NURS 225 Health Assessment Tutoring Exam 4

Which assessment is not common to monitoring both urine and stool?

Which assessment is not common to monitoring both urine and stool?

The nurse is interviewing an adult client in the clinic. The client asks about actions that can reduce the future risk of a stroke. What health promotion activity should the nurse prioritize?

smoking cessation

The nurse is performing inspection on a physical assessment. Which finding indicates a normal abdominal inspection?

Abdomen slightly rounded with even skin tone and no visible scarring.

In order to examine the ocular mobility of a client who recently experienced a stroke, the nurse should examine which of the following cranial nerves? Select all that apply.

Cranial nerve VI Cranial nerves III and IV

When percussing a client's chest, what should the nurse expect to hear?

Resonance Resonance is a normal finding on percussion of healthy lung tissue. Hyperresonance may occur on percussion of hyperinflated lungs such as in a client with emphysema. When percussing over the abdomen, the nurse may assess tympany, such as with a gastric air bubble or intestinal air. Dullness occurs over the liver, a full bladder, and a pregnant uterus.

The nurse is performing a focused assessment on a client's gastrointestinal system. Which assessment is an expected finding?

high pitched gurgling noises in four abdominal quadrants

The nurse assesses function of cranial nerve XII (hypoglossal nerve) by asking the client to

stick out the tongue and move it side to side

The clinic nurse is interviewing a 20-year-old male. The client states, "I am fairly sure I have another STD. This is, like, the 4th one this year!" What action would be most appropriate for this client?

Assess the client's understanding of safe sexual practice.

Decerebrate posturing is characterized by which of the following?

Extension of the extremities and pronation of the arms. Explanation: Posturing is a late sign of deterioration of the client's neurological status and warrants immediate physician notification. Decerebrate posturing (abnormal extension), which is associated with dysfunction in the brainstem area, consists of extension of the extremities and pronation of the arms.

To assess the status of the median nerve, which of the following does the nurse perform?

Have the client grasp the nurse's hand while noting the client's strength of the first and second fingers. explanation: to assess the median nerve status, the client should be instructed to grasp the nurse's hand. The nurse should not the strength of the client's first and second fingers. A weak grip may indicate compromise of the median nerve.

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

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

if performing a rectal examination of a client, which techniques are important to include?

The health care provider should make sure to: -explain every step of the process -utilize lubrication and gloves -allow the anal sphincter to relax as much as possible prior to inserting the gloved finger(s).

The nurse is caring for a client experiencing acute abdominal pain. What is the first action by the nurse?

auscultation of all four quadrants using a stethoscope the order of abdominal assessment includes observation, auscultation, percussion, and palpation

If a male client is uncircumcised, the glans of the penis is covered by the:

foreskin

Which statement made by the client indicates an understanding of how the nurse will perform the Romberg test?

"You want me to stand with my feet together and eyes closed for a short time." Explanation: The Romberg test is performed to test motor function. The client is asked to stand with feet together, arms resting at the sides and then to close the eyes. The nurse watches for the Prescence of swaying,

The nurse is caring for a client who reports right lower quadrant pain. Which assessment is most important for this client?

Palpation

A nurse is examining the abdomen of a client with suspected peritonitis. How does the nurse elicit rebound tenderness?

Press the affected area firmly with one hand, release pressure quickly, and note any increased tenderness on release.

A nurse is assessing a client's orientation times three. Which nursing intervention should be included in this assessment? Select all that apply.

Ascertain if the client knows the current environment. Have the client state the time of day. Ask the client's name.

While walking, a client becomes weak and the knees begin to buckle. Which should the nurse do?

Lower the client to the floor carefully.

Moving a part of the body away from the midline is called?

Movement of a part away from the center of the body is called abduction

decerebrate posturing vs decorticate

decerebrate is worse, it means more brain damage

Which sound should the nurse expect to hear when percussing a distended bladder?

dullness

The nurse is assessing a client's testes. Which finding indicates the testes are normal?

egg shaped

The client is admitted with diarrhea. When auscultating bowel sounds, what should the nurse expect to assess?

increased bowel sounds

A nurse suspects a client has peritonitis. Which assessment finding would the nurse expect to find?

abdominal wall rigidity peritonitis-inflammation of the membrane lining the abdominal wall and covering the abdominal organs.

movement of a part of the body toward the midline.

adduction

The ambulance brings the client with a head injury to the emergency department. The client responds to painful stimuli by opening the eyes, muttering, and pulling away from the nurse. How would the nurse rate this client on the Glasgow Coma Scale?

A score of 8 indicates severe increased intracranial pressure, but with appropriate care the client may survive. The nurse would rate at an 9: 2 for the opening of the eyes, 3 for verbal response, and 4 for motor response. (Closer to 15 the more alert and oriented the pt. is, 15 is completely normal)

Before palpating the abdomen during an assessment, the nurse should perform which of the following actions?

auscultate bowel sounds