NURS 228 Final Exam
You are assessing your client and notice a circumscribed skin elevation, less than 0.5 centimeters in diameter, containing serous fluid. This type of skin lesion is a:
Vesicle
You are assessing your patient's respiratory status. You auscultate and note musical pitched sounds upon expiration. The documentation would be:
Wheezes
The nurse asked several questions while interviewing a client. Which question would be the best example of a closed-ended question/statement?
When did your symptoms start?
During the care of a post-op client, the nurse needs to evaluate the client's pain. Which rating scale would be most appropriate for a 4-year-old client following tonsillectomy?
Wong-Baker Faces Scale
The nurse is speaking to a group of nursing students about health promotion and is preparing to discuss the ABCDEs of melanoma. Which of the following descriptions is correct for the ABCDEs?
a= asymmetry, b=irregular border, c=color changes, d=diameter > 6 mm, e=evolution
When assessing for PERRLA, the nurse understands that the functional reflex allowing the eyes to focus on near objects is termed
accommodation
The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an itching rash. Which question would be the most important for the nurse to ask?
"Are you allergic to foods, medications, or other substances?"
During an eye assessment, the nurse is testing a client's visual acuity using using a Snellen chart. In order to prepare the client for this component of assessment, what instruction should the nurse provide?
"Cover one of your eyes and then read out the letters on the chart, starting from the top."
A nurse is integrating health promotion education in the assessment of a client's mouth, nose, and throat. What interview question is most likely to identify a risk for oral cancer?
"Do you use tobacco, whether smoking or chewing?"
A nursing student has learned the importance of documenting only appropriate and accurate information. Which of the following is an appropriate notation in a patient's record?
"Patient stated dull, aching pain in the lower abdomen-rates as a 5 on scale of 1-10."
The nurse is conducting a newborn assessment in the nursery. Upon auscultating the newborn's apical pulse, the nurse knows a newborn to 1-month-old child's normal heart rate is:
120-140 beats/min
The nurse performs a health screening on a group of people. The nurse identifies which individual is at the greatest risk for developing skin cancer?
A 62-year old male with light skin worked as a roofer for 40 years
A 2-month-old infant is being examined at the pediatrician's office. The mother said she noticed the baby was not making tears in the left eye. What does this finding suggest?
A blocked lacrimal apparatus
Which of the following client situations would the nurse interpret as requiring an emergency assessment?
A client who took a drug overdose
The nurse is assessing a dark-skinned client who has been transported to the emergency room by ambulance. When the nurse observes that the client's skin appears pale, with blue-tinged lips and oral mucosa, the nurse should document the presence of:
A great degree of cyanosis
A client has just undergone surgery for glaucoma and the nurse is providing discharge instructions, which of the following instructions should be included for post op eye surgery care?
A shield or eye patch should be worn to protect the eye while healing
The nurse is performing an otoscopic examination on a client with a suspected diagnosis of mastoiditis. What assessment finding would confirm this possibility?
A thick, red, and immobile tympanic membrane
The ER nurse is assessing Mrs. Smith. She knows the patient has history of respiratory illness and is presently on oxygen. The physician ordered lab work and the results are in the patient's chart. What lab work would the physician review to help determine the best treatment for Mrs. Smith's respiratory status?
ABG- Arterial Blood Gas
A client suffering from a headache complains of throbbing, severe, unilateral pain that feels worse when exposed to bright lights. The client also complains of nausea and vomiting. What is the nurse's best action?
Administer migraine medications per MD order
A 45 yr. old African American male, client presents to the ER with complaints of not feeling well the last two days and new onset of breathing difficulty. VS are: BP 188/90mmhg, HR 102, Resp 32, Temp 103.2 F, SpO2 86%. Pt is a full code, no allergies, and is alone due to COVID-19 precautions. As the RN administers oxygen via a NC and completes the assessment what labs do they anticipate being ordered for this pt?
All of the Above
The client has notable wheezing when you auscultate his lungs. Wheezes (sibilant) are adventitious breath sounds that:
Are high-pitched, musical sounds heard primarily during expiration
You are assessing your patient. You know the nursing process has five phases and want to move to the next phase. What are the steps in the nursing process? Is it always in this order exactly?
Assessment, diagnosis, planning, implementation and evaluation. No.
A nurse has finished interviewing her client gathering some health history. The client has multiple health problems that stem from heavy drug use. The nurse has then reflected on her personal feelings about the client and his circumstances. The nurse does this primarily to accomplish which of the following?
Avoid biases and judgements
You are performing care for your patient with severe meningitis and brain damage. You notice the respiratory pattern is irregular characterized by varying depth and rate, with periods of apnea. You would document this as:
Biot's Respirations
You are performing cares for your patient with severe meningitis and brain damage. You notice the respiratory pattern is irregular characterized by varying depth and rate, with periods of apnea. You would document this as:
Biot's respiration
A new nurse on the long-term care unit is learning how to assess a patient's risk for skin breakdown. What would be the most likely instrument this nurse would use?
Braden scale
Your patient just returned from surgery. He complains of pain, you complete your vital signs and note his respiratory rate is 9 breaths per minute. You would document this as:
Bradypnea
Normal breath sounds auscultated mainly over the trachea area are what type of breath sounds?
Bronchial
In which health condition would the nurse most likely expect to assess a capillary refill time that is longer than 2 seconds?
Cardiovascular Disease
Mr. Jones is seeing his doctor for a routine checkup. Mr. Jones is complaining of bilateral knee point and joint pain for the last 8 months. His pain would be best described as:
Chronic pain
The nursing process has five phases, including assessment. 'Assessment' refers to:
Collecting subjective and objective data
Which risk factor for TBI should a nurse include in a discussion about prevention for a group of adolescents?
Concussion in sports and motor vehicle accidents cause the largest number of TBIs in teens
The client is concerned because the sclera of the right eye has been pink in color for several days and tearing. What should the nurse suspect is occurring with this client?
Conjunctivitis
The nurse is palpating during the thorax and lung assessment. She feels a crackling sensation, like bubble wrap or hairs rubbing against each other. She documents this as:
Crepitus
What is one way nurses use critical thinking in regard to the nursing process?
Critical thinking helps nurses work through the analysis, develop alternative, and implement the best interventions
When assessing an adult client experiencing diarrhea, the nurse notes a round moon face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What is the possible cause of the signs?
Cushing's syndrome
The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin:
D
Why is it important to ask the client regarding discharge or drainage from the eyes?
Discharge is associated with inflammation or infection
The nurse walks into the patient's room and discovers that the patient's respiratory rate is regular at 16 breaths/minute. The nurse should:
Document respirations are WNL (within normal limits)
A nurse is caring for a hospitalized infant and is monitoring for increased intracranial pressure (ICP) and notes that the anterior fontanel bulges when the infant cries. Based on this assessment finding, which action would the nurse take?
Document the findings
An adult female client visits the clinic for the first time. The client has many bruises around her neck and face, and she tells the nurse that the bruises are the result of an accident. The nurse suspects that the client may be experiencing
Domestic abuse
A client in the ED tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding?
Dyspnea
The nurse is inspecting the client's nails and the client has a history of emphysema. The fingernail shape that suggests on underlying oxygen deficiency is:
Early or late clubbing
On inspection of the chest of a 68-year-old hispanic male patient with a history of COPD, you note the client is barrel chest, thin and having retractions of the intercostal spaces while breathing, he is in tripod position. You note that his lung sounds are quiet and there is a reddish/pink tone to his dark skin. The nurse understands that COPD is an umbrella term for different lung conditions. Which condition do these symptoms point to?
Emphysema
The nurse's assessment of an adult female client reveals the presence of excessive hair on her face and chest. The nurse should plan further evaluation of which body system?
Endocrine
A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis?
Exophthalmos
To alleviate a client's anxiety during a comprehensive assessment, the nurse should:
Explain each procedure being performed and the reason for the procedure
The nurse hears a high pitched, short popping sound during inspiration of a client with pneumonia. The nurse would document what type of lung sound?
Fine crackles
The nurse is preparing to examine the ears of an adult client with an otoscope. The nurse should plan to
Firmly pull the auricle out, up, and back
A client has sought care with complaints of increasing swelling in her feet and ankles, and the nurse's assessment confirms the presence of bilateral edema. The nurse's subsequent assessment should focus on the signs and symptoms of what health problem?
Heart failure
The nurse collects vital signs on a client with pain. Which of the following would indicate to the nurse that the client is experiencing a stressful situation?
Heart rate of 110 bpm
Health histories are organized according to a nursing framework. The nurse knows a nursing framework:
Helps to organize information and promotes the collection of holistic data.
The nurse is inspecting the color of the patient's nails. They appear pale or cyanotic looking. The nurse would know this may indicate:
Hypoxia
The nurse is inspecting the color of the patient's nails. They appear pale or cyanotic looking. the nurse would know that this may indicate:
Hypoxia
When discussing the nursing process with a group of students, which of the following statements best describes it?
It is ongoing and continuous
Your pt has been admitted, they are confused and you notice a fruity scent to his breath as you lean down to auscultate his lungs. While auscultating you note that his breathing pattern is rapid, deep, and labored. You know that this type of hyperventilation is associated with diabetic ketoacidosis. You document this type or respiratory pattern as:
Kussmaul
Which action by a nurse demonstrates the proper technique for auscultation of the lung fields?
Listen at each site for at least one complete respiratory cycle
The nurse feels a small mass in the neck of a client. It is mobile in both the up-and-down and side-to-side directions. Which of the following is the nurse most likely feeling?
Lymph node
In reviewing a client's health history, the nurse notes that the client had a history of TMJ pain. The nurse recognizes that which of the following bones is involved in this dysfunction?
Mandible
After teaching a group of students about the structure and function of the skin, the instructor determines that the teaching was successful when the students identify which of the following as responsible for variations in skin color?
Melanin
As the nurse assesses vital signs, he notices the client is shaking. The nurse notes a chance in the client's tone and in a loud voice the hospitalized client insists, "You're not my wife. How did you get into my house?". Based upon the client's behavior, which assessment will the nurse now focus upon?
Mental
A nurse is collecting a thorough and accurate subjective history of a client's nail problems. The client asks why this is necessary. Which of the following should the nurse mention in response?
Nail problems can be caused by an underlying systemic illness
In a small child, what early sign of respiratory distress would signal the nurse to investigate further?
Nasal flaring
The client with valvular hear disease is at risk for developing Heart Failure. When monitoring the patient for symptoms of Heart Failure, which assessment finding would be most concerning?
New presence of crackles in lower lobes of the lungs bilaterally
The assessment technique of inspection includes:
Observation of the client to detect any normal or abnormal findings in the client
The nurse is preparing to assess a client's carotid arteries. Which nursing action would be the most appropriate?
Palpate each artery individually to compare
The nurse is reviewing a client's health history and physical examination. Which of the following would the nurse identify as subjective data?
Patient states "My father died of a heart attack"
When inspecting the skin of an older adult client, the nurse notes multiple small 1-2mm, flat reddish-purple macules. She also notes this is associated with bleeding tendencies or emboli to skin. The nurse documents this finding as which of the following?
Petechiae
Which characteristic of the gums should a nurse expect to assess in a client who is healthy?
Pink, moist, firm
The nurse assesses an adult client's head and neck. While examining the carotid arteries, the nurse assesses each artery individually to prevent:
Reduction of the blood supply to the brain
During a patient interview it is important to use nonverbal communication. What is not an example of nonverbal communication?
Rephrasing
The nurse is assessing a 3 day old infant who has been diagnosed with respiratory distress syndrome (RDS). Which assessment finding indicates that the infants respiratory status is improving?
Respiratory rate of 50-60 breaths per minute
The nurse is caring for a client who has been experiencing dysphagia secondary to a stroke. What risk nursing diagnosis should the nurse associate with this health problem?
Risk for aspiration related to decreased swallowing ability
A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. The client states that he almost ran into a parked car yesterday because he misjudged the distance from the bumper of his own car. He works for a computer software company and has noticed he is experiencing difficulty reading the manuals that accompany the software he installs for companies. What nursing diagnosis can the nurse confirm based on this data?
Risk for injury
A client presents at the clinic complaining of a loss of balance. What test should the nurse expect the physician to carry out on a client with a loss of balance?
Romberg test
A dark-skinned client visits the clinic because he hasn't been feeling well. To assess the client's skin for jaundice, the nurse should inspect the client's
Sclera
Throughout a nursing career, a nurse works with many different culture. The term "culture" is best described as:
Shared system of values, beliefs, and patterns of behavior.
The nurse is assessing the skin of the client. He notices on the right heel of the foot a red-pink wound bed. There is partial thickness loss of the dermis with a shallow open ulcer, without slough. What stage would the nurse rate this as?
Stage II
The nurse notes a wound on her patient's coccyx. She notifies the doctor and describes it as, full thickness tissue loss with exposed bon, tendon, and muscle. Some slough is noted on the inner wound bed. The nurse would identify this as?
Stage IV
Auscultation of the client's lungs should be done in a consistent sequence. What is the best way to do this?
Start at the anterior apices, comparing bilaterally for each site, while moving down to the bases. Continue in the same pattern posteriorly, avoiding auscultation over bony prominences. Listen for a full breath sound at each site.
The Braden Scale assesses six different categories. The nurse knows all of these are on the assessment tool except:
Tachypnea
The nurse assesses shallow respiration of 35 breaths/minute in a client with extreme anxiety. What would be a correct description of this assessment?
Tachypnea
The nurse knows that when documenting on a patient's chart, assessment information must be concise and accurate, and that all descriptions must be as precise as possible. The best example of documentation of a wound is:
The abdominal wound measures 6 cm by 9 cm with a 1-cm depth
The nurse is assessing an elderly woman who reports lethargy and weakness. During the examination, the nurse notices that the client's face is drooping slightly on the right side. Why does this finding require an emergency intervention?
The client could be experiencing a stroke
The client recently became febrile and stated he "felt hot." You take the client's temperature and find it to be 99.8 degrees F. In addition, his pulse is 88/min and his blood pressure is 168/80. Which of these data are subjective data?
The client's statement about feeling hot.
The nurse is working in an outpatient clinic. When examining a client, the nurse notes asymmetric borders on a pigmented lesion. The nurse knows this suggests:
The lesion may be cancerous
The nurse is caring for a patient who comes to the clinic reporting a lump by her ear. What are the symptoms of a cancerous lymph node?
The node is fixed, nontender, and rubbery
The nurse takes the apical pulse of the client receiving Digoxin, which requires the nurse to know the most accurate heart rate. Which nursing procedure is correct?
The nurse places a stethoscope over the point of maximal impulse and counts the number of heartbeats for one full minute
The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs?
The right lung has three lobes, while the left lung has two lobes
Which of the following statements most accurately conveys an aspect of the anatomy and physiology of the skin?
The skin is composed of an epidermis, dermis, and subcutaneous tissue
A nurse is preparing to perform the physical exam on an adult client. Which of the following statements should guide the nurse's use of a stethoscope during this phase of assessment?
The stethoscope's diaphragm should be held firmly against the skin
Which is a correct statement regarding the location of the vesicular breath sounds?
They are heard in the peripheral lung fields
During a pharmacology class the students are told that some drugs need to be closely monitored. What should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides
Tinnitus and sensorineural hearing loss
Which of the following statements best describes the purpose of a health history?
To provide a database of subjective information about the client's past and present health.
You are assessing your patient with a diagnosis of chronic obstructive pulmonary disease. Upon entering the room, you note he is sitting forward with his arms to support his weight. You would document this as:
Tripod position
Mr. Jones enters the emergency room complaining of chest pain for over 3 hours he is diaphoretic and short of breath. The admitting nurse quickly takes Mr. Jones back to the exam room. The physician orders a lab test to determine if Mr. Jones is having a heart attack. What test is specific to heart damage 2-6 hours after a heart attack?
Troponin 1
A decrease in oxyhemoglobin will result in documentation of pallor. T or F?
True
Which area of the body should a nurse inspect for possible loss of skin integrity when performing a skin examination on a female who is obese?
Under the breasts
When entering a client's room, what is the nurse's first action?
Verify the client's name, date of birth, and any allergies they may have
The clinic nurse is assessing an older adult client who fell. The nurse asks if the client ever feels dizzy or has problems with balance. What is the nurse assessing for?
Vertigo
