia- loss of smell
What is meningitis?
Dangerous infection of the outer lining of the brain
The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/min. On the basis of this finding, which action is most appropriate?
Document the findings. The normal respiratory rate in a 12-month-old infant is 20 to 40 breaths/min. The normal apical heart rate is 90 to 130 beats/min, and the average blood pressure is 90/56 mm Hg. The nurse would document the findings.
2.Muscle strength graded 5/5 3.Symmetrical movements bilaterally 4.Increased muscle size on the dominant arm 5.A 1-cm hypertrophy of the right upper arm
Pulsation between the umbilicus and the pubis The presence of pulsation between the umbilicus and the pubis could indicate an abdominal aortic aneurysm and should be reported to the PHCP. Bruits normally are not present. The umbilicus should be in the midline with a concave appearance. Bowel sounds vary according to the timing of the last meal and usually range in frequency from 5 to 35 per minute.
A client is diagnosed with external otitis. Which finding would the nurse expect to note on assessment of the client?
Redness and swelling in the ear canal
The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. On the basis of this documentation, which pattern did the nurse observe? Check vital signs Check laboratory test results Monitor for any rhythm change
Respirations that are abnormally deep, regular, and increased in rate
The nurse has obtained a personal and family history from a client with a neurological disorder. Which factors in the client's history are associated with added risk for neurological problems? Select all that apply.
2.History of headaches 3.Previous back injury 4.History of hypertension 5.History of diabetes mellitus
The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which areas helpful in assessing for pallor or cyanosis? Select all that apply.
2.Tongue 3.Nail beds 5.Mucous membranes
what is Brudzinski's sign ?
Brudzinski's sign is one of the physically demonstrable symptoms of meningitis. Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed.
The nurse assesses a client for the presence of Homans' sign. Which could be an indication that this sign is positive?
3.Pain with dorsiflexion of the foot To elicit Homans' sign, the nurse would dorsiflex the client's foot and assess for pain in the calf area. The presence of pain may indicate a positive Homans' sign.
The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe? 1. A pink-colored tympanic membrane 2. A pearly colored tympanic membrane 3. A transparent and clear tympanic membrane 4. A red, dull, thick, and immobile tympanic membrane
A red, dull, thick, and immobile tympanic membrane
The nurse notes that the health care provider has documented a diagnosis of presbycusis on a client's chart. The nurse understands that which describes this condition? Tinnitus that occurs with aging Nystagmus that occurs with aging. conductive hearing loss that occurs with aging4. A sensorineural hearing loss that occurs with aging
A sensorineural hearing loss that occurs with aging
When preparing the female patient for an examination of both her rectum the patient should be place in which position?
Left lateral
A client's physical examination record states that the client's eyes moved normally through the six cardinal fields of gaze. This exam measures which function?1. Central vision 2. Corneal reflexes 3. Peripheral vision 4. Ocular movements
Ocular movements
A clinic nurse is reviewing the record of a client with a diagnosis of a cataract. Which clinical manifestation is associated with this disorder? 1. Eye pain 2. Opacity of the lens 3. Loss of central vision 4. Inability to identify the color red on an eye examination
Opacity of the lens
The nurse is performing a neurological assessment on a client experiencing vertigo. The nurse wants to perform the Romberg test. The nurse would correctly provide which set of instructions to the client? "Touch your finger to your nose alternating hands." "Walk on your toes, then on your heels." "Stand with your feet together and your arms at your sides." "Walk across the room by placing one foot in front of the other heel to toes."
"Touch your finger to your nose alternating hands."
The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye disorder? a. Total loss of vision b. Pain in the affected eye c. A yellow discoloration of the sclera d. A sense of a curtain falling across the field of vision
A sense of a curtain falling across the field of vision
Which action by the nurse will best facilitate adherence to the treatment regimen for a client with a chronic illness?
Arranging for home health care
The results of a client's eye examination indicate that he or she has an abnormal shape to the curvature of the cornea, which is impairing the ability to see clearly. The nurse determines that the client has which eye condition? 1. Myopia 2. Hyperopia 3. Astigmatism 4. Exophthalmos
Astigmatism
The nurse is examining an adult male and notes thick and curly hair over the pubis area, a pear-shaped scrotum, and slightly darkened skin on the penis. The nurse would correctly choose which of the following actions? Ask the client about risky sexual practicesx Document the findings as normal. Ask the client about childhood illnesses. Notify the physician of the findings.
Document the findings as normal.
A student nurse is assisting with an assessment of a client's level of consciousness using the Glasgow Coma Scale. The student understands that which categories of client functioning are included in this assessment? Select all that apply. 1. Eye opening 2. Reflex response 3. Best verbal response 4. Best motor response 5. Pupil size and reaction
Eye opening Best verbal response Best motor response
How would you adjust abdominal palpation for a patient who is:ticklish?
I would use their had below mine. keep the person's hand under your own with your fingers curled over his or her fingers. Move both hands around as you palpate; people are not ticklish to themselves.
A nurse conducting an eye examination notes that the client exhibits rapid, involuntary oscillating movements of the eyeball when looking at the nurse. The nurse documents this finding as which condition? 1. Nystagmus 2. Photophobia 3. Unequal pupils 4. Consensual response
Nystagmus
The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How should the nurse best determine the presence of erythema?
Palpate for increased skin temperature around the wound edges. Erythema is a form of macula characterized by diffuse redness of the skin. In a dark-skinned client, erythema is best determined by palpating for increased skin temperature. Redness around the wound edges may be difficult to note in the dark-skinned client. Swelling and drainage from the wound are not specific indicators of erythema.
The nurse notes that the primary health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action should the nurse take? a. Speak loudly but mumble or slur the words. b. Speak loudly and clearly while facing the client. c. Speak at normal tone and pitch, slowly and clearly. d. Speak loudly and directly into the client's affected ear.
Speak at normal tone and pitch, slowly and clearly.
A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear? 1.Pruritus 2. Tinnitus 3. Hearing loss 4. Burning in the ear
Tinnitus
A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client?
Wheezes
The nurse is assessing a client who is experiencing an acute episode of cholecystitis [inflammation of the gallbladder.] Which of these clinical manifestations support this diagnosis? Select all that apply. a. Fever b. Positive Cullen's sign c. Complaints of indigestion d. Palpable mass in the left upper quadrant e. Pain in the upper right quadrant after a fatty meal
a. Fever c. Complaints of indigestion e.Pain in the upper right quadrant after a fatty meal
A client states that she has recently been having difficulty swallowing, occasionally causing coughing and choking. The nurse should document this as:
dysphagia.
cluster headache
excruciating stabbing or burning sensations located in the eye or cheek
The nurse is performing a neurological assessment on a client with a head injury. The nurse should use which technique to assess the plantar reflex?
plantar reflex is assessed by stroking the outer plantar surface of the foot from the heel to the toe.
The nurse is volunteering with an outreach program to provide basic health care for homeless people. Which finding, if noted, should be addressed first? Blood pressure 154/72 mm Hg Visual acuity of 20/200 in both eyes Random blood glucose level of 206 mg/dL (11.47 mmol/L) Complaints of pain associated with numbness and tingling in both feet
Complaints of pain associated with numbness and tingling in both feet
The nurse is preparing to check the breath sounds of a client. When auscultating for bronchovesicular breath sounds, the nurse should place the stethoscope over which area?
The trachea and larynx
The registered nurse (RN) is educating a new RN on conducting a problem-based or focused assessment on a client. Which statement by the new RN indicates that the teaching has been effective?
This is mostly used in a walk-in clinic or emergency department."
The nurse is caring for a client who is hospitalized for a head trauma, and requires frequent neurologic rechecks. Which of the following is one of the essential components of the neurologic recheck? Diabetic neuropathy screening. Graphesthesia. Level of consciousness.
Level of consciousness.
Which of the following is true of a deviated septum? Feels symmetrical on both sides of the nose with palpation. Looks like a hump with inspection. Is usually secondary to a viral infection. Is seen as a spot of light, when shining a penlight from one naris to the other.
Looks like a hump with inspection.
The saliva produced in the parotid gland is secreted through the sublingual duct. the Wharton duct. the Stensen duct. the submandibular duct.
the Stensen duct.
The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which action to obtain the assessment data?
Ask the client to follow the flashlight through the 6 cardinal positions of gaze.
A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan? Monitoring the temperature b. Monitoring complaints of heartburn c. Giving warm gargles for a sore throat d. Assessing for the return of the gag reflex
Assessing for the return of the gag reflex Remember that assessment always takes priority before acting, so the answer is probably not C. A, B, and D are all assessments, but D reflects a more concerning underlying process
The nurse is examining the genitalia of a male client. On palpation of the right inguinal area, the nurse detects a bulge as the client bears down. The nurse would correctly interpret this finding as which of the following conditions? Cremasteric reflex Hernia Variocele Prostatitis
Hernia
Which of the following is part of the general survey?
Personal hygiene
After performing an initial abdominal assessment on a client, the nurse documents that the bowel sounds are normal. Which description bestdescribes normal bowel sounds?
Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants
The nurse conducting a health screening is performing hearing assessments on clients. Senior nursing students are assisting the nurse with the assessments. The nurse instructs the students to perform a voice test by taking which action?
Stand 1 to 2 ft (30 to 60 cm) away from the client and ask the client to block 1 external ear canal. To perform a voice test, the examiner stands 1 to 2 ft (30 to 60 cm) away from the client and asks the client to block 1 external ear canal. The nurse quietly whispers a statement and asks the client to repeat it. Each ear is tested separately. The client is not asked to block both ears, and the examiner should face the client during the test.
Which therapeutic communication technique is most helpful when working with transgender persons? Using open-ended questions Using their name to address them Using pronouns associated with birth sex Anticipating the client's needs and making suggestions
Using open-ended questions
Cloudy urine is most indicative of
a urinary tract infection
Which of the following describes the purpose of the tuning fork tests? helps to test for hearing loss in specific frequencies helps distinguish conductive hearing loss from sensorineural hearing loss will detect proper alignment of the ears is useful in detecting a middle ear infection
helps distinguish conductive hearing loss from sensorineural hearing loss
A functional assessment is necessary tosee
if the patient can perform ADLs
The nurse places his thumbs on the upper lids and exposes under the lids. This is done in order to assess the: red reflex. eyebrows. lacrimal apparatus.
lacrimal apparatus
where could you percuss lung resonance ?
left upper quadrant at midclavicular
what sound would you hear with cardiac tamponade?
muffled sounds
A fine, oscillating movement seen around the iris is known as
nystagmus
A patient states to the nurse that it feels like the room is spinning. Which of the following terms describes this symptom? presbycusis tinnitus subjective vertigo objective vertigo
objective vertigo
varicose veins are more like to occur in
old age and obese or pregnant women
While palpating the rectum, the patient reports feeling a need to move the bowels. Which of the following statements should the nurse make? "This is a normal feeling." "I will stop the assessment immediately." "I will inform your physician." "Do you have a family history of hemorrhoids?"
"This is a normal feeling."
The nurse asks a patient to raise her extended legs so that her feet are elevated 12 inches, and then wag her feet for 30 seconds. How should the nurse explain the purpose of this?
"This will drain the venous blood from the legs."
A nurse notes during assessment that an older client is exhibiting a number of visual changes. The nurse determines that which assessment findings are associated with normal age-related changes of the eye? Select all that apply. 1. Photophobia 2. Decreased visual acuity 3. Loss of peripheral vision 4. Decreased tolerance of glare 5. Decreased ability to adapt to dark and light
2. Decreased visual acuity 3. Loss of peripheral vision 4. Decreased tolerance of glare 5. Decreased ability to adapt to dark and light
A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. a. Diarrhea b. Black, tarry stools c. Hyperactive bowel sounds d. Gray-blue color at the flank e. Abdominal guarding and tenderness f. Left upper quadrant pain with radiation to the back
Gray-blue color at the flank Abdominal guarding and tenderness Left upper quadrant pain with radiation to the back
A patient's abdomen is bulging and stretched in appearance. The nurse should describe this finding as: A) obese. B) herniated. C) scaphoid. D) protuberant.
protuberant
709. The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? Hyperreflexia b. Positive reflexes c. Flaccid paralysis d. Reflex emptying of the bladder
Flaccid paralysis
A nursing student is asked about the procedure used to elicit Homans' sign. Which response by the student indicates an understanding of this assessment technique?
A nursing student is asked about the procedure used to elicit Homans' sign. Which response by the student indicates an understanding of this assessment technique?
Which characteristic of the prostate gland would the nurse recognize as an abnormal finding while palpating the prostate gland through the rectum? Nodular surface. Rubbery consistency. Nontender to palpation. palpable central grove
Nodular surface
It is most important to ask the patient to exhale, and to hold it briefly when:
auscultating for a carotid bruit
The gland surrounding the neck of the bladder in male mammals and releasing fluid. median sulcus. sigmoid colon. prostate. rectum
postate
Ophthalmoscopy, also called funduscopy is used to test for ?
diabetic retinopathy
what occurs to the diaphragm with COPD patients?
diaphragm becomes flatter.
subjective vertigo is described as
feeling of spinning person
What is lanugo?
fine downy hair
A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem?
A physical obstruction to the transmission of sound waves A conductive hearing loss occurs as a result of a physical obstruction to the transmission of sound waves. A sensorineural hearing loss occurs as a result of a pathological process in the inner ear, a defect in cranial nerve VIII, or a defect of the sensory fibers that lead to the cerebral cortex.
A nurse is listening to a health care provider (HCP) explain the results of an eye examination to a client. The HCP states that the client has glaucoma because of a congenitally narrow anterior chamber angle, which suddenly has become blocked by the base of the iris. The nurse understands that the HCP is describing which type of glaucoma? 1. Primary open-angle glaucoma 2. Angle-closure glaucoma 3. Low-tension glaucoma 4. Secondary glaucoma
Angle-closure glaucoma
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention? a. Administer the prescribed pain medication. b. Notify the primary health care provider (PHCP). c. Call and ask the operating team to perform surgery as soon as possible. d. Reposition the client and apply a heating pad on the warm setting for the client's abdomen.
Notify the primary health care provider (PHCP). decreased bowel sounds describe a GI tract that is slowing down, and it's gotten so bad that things are backing up, causing abdominal distention.
A client who sustained an eye injury arrives at the hospital emergency department. Which initial action should the nurse take?1. Instill an antibiotic solution. 2. Place an ice pack on the eye. 3. Flush the eye with sterile saline solution. 4. Obtain a history regarding the cause of the injury
Obtain a history regarding the cause of the injury
The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding? 1-Rhythmic respirations with periods of apnea 2-Regular rapid and deep, sustained respirations 3-Totally irregular respiration in rhythm and depth 4- Irregular respirations with pauses at the end of inspiration and expiration
Rhythmic respirations with periods of apnea
The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. a. The client is aphasic. b. The client has weakness on the right side of the body. c. The client has complete bilateral paralysis of the arms and legs. d. The client has weakness on the right side of the face and tongue. e. The client has lost the ability to move the right arm but is able to walk independently. f. The client has lost the ability to ambulate independently but is able to feed and bathe herself or himself without assistance.
The client is aphasic. The client has weakness on the right side of the body. The client has weakness on the right side of the body. F-A-S-T Face drooping - D, Arm weakness - B, Speech difficulty - A. Call 911 right away -T
A scaphoid abdomen refers to an abdomen which? is stretched. has a normal shape. is full of fluid caves in
caves in
The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer?
d. A rigid, board-like abdomen The rigid, board-like abdomen is a classic and specific finding of peritonitis.
The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation? Diplopia b. Eye pain c. Floating spots d. Blurred vision
d. Blurred vision
Which of the following is true of age-related presbycusis? it is a conductive hearing loss will cause the perception of sound without an external source it is a rare form of hearing loss first affects high-frequency tones
first affects high-frequency tones
