NUR 3306 Final Exam Review

Kiesselbach plexus is the most common site of ________________.

Epistaxis Anterior nosebleeds

Gustatory rhinitis occurs most frequently in children. T/F

False

The nurse auscultates an extra sound on a patient 1 week after an MI. It is immediately after S2 and is heard best at the apex. Which of the following does the nurse suspect? 1. S3 gallop 2. S4 gallop 3. Split S2 4. Systolic ejection click

S3 gallop

The nurse is educating a new mother about safety precautions for a child who is beginning to walk. What information should the nurse include in this teaching session? 1. Wearing helmets when bike riding 2. Increasing formula intake to meet caloric needs 3. Team sport precautions 4. Setting up gates around stairs

Setting up gates around stairs

A nurse is presenting a class to new mothers preparing for postpartum discharge from the hospital. What topics would the nurse be sure to include in teaching? (Select all that apply.) 1. Choking prevention 2. Bundling the baby 3. Reading to the baby 4. Sleep positioning 5. Suffocation prevention

- Choking prevention - Sleep positioning - Suffocation prevention

A woman in her second trimester of pregnancy calls the obstetrician's office and tells the nurse that she is having pains all around her umbilicus. What would be the nurse's best response? 1. "These are called Braxton Hicks contractions. They are a kind of 'practice' for when the baby is born." 2. "These pains are caused by the stretching of ligaments as your uterus grows. They are nothing to worry about.' 3. "You are having growing pains. There is nothing to worry about." 4. "You are having preterm labor. Go to the emergency room right away."

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

What is the purpose of the tongue? (Select all that apply.) 1. Helps with the identification of sweet, sour, salty, and bitter tastes 2. Provides resonance to the voice 3. Aids in the production of saliva 4. Manipulates solids and liquids when eating and drinking 5. Assists in speech production Question

- Helps with the identification of sweet, sour, salty, and bitter tastes - Manipulates solids and liquids when eating and drinking - Assists in speech production

When auscultating a client diagnosed with aortic stenosis, the nurse should place the stethoscope at what location on the client's chest? 1. Right sternal border, 2nd ICS 2. Left sternal border, 3rd ICS 3. Right sternal border, 4th ICS 4. Left mid-clavicular line, 5th ICS

1. Right sternal border, 2nd ICS

Which formula will the nurse use to calculate cardiac output? 1. heart rate x stroke volume 2. systolic x diastolic 3. heart rate x preload 4. preload x afterload

1. heart rate x stroke volume

During the assessment of deep tendon reflexes, the nurse finds that a patient's responses are bilaterally normal. What number is used to indicate normal deep tendon reflexes when the documenting this finding? ____+

2

The autonomic nervous system innervates the salivary glands along with which cranial nerves? (Select all that apply.) 1. CN VIII 2. CN IX 3. CN VII 4. CN XII

2. CN IX 3. CN VII 4. CN XII

The lymph nodes that lie in front of the mastoid bone are called what? 1. occipital nodes 2. preauricular nodes 3. supraclavicular nodes 4. superficial cervical nodes

2. preauricular nodes

A patient has dyspnea, edema, weight gain, and liquid intake greater than output. These symptoms are consistent with which nursing diagnosis? 1. Ineffective cardiac tissue perfusion 2. Excess fluid volume 3. Decreased cardiac output 4. Impaired gas exchange

2. Excess fluid volume

Which of the following is NOT standard care for a patient who is at high risk for ear infections? 1. Clean only external ear. 2. Have audiogram yearly. 3. Be current on immunizations. 4. Avoid secondhand smoke.

2. Have audiogram yearly.

The nurse assess the response of the eye to light and documents normal findings as what? 1. PEARL 2. PERRLA 3. PERLA 4. PEERLA

2. PERRLA

A patient presents with a complaint of drooping of the eyelid on one side. The nurse should document this finding as what? 1. Thyroglossal cyst 2. Ptosis 3. Pharyngitis 4. Kernig sign

2. Ptosis

What is the most important lifestyle change a client can make to improve cardiovascular health? 1. Eating a diet high in fat 2. Quitting smoking 3. Getting less exercise and more rest 4. Living a more sedentary lifestyle

2. Quitting smoking

Which of the following best describes the instructions the nurse should give a patient when assessing the thyroid from the posterior approach? 1. Turn your head as far to the right as you can. 2. Tilt your head slightly down and to one side. 3. Tilt your head back as far as possible. 4. Bring your chin down towards your neck.

2. Tilt your head slightly down and to one side.

The nurse positions the client for auscultation of heart sounds. What does the nurse do first? 1. Warm the bell of the stethoscope 2. Wash the client's chest 3. Clean the stethoscope 4. Auscultate the carotid arteries

3. Clean the stethoscope

Physical examination of a patient reveals an enlarged tonsillar node. Acutely infected nodes would be which of the following? 1. hard and nontender 2. fixed and soft 3. firm but movable and tender 4. irregular and hard

3. firm but movable and tender

How many quadrants is the abdomen divided in to during an assessment? A. 6 B. 4 C. 2 D. 8

4

Which nursing diagnosis is appropriate for a patient with an ear problem? 1. Kinesthetic disturbed perception 2. Olfactory sensory perception 3. Sensory perception, gustatory 4. Disturbed sensory perception

4. Disturbed sensory perception

While examining the patient's neck, the nurse finds the trachea midline but has difficulty palpating the thyroid. What action would the nurse take next? 1. Report to the physician a suscicion of a slow-growing goiter. 2. Look for signs of hypothyroidism. 3. Tell the patient that the finding is unexpected. 4. Document the finding as normal.

4. Document the finding as normal.

Which of the following would the nurse consider objective data? 1. Smoking history 2. Chest pain 3. Reported palpitations 4. Evaluating the jugular pulse

4. Evaluating the jugular pulse

Which of the following clusters of symptoms are common in women preceding an MI? 1. Chest pain, nausea, diaphoresis 2. Dizziness, palpitations, low pulse 3. Weight gain, edema, nocturia 4. Fatigue, difficulty sleeping, dyspnea

4. Fatigue, difficulty sleeping, dyspnea

When working with an older adult, what would the nurse emphasize as increased risks for the patient? 1. Myopia and strabismus 2. Exophthalmos and presbyopia 3. Blepharitis and chalazion 4. Glaucoma and cataracts

4. Glaucoma and cataracts

The nurse is caring for a patient with a sudden onset of chest pain. Which assessment is highest priority? 1. Auscultate heart sounds 2. Inspect the predorium 3. Percuss the left border 4. Obtain pulse and BP

4. Obtain pulse and BP

When caring for an older adult, the nurse would know that wound healing rate reduces normally with aging by 1. 40% 2. 20% 3. 50% 4. 30%

50%

When assessing a client's strength, it is necessary to A. Compare one side to the other B. Assess the extremities at the same time C. Compare upper and lower extremities D. Assess upper and lower extremities at the same time

A. Compare one side to the other

A client comes to the clinic and reports a sore knee. The nurse notes popping and cracking noises when the client attempts to bend the knee. The client exhibits signs of pain by facial expression. The nurse knows that the popping and cracking noises should be charted as what? A. Crepitus B. Grating noise C. Tactile emphysema D. Popping and cracking noises

A. Crepitus

The lymphatic system functions to? (Mark all that apply.) A. Fight infection B. Hydrate the thymus C. Maintain protein balance D. Maintain fluid balance E. Drain lymph from the bloodstream

A. Fight infection C. Maintain protein balance D. Maintain fluid balance The lymphatic system consists of the lymph nodes and lymphatic vessels as well as the spleen, tonsils, and thymus. It maintains fluid and protein balance and functions with the immune system to fight infection. The lymph system does not drain lymph from the bloodstream or hydrate the thymus.

A nurse asks a client to say "ninety-nine" as the nurse palpates the posterior thorax. The nurse is assessing which of the following? A. Fremitus B. Egophony C. Chest expansion D. Bronchophony

A. Fremitus Fremitus is assessed by asking a client to say "ninety-nine" as the nurse palpates the thorax. Bronchophony is assessed by asking the client to say "ninety-nine" as the nurse auscultates the chest wall. Chest expansion is assessed by measuring the distance the examiner's thumbs move when the client takes a deep breath. Egophony is assessed by having the client repeat the letter "e" as the nurse auscultates.

A nurse is teaching a client about self breast examination. What would the nurse emphasize? (Mark all that apply.) A. Inspection B. Pain C. Timing D. Palpation E. Pallor

A. Inspection C. Timing D. Palpation It is important to guide clients through self breast examination that emphasizes timing, inspection, and palpation. Pain and pallor are not emphasized when teaching self breast examination.

Which of the following would be most important for the nurse to remember when auscultating the thorax? A. Listen at each site for at least one complete respiratory cycle B. Have the client breathe deeply through the mouth C. Be alert to the client's comfort and offer rest periods D. Auscultate the base at the level of the sixth rib

A. Listen at each site for at least one complete respiratory cycle Although having the client breathe deeply through the mouth and being alert to the client's comfort are important when auscultating the lungs, it would be most important to listen at each site for one complete respiratory cycle to obtain the most accurate information. The nurse would auscultate from the apices to the bases at T10 and laterally from the axilla down to the seventh or eighth rib.

A modifiable risk factor for breast cancer includes what? A. Obesity B. Age C. Genetics D. Asthma

A. Obesity It is important for women to be aware of their specific risk factors for breast cancer. Although many factors are not modifiable, some are. When a client is aware of her own specific risk factors, she may be more diligent in practicing healthy habits (monthly SBEs, yearly physical examinations, and mammograms if indicated) and adjust other personal behaviors (especially physical inactivity and obesity). Asthma is not correlated with breast cancer. Genetics and age are not modifiable risk factors.

An older adult client has been admitted to the unit. The client has problems with fine motor movement. What would be important to do for this client? A. Open all packages and arrange the meal tray while communicating actions to the client B. Teach the client to call for assistance when getting up to bathroom C. Evaluate for assistance devices D. Assess gross motor function

A. Open all packages and arrange the meal tray while communicating actions to the client

When assessing for acute arterial occlusion, what would the nurse include? (Mark all that apply.) A. Pain B. Pallor C. Paralysis D. Presence E. Paresthesia

A. Pain B. Pallor C. Paralysis E. Paresthesia Assessment for acute arterial occlusion involves evaluation of the "Six Ps": pain, poikilothermia, paresthesia, paralysis, pallor, and pulselessness. Presence is a distracter for this question.

A nurse is performing a physical exam on an older client. She reports that her feet feel numb. What assessment should the nurse perform first? A. Palpate the dorsalis pedis pulses. B. Measure capillary refill. C. Locate the inguinal lymph nodes. D. Measure calf circumference.

A. Palpate the dorsalis pedis pulses.

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

Achilles reflexes

A nurse is preparing an educational event for the parents of children with respiratory disorders. What would the nurse tell the parents about allergies? 1. Allergy can affect any target organ in the body. 2. There are few effective treatments for allergies. 3. If a parent has allergies, the child has a 25% chance of developing them as well. 4. Children will outgrow their allergies.

Allergy can affect any target organ in the body.

The RN may delegate which care component to a nursing assistant? 1. Evaluating vital signs 2. Check client's pain level 3. Ambulation assistance 4. Wound care and assessment

Ambulation assistance

Temporary heart pain, resolving in less than 20 minutes, aggravated by physical activity and stress is known as what? 1. Angina 2. Crushing 3. Musculoskeletal 4. Gastrointestinal

Angina

A patient is reporting pain after palpation of the right lower quadrant. What condition does the nurse expect? 1. Gastroenteritis 2. Irritable bowel syndrome 3. Nephrolithiasis 4. Appendicitis

Appendicitis

What is the most appropriate nursing intervention when writing a care plan for a pregnant woman and using the nursing diagnosis "Readiness for enhanced family coping due to new role?" 1. Provide breast-feeding support 2. Educate the client about nutrition and overeating, exercise, and stress management techniques 3. Help the client move toward an enriching lifestyle 4. Assess the structure, resources, and coping abilities of the family

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

What is the second step of physical assessment when assessing the abdominal? 1. Palpation 2. Inspection 3. Auscultation 4. Percussion

Auscultation

A client diagnosed with rheumatoid arthritis exhibits edema, redness, and tenderness of the fingers. What is the nurse's priority action? A. Apply ice and immobilize the fingers. B. Administer prescribed anti-inflammatory. C. Teach finger stretching exercises. D. Notify the healthcare provider.

B. Administer prescribed anti-inflammatory.

When doing a shift assessment on a newly admitted client, the nurse notes lack of hair on the right lower extremity; thickened nails on the right lower digits; dry, flaky skin on the right lower extremity; and diminished tibial pulses bilaterally and absent pedal pulses. What nursing diagnosis should this client receive? A. Pain related to decreased blood flow and altered tissue perfusion B. Altered tissue perfusion, arterial related to reduced blood flow C. Risk for peripheral neurovascular dysfunction D. Activity intolerance related to pain and claudication with ambulation

B. Altered tissue perfusion, arterial related to reduced blood flow Signs of altered tissue perfusion, arterial related to reduced blood flow include decreased oxygen, resulting in a failure to nourish tissues at the capillary level; reduced hair on the extremity; thick nails; dry skin; weak or absent pulses; pale skin; cool, reduced sensation; and prolonged capillary refill. The other options are distracters to the question.

A college age athlete presents to the clinic with pain in the tibiotalar joint. It is a hinge joint limited to flexion and extension. The terms used to describe these movements are what? A. Adducting and abducting B. Dorsiflexion and plantar flexion C. Supination and pronation D. Rotation and supination

B. Dorsiflexion and plantar flexion

The nursing instructor is discussing the collection of subjective information when assessing a client with arterial, venous, and lymphatic disorders. What would the instructor tell the students to include in the subjective portion of the health assessment? A. History related to grandparents' health B. Identification of cardiovascular risk factors C. Plan for modifying risk factors D. Education on nonmodifiable risk factors

B. Identification of cardiovascular risk factors The subjective portion of the health assessment includes the identification of cardiovascular risk factors and history related to those symptoms that are frequently associated with arterial, venous, and lymphatic disorders. The subjective portion of the health assessment would not include a plan for modifying risk factors, education on nonmodifiable risk factors, or a history of the grandparents' health.

The nurse is assessing the musculoskeletal system of a teenage boy for participation in athletics. The nurse would expect to find that this client's bones are what as compared to a female of the same age? A. No difference B. Larger and stronger C. Longer and stronger D. More curved

B. Larger and stronger

Students are practicing documentation of peripheral vascular and lymphatic assessment before going into the clinical setting. A student documents the following: Lower left leg cool to touch with dorsalis pedis, back knee pulse and femoral pulse palpable. How could the following charting be changed to communicate information in appropriate medical terminology? A. Left extremity cool to touch with femoral, posterior popliteal, dorsalis and pedis pulses palpable B. Left lower extremity cool to touch with femoral, posterior popliteal, and dorsalis pedis pulses palpable C. Left lower leg cool to touch with femoral, posterior popliteal, dorsalis and pedis pulses palpable D. No changes are necessary

B. Left lower extremity cool to touch with femoral, posterior popliteal, and dorsalis pedis pulses palpable Appropriate medical terminology would be "left lower extremity cool to touch with femoral, posterior popliteal, and dorsalis pedis pulses palpable." The other options are distracters to the question.

After teaching a group of students about age-related changes in the lungs, the instructor determines that the teaching was successful when the students identify which of the following as an age-related change? A. Increased resiliency B. Loss of elasticity C. Increased functional capillaries D. Loss of subcutaneous fat

B. Loss of elasticity Aging leads to a loss of lung elasticity, fewer functional capillaries, and a loss of lung resiliency. There is a loss of subcutaneous fat, but this may make the sternum and ribs appear more prominent on inspection. It does not affect the lungs.

A nurse is preparing a teaching plan for a client newly diagnosed with peripheral arterial disease. The nurse knows to address in this teaching plan the most modifiable risk factors. What risk factors would the nurse include? (Mark all that apply.) A. Low sodium diet B. Smoking C. Activity level D. Anaerobic exercise E. Low-protein diet

B. Smoking C. Activity level Identifying options for the modification of risk factors can significantly improve the outcome for patients with peripheral arterial disease. The most modifiable risk factors are smoking, high-fat diet, and limited activity level. Low-protein diets and anaerobic exercise are not considered modifiable risk factors for peripheral arterial disease.

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

Balance

Which client-satisfaction related intervention of staff nurses may lead to improved client outcomes? 1. Daily client rounds 2. Leaving client room doors open 3. Request that visitors remain in waiting room 4. Bedside hand-off reports

Bedside hand-off reports

The nurse is assessing a client who presents with shoulder pain. No signs of inflammation are present. What is the nurse's priority action? A. Notify the healthcare provider immediately. B. Administer prescribed pain medication. C. Assess for shortness of breath. D. Check for passive range of motion.

C. Assess for shortness of breath.

A client presents to the emergency department after falling off a ladder while doing some outside painting at home. The client's ankle appears swollen, out of alignment, and is painful to touch. What is the nurse's first action? A. Encourage early weight bearing and ambulation. B. Apply an ice pack to the affected extremity. C. Check for a pulse, color, temperature, and capillary refill. D. Splint and immobilize the affected extremity.

C. Check for a pulse, color, temperature, and capillary refill.

Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would most likely suspect which of the following? A. Diabetes mellitus B. Heart failure C. Chronic obstructive pulmonary disease D. System lupus erythematosus

C. Chronic obstructive pulmonary disease The client is assuming the tripod position which is often seen in chronic obstructive pulmonary disease. A client with heart failure would most likely assume an orthopneic position to ease any breathing difficulties. The tripod position is usually not associated with diabetes or systemic lupus.

When percussing the scapula of a client, which of the following would the nurse expect to hear? A. Resonance B. Dullness C. Flatness D. Hyperresonance

C. Flatness Normally, percussion over the scapula elicits flat tones. Resonance is heard over the normal lung tissue. Dullness is heard when fluid or solid tissue replaces air in the lung. Hyperresonance is elicited in cases of trapped air, such as in emphysema or pneumothorax.

A mother of three young children is newly diagnosed with breast cancer. The client tells the nurse that she is so sad and cannot stop crying. She adds that she feels like she is less of a woman and is having trouble sleeping. When initiating the plan of care, what would be the most appropriate nursing diagnosis? A. Altered body image B. Altered self-concept C. Grieving D. Altered sleeping pattern

C. Grieving Manifestations of grieving related to loss of breast, functional ability, and cancer diagnosis include sadness, crying, anger, depression, altered eating and sleep patterns, and reliving of past experiences. All options may be appropriate, but for this client, the most correct option is grieving.

The nurse is developing a plan of care for a client found to have a strength problem. What would be an appropriate nursing diagnosis for this client? A. Activity intolerance B. Self-care deficit C. Impaired physical mobility D. Impaired walking

C. Impaired physical mobility

When assessing the extremities of a client, the nurse notes muscle atrophy. What does the nurse know may be the cause? A. Venous insufficiency B. Chronic lymphedema C. Peripheral arterial disease D. Arterial aneurysm

C. Peripheral arterial disease Peripheral arterial disease may result in muscle atrophy. Hypertrophy may result from activity in which the patient uses one arm more than the other, such as tennis. Muscle atrophy is not caused by chronic lymphedema, venous insufficiency, or arterial aneurysm.

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

C. Posterior tibial The posterior tibial pulse is located in the groove between the medial malleolus and the Achilles tendon. The femoral pulse is about halfway between the symphysis pubis and the anterior iliac spine, just below the inguinal ligament. The popliteal pulse is often difficult to locate. It may be felt immediately lateral to the medial tendon. A light touch is important to avoid obliterating the dorsalis pedis pulse. It is normally about halfway up the foot immediately lateral to the extensor tendon of the great toe.

A client is thought to have a balance problem. What would be an advanced method of assessing balance in this client? (Mark all that apply.) A. Walking heel to toe B. Standing on one foot C. Romberg's test D. Standing E. Hopping on one foot

C. Romberg's test D. Standing E. Hopping on one foot

When assessing the apices of the lungs, the nurse would locate them at which position? A. At the level of the diaphragm B. Near the level of the eighth rib C. Slightly above the clavicle D. At about the tenth rib

C. Slightly above the clavicle The apex of each lung extends slightly above the clavicle. The base is at the level of the diaphragm. Laterally, lung tissue reaches the level of the eighth rib; posteriorly, the base lies at about the tenth rib.

Included in the subjective assessment of the breast are the client's statements about what? (Mark all that apply.) A. Breast size B. Palpation C. Surgeries D. Nipple discharge E. Personal history

C. Surgeries D. Nipple discharge E. Personal history Subjective data collection begins with the current health history related to the breast (such as breast discomfort, masses or lumps, or nipple discharge) and continues with questions related to past history (previous breast disease; surgeries; menstrual, pregnancy, and lactation history; and past hormone replacement therapy), family history (of breast cancer or other breast disease), and personal history (breast trauma, surgery, and self-care behaviors). Palpation and breast size are not part of subjective data collection.

A white coating of the tongue may be oral ____________ and is common in patients taking antibiotics.

Candidiasis

A client presents at the urgent care clinic with sever pain and pressure around the eyes. The nurse practitioner suspects a sinus infection. What is considered the gold standard diagnostic technique in evaluating sinus disease? 1. Transillumination 2. Percussion of the sinus cavities 3. Computed tomography (CT) scanning 4. Magnetic resonance imaging

Computed tomography (CT) scanning

Which of the following scores for distance vision indicates the patient with the poorest vision? A. 200/20 B. 18/20 C. 24/20 D. 20/100

D. 20/100

A trauma client reports pain in the left lower extremity. The nurse notes that the extremity has pallor. Pedal pulses are diminished, and paresthesia is present. What nursing diagnosis might the nurse use? A. Altered tissue perfusion, arterial related to reduced blood flow B. Activity intolerance related to pain and claudication with ambulation C. Pain related to decreased blood flow and altered tissue perfusion D. Risk for peripheral neurovascular dysfunction

D. Risk for peripheral neurovascular dysfunction Those with risk for peripheral neurovascular dysfunction are at risk for a disruption in circulation, sensation, or motion of an extremity. Risk factors include trauma, fractures, mechanical compression, surgery, burns, immobilization, and obstruction. The other options are distracters to the question.

The nurse should recognize that which acute change in heart rate requires urgent attention and intervention in an adult hospitalized client? 1. Decrease to 44 beats/minute 2. Decrease to 54 beats/minute 3. Increase to 112 beats/minute 4. Increase to 90 beats/minute

Decrease to 44 beats/minute

The nurse has entered a client's room to begin a head-to-toe assessment. The client appears anxious, is pale, and is struggling to breathe. What is the nurse's priority action? 1. Count respirations. 2. Assess blood pressure. 3. Check for pupil reaction. 4. Ensure a patent airway.

Ensure a patent airway.

The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviors is the __________ lobe. A. Frontal B. Occipital C. Temporal D. Parietal

Frontal

At the beginning of the shift, an older adult hospitalized for pneumonia complains of shortness of breath with an oxygen saturation of 90% on room air. Which type of assessment should the nurse perform at this time? 1. Immediate 2. Focused 3. Shift 4. Comprehensive

Immediate

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

Impaired swallowing.

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

Inability to wrinkle the forehead

A patient with a history of kidney stones presents with complaints of pain, hematuria, and nausea with vomiting. What assessment technique will elicit kidney pain? 1. Inspection with indirect lighting 2. Iliopsoas muscle sign 3. Indirect percussion of CVA tenderness 4. Blumberg sign

Indirect percussion of CVA tenderness

When conducting a focused health assessment, the nurse asks questions specifically targeting what? 1. The client's gender 2. The client's sexual orientation 3. Issues and symptoms specific to the client 4. The client's culture

Issues and symptoms specific to the client

The nurse is collecting a history on a 4-year-old and discovers that the child is being cared for by his grandmother during the days while the parents are at work. The grandmother's house was built in the early 1940s. Which lab should the nurse prepare to collect from the child? 1. Bleeding time 2. Lead level 3. Iron level 4. Potassium level

Lead level

The nurse enters a client's room to administer scheduled medications through a barcode system. The client is not wearing an armband. What is the nurse's best action? 1. Ask the client for name and birth date, then administer the medications. 2. Confirm the client's identity with visitors who are present. 3. Scan the barcode on the client's chart, then administer the medications. 4. Leave the room to obtain another armband for the client. Q

Leave the room to obtain another armband for the client.

The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient: 1. Moves the head and shoulders against resistance with equal strength. 2. Demonstrates the ability to hear normal conversation. 3. Follows an object with his or her eyes without nystagmus or strabismus. 4. Sticks out the tongue midline without tremors or deviation.

Moves the head and shoulders against resistance with equal strength.

Which assessment finding is priority for the nurse to address during an assessment of a one-week-old neonate? 1. Poor pupillary reflex 2. Small tonsils and adenoids 3. Lack of deciduous teeth 4. Mucus in the nasal passages

Mucus in the nasal passages

A patient with a tympanic abdomen complains of pain in the RUQ. Which sign would the nurse expect to be positive? 1. Rovsing sign 2. Psoas sign 3. Murphy sign 4. Obturator sign

Murphy sign

A hospitalized client complains of pain 10/10 one hour after receiving a dose of intravenous Morphine sulfate intravenously. The next dose is not due for over an hour. What is the nurse's best action? 1. Document the pain assessment findings and reassess in 30 minutes. 2. Tell the client he/she can not have anymore pain medication. 3. Notify the healthcare provider. 4. Administer another dose of Morphine early.

Notify the healthcare provider.

The nurse enters an unassigned client's room to investigate an alarm. The client's intravenous (IV) bag is empty and the IV bag on the pole, left by the client's assigned nurse to hang next, is a different solution. What is the nurse's best action? 1. Hang the IV solution the client's assigned nurse left on the pole. 2. Obtain an IV bag of the current solution and hang it. 3. Obtain an IV bag of the current solution and hang it. 4. Discontinue the current solution and disconnect it from the client.

Obtain an IV bag of the current solution and hang it.

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

Palpate the temporal and masseter muscles while the client clenches teeth

A patient with a history of cirrhosis tells the nurse that his abdomen seems to be getting larger and that he has gained 9.7 kg (20 lb) in the past 6 months. How will the nurse determine whether the abdominal enlargement is from accumulation of fluid or fat from the weight gain? 1. Percuss the abdomen for shifting dullness 2. Stroke the abdomen to elicit the abdominal reflex 3. Listen for a fluid wave 4. Auscultate for lymph nodes

Percuss the abdomen for shifting dullness

When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as: A. Positive Romberg sign. B. A normal finding. C. Lack of coordination. D. Ataxia.

Positive Romberg sign.

At each prenatal visit, a client provides a urine sample to the health care provider. What is this urine sample tested for at each visit? 1. White blood cells and albumin 2. Protein and glucose 3. Glucose and white blood cells 4. Protein and albumin

Protein and glucose

The RN working on a surgical unit should question which of these orders before completing it? 1. Check intracranial pressure 2. Reapply a staple in an incision 3. Administer a narcotic infusion 4. Change a central line dressing

Reapply a staple in an incision

The nurse is preparing to conduct an admission assessment on an older adult client. What would be important to do before interviewing this client? 1. Make sure the door is not blocked 2. Turn up the client's hearing aid 3. Speak in a louder than normal voice 4. Reduce or eliminate background noise

Reduce or eliminate background noise

When auscultating the abdomen, the nurse hears a bruit to the right of the midline slightly below the umbilicus. The nurse documents this finding as a bruit of which of the following? 1. Right iliac artery 2. Right renal artery 3. Abdominal aorta 4. Right femoral artery

Right iliac artery

A student nurse is taking a nursing test and is asked a question about the columella. What is the best description of the term coumella? 1. The lining of the nares 2. The mound of tissue just posterior to the eustachian tube 3. The lining of lymphatic ducts 4. The structure that divides the nares

The structure that divides the nares

Patients can gag even if they have an intact gag reflex. T/F

True

What percussion sound is heard over most of the abdomen? 1. Tympany 2. Resonance 3. Hyperresonance 4. Dullness

Tympany

Which food is most appropriate for the nurse to recommend for a client who suffers frequent nosebleeds due to hereditary hemorrhagic telangiectasia? 1. Chocolate pudding 2. Garlic chicken 3. Salad with ginger dressing 4. Vegetable omelet

Vegetable omelet

During the taking of the health history, a patient tells the nurse that "it feels like the room is spinning around me." The nurse would document this finding as: 1. Dizziness 2. Vertigo 3. Tinnitus 4. Syncope

Vertigo

A client has just been diagnosed with osteopenia. To help prevent progression to osteoporosis, the nurse would teach this client about what? 1. Vitamin A supplements 2. Vitamin D supplements 3. Vitamin E supplements 4. Vitamin B12 supplements

Vitamin D supplements

A patient reports changes in bowel pattern. Which is the best question to determine normal bowel habits? 1. Is there a family history of irritable bowel syndrome? 2. Have any of your parents or siblings had cancer of the colon? 3. What was your bowel pattern before you noticed the change? 4. How often do you have a bowel movement?

What was your bowel pattern before you noticed the change?

When documenting a finding over the stomach, the nurse most accurately identifies the region as which of the following? 1. hypogastric 2. LUQ 3. epigastric 4. RUQ

epigastric