Hollistic NClEX

When assessing the facial lacerations of a middle- aged client admitted to the facility 1 week ago, the nurse observes scabs around the lacerations. Scabs indicate which phase of wound healing?

Lag

Why should an infant be quiet and seated upright when the nurse assesses his fontanels?

Lying down and crying can cause the fontanels to bulge

A 76 year old client with no debilitating conditions belongs to which geriatric population?

Middle old

When auscultating a clients abdomen, the nurse detects high0 piched gurgles over the lower right quadrant. Based on this finding, the nurse suspects:

Nothing abnormal

The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling, and in duration at the wound site. What do these signs suggest?

Infection

The nurse is auscultating a client's chest. How can the nurse differentiate a pleural friction rub from other abnormal breath sounds?

A rub occurs during both inspiration and expiration and produces a squeaking or gating sound

Why should the nurse inspect first and then auscultate when performing an assessment of a pediatric client

Because the child may cry as the assessment proceeds, making auscultation difficult

The nurse must assess a client's splinted extremity for neurovascular damage. What should she do?

Compare the capillary refill of each extremity, making sure it's the same bilaterally

When testing a client's pupils for accommodation, the nurse should interpret which findings as normal?

Constriction and convergence

To avoid recording an erroneously low systolic blood pressure because of failure to recognize an auscultatory gap, the nurse should.

Have the client lie down while taking his blood pressure

To help assess a client's cerebral function, the nurse should ask:

Have you noticed a change in your memory?

A client has lymphedema in both arms and the nruse must measure blood pressure using a thigh cuff. In reference to the clients baseline arm blood pressure, the nurse should exepct the thigh to have a:

High systolic blood pressure reading

A client comes to the clinic for a routine checkup. To assess the clients gag reflex, the nurse should use which method?

Place a tongue blade lightly on the posterior aspect of the tongue

A client comes to the clinic for a routine checkup. To assess the clients gag reflex, the nurse should use which method?

Place a tongueblade lightly on the posterior aspect of the tongue

The nurse is monitoring a client for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use?

Potential of drug dependence

The nurse is assessing a clients abdomen. Which finding should the nurse report as abnormal?

Shifting dullness over the abdomen

The ear canal of an infant or young child

Slant upward

A client who was involved in a motor vehicle accident is admitted to the intensive care unit. The emergency department admission record indicates that the client hit her head on the steering wheel. The client complains of a headache, and a nursing assessment reveals that she has difficulty comprehending language and diminished hearing. Based on these findings, the nurse suspects injury to which lobe of the brain?

Temporal

The nurse is helping a client ambulate for the first time after 3 days of bed rest. Which observation by the nurse suggest that the client tolerated the activity without distress?

The clients pulse and respiratory rates increased moderately during ambulation

The nurse uses a stethoscope to auscultate a client's chest. Which statement about a stethoscope with a bell and diaphragm is true?

The diaphragm detects high- pitched sounds best

The nurse is assessing a client who may be in the early stages of dehydration. Early manifestations fo dehydration include:

Thirst or confusion

When obtaining a client's history, the nurse develops a genogram. What is the purpose of developing a genogram?

To identify genetic and familial health problems

THe nurse is assessing a client who has a rash on the chest and upper arms. Which questions should the nurse ask in order to gain further information about the cleint's rash?

When, Are, What, Have

Before a transesophageal echocardiogram, a client is given an oral topical anesthetic spray. Upon return from procedure, the nurse observes that the client has no active gag reflex. In response, the nurse should

Withhold food and fluids

The nurse prepares to measure a clients blood pressure. What is the correct procedure for measuring blood pressure?

Wrapping the cuff around the limb, with the uninitiated bladder covering and three- quarters of the limb circumference

When routinely evaluating a geriatric client for any atypical signs or symptoms, the nurse should remember that:

aging can reduce the body's ability to regulate body temp.

When assessing a geriatric client, the nurse expects to fin various aging- related physiologic changes. These changes include:

delayed gastric emptying

When assessing a geriatric client, the nurse expects to fin various aging- related physiologic changes. these changes include:

delayed gastric emptying

Why shouldn't the nurse palpate both carotid arteries at one tiem?

it may cause severe bradycardia

When examining a client with abdominal pain, the nurse should assess:

the symptomatic quadrant last

Which of the following is the most common source of airway obstruction in an unconsciou svictim?

the tongue

A child with rheumatic fever must have his heart rate measured while awake and wile sleeping. Why are two readings necessary?

to compensate for the effects of activity on the heart rate

The nurse is caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices cheyne- stokes respiration. Cheyne- stokes respiration are:

Progressively deeper breaths followed by a shallower breaths with apneic periods

The nurse reviews the (ABG) values of a client admitted with pneumonia pH, 7.51; Paco2, 28mmHg; Pao2, 70 mm Hg and HCO3-, 24 mEq/L. What do these values indicate?

Respiratory Alkalosis

Which of the following factors are major components of a client's general background drug history?

Allergies and socioeconomic status

The nurse is assessing a clients pulse. Which pulse feature should the nurse document?

Amplitude

The nurse is helping a plan a teaching session for a client who will be discharged with a colostomy. When describing a hellcat stoma, which testament should the nurse be sure to include?

At first, the stoma may bleed when touched

When inspecting a clients skin, the nurse finds a vesicle on the clients arm. Which description applies to a vesicle?

Circumscribed, elevated, and filled with serous fluid

To evaluate a clients cerebellar function, the nurse should ask:

Do you have any problems with balance

The nurse is assessing a 47- year-old client who has come to physicians office for his annual physical. One of the first physician's office for his annual physical. One of the first physical signs of aging is:

Failing eyesight, especially close vision.

Tachycardia can result from:

Fear, pain, or anger

Vasodilation or vasoconstriction produced by an extrenal cause will interfere with an accurate assessment of a client with peripheral vascular disease (PVD) therefore, the nurse should.

Keep the client warm

A client comes to the clinic for a diagnostic allergy testing. Why is intradermal injection used for such testing?

Intradermal drugs diffuse more slowly

The nurse is performing a preoperative assessment. Which statement by the client would alert the nurse to the presence of risk factors for postoperative complications?

Ive cut my smoking down from two pack s to one pack a day

When a nurse enters the client's room, the client complains that she's spitting up blood when she coughs. The nurse takes a quick health history that includes:

The history of the present problem, allergies, medications, and recent major operations

The nurse correctly identifies which terms as belonging to the dorsal cavity?

Vertebral canal

Validation or vasoconstriction produced by an external cause will interfere with an accurate assessment of a client with peripheral vascular disease (PVD).Therefore, the nurse should:

keep the client warm

The nurse can auscultate for heart sounds more easily if the client is:

leaning forward

Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain, and venography reveals DVT. When assessign this client,the nurse is most likely to detect:

left calf circumfrence

Which of the following sentences correctly describes the anatomic position?

palms are turned forward

Hyperactive bowel sounds can result from all of the following except:

paralytic illus

At 8 am, the nurse assesses a client who's scheduled for surgery at 10 am. During the assessment, the nurse detects dyspnea, a nonproductive cough, and back pain. What should the nurse do next?

Notify the physician immediately of these findings

During assessment, the nurse auscultates for a clients breath sounds. Auscultation procedures which type of data?

Objective