NURS212 FINAL

which vital signs are orthostatic?

heart rate, blood pressure (affected by position)

A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?

perform a Romberg's test

chronic pain is pain that is felt for at least ___ months

six

pain is defined by...

the patient's self-report

A nurse is caring for a client who reports abdominal pain. The nurse asks the client to describe what the pain feels like. The nurse is using which of the following components of the PQRST mnemonic?

quality

While conducting an HEENT exam, a nurse shines a light into the client's pupils, noting a brisk reflexive constriction. In describing the meaning of this assessment to the client, which of the following is a correct statement by the nurse?

"This tests the pupil muscles themselves, as well as the cranial nerves that control them."

a pus-filled cavity is termed...

pustule / abscess

A nurse is teaching a newly licensed nurse about heart sounds. Which of the following sounds is heard when the aortic and pulmonic valves close?

S2

bleeding in the intestines results in...

a black, tar-like stool (distinct smell)

A nurse is assessing a client who has mitral valve stenosis. Which of the following findings should the nurse expect?

a heart murmur

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (3)

increased blood pressure increased respiratory rate crackles, or wet, congested breath sounds

what is pain or leg cramping evident of?

peripheral arterial disease (PAD)

During the assessment interview with a 26-year-old male client, he states "the world would be better off if I weren't around." Which of the following is the nurses' priority response?

"Are you having thoughts about harming yourself?"

what heart sound is created by S2

"dub" - semilunar valves closing

A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? -dyspnea -bradycardia -barrel chest -clubbing of the fingers -deep respirations

-dyspnea -barrel chest -clubbing of the fingers

A nurse is assessing a client who has fluid overload. Which of the following findings the nurse expect? -decr heart rate -incr lower extremity edema -incr respiratory rate -crackles / wet, congested breath sounds -incr temperature

-incr lower extremity edema -incr respiratory rate -crackles / wet, congested breath sounds

what order and where are the heart sounds assessed? (5)

1 - aortic 2 - pulmonic 3 - erb's point 4 - tricuspid 5 - bicuspid (mitral)

Describe the notations of edema and pitting (in mm) of the four categorizations?

1+ = less than 2mm 2+ = 2-4mm 3+ = 5-7 mm 4+ = more than 7mm

A nurse is assessing a client for pitting edema and notes an indentation of 6mm (0.25 in) at the point of pressure. Which of the following notations should the nurse use to document the severity of the client's edema?

3+

when conducting a skin assessment, ABCDE refers to...

A - asymmetry B - border C - color D - diameter E - evolution

A nurse is assessing an older client who is being admitted to an assistive living facility, and conducting a general survey of the client's emotional state. What is a subjective unexpected finding?

Client reports feeling sad and lonely most of the time

when assessing visual acuity, OS, OR, and OU describe:

OS - left eye OR - right eye OU - both eyes

additional/unexpected heart sounds include...

S3 and/or S4 can be heard as eighth or sixteenth notes to S1/S2

Of the following assessment, what should the nurse report to the provider? The client reports abdominal pain for the last two days that is now moving to the right lower quadrant. The pain has started to increase over the last hour and is a 9 on a 0 to 10 scale. Bowel sounds positive x 4 quadrants. The client's tympanic temperature is 37.2C (99.0F). Respiratory rate 22/min. Lung sounds clear bilaterally. Oxygen saturations is 96% on room air. Heart rate is 110/min. Blood pressure is 88/58 mm Hg while laying down. Casula capillary blood glucose is 145 mg/dL.

The client reports abdominal pain for the last two days that is now moving to the right lower quadrant The pain has started to increase over the last hour and is a 9 on a 0 to 10 scale Respiratory rate 22/min Heart rate is 110/min Blood pressure is 88/58 mm Hg while laying down

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?

agitation

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? -nausea -agitation -hypotension -hypertension

agitation

ms/neuro assessment focused interview questions (5)

any history of neurological disorders (headache, head injury, stroke, seizure)? any joint pain? any weakness or loss of function in joints to muscles? any problems with balance or coordination? any numbness/tingling/loss of sensation?

When checking a client's capillary refill, the nurse finds that the color returns in 10 seconds. The nurse should understand that this finding indicates which of the following? -arterial insufficiency -venous insufficiency -thrombus formation in the vein

arterial insufficiency

A nurse is preparing to perform an abdominal assessment on a client. Identify the sequence of steps the nurse should take to conduct the assessment.

ask the client about having a history of abdominal pain inspect the abdomen for skin integrity auscultate the abdomen for bowel sounds percuss the abdomen in each of the four quadrants palpate the abdomen lightly for tenderness

A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve II?

ask the client to read a Snellen chart

A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve XII?

ask the client to stick out their tongue and observe if its midline

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

assessment

A client has come to the clinic for evaluation of fever and sore throat. During the interview, they state "Yesterday I also got sick to my stomach and broke into a sweat." This represents what type of information? -urgent unexpected finding -perception of symptoms -irrelevant data -associated factors

associated factors

A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nurse's priority? blood pressure of 92/50 mm Hg heart rate 72/min abdominal pain rated 4 on a 0 to 10 scale respiratory rate 20/min

blood pressure of 92/50 mm Hg

A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as a result of the long-term inadequate oxygenation? -restlessness -dependent edema -clubbing of the fingers

clubbing of the fingers

What is a communication technique that will be helpful when there is a discrepancy between a pts words and behavior?

confrontation

A nurse is caring for a client who has hypovolemic shock and associated poor distal tissue perfusion. Which of the following should the nurse recognizer as an expected finding?

confusion or other mental status change

a nurse is assessing for cyanosis in a client who has dark skin. which of the following sites should the nurse examine to identify cyanosis in this client? -pinnae of the ears -dorsal surface of the hand -conjunctivae -dorsal surface of the foot

conjunctivae

A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (3)

dyspnea barrel chest clubbing of the fingers (also possible: tachycardia, shallow respirations)

A nurse is caring for a client who has emphysema. This chronic lung disease is a component of COPD, and can involve chronic over-inflation of the lungs and decreased oxygen levels. Which of the following findings should a nurse expect to assess in this client? (3) -dyspnea -bradycardia -barrel chest -clubbing of the fingers -deep respirations

dyspnea, barrel chest, clubbing of the fingers

A nurse is planning to care for a patient who states he is anxious concerning abdominal surgery. Which of the following actions should the nurse take?

encourage the client to express negative emotions

A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve I?

have the client identify specific smells

During a health assessment interview, a client identifies smoking cigarettes. Below, identify the priority follow-up questions. (3)

how many years have you smoked? how many packs of cigarettes do you smoke in a day? are you ready to consider quitting?

A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the client's affected arm?

increasing edema

A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the client's affected arm? -bounding distal pulse -acute pain -ecchymosis of surrounding skin -increasing edema

increasing edema

A nurse is assessing a client's abdomen who reports stomach pain. Which of the following steps should the nurse take first?

inspect

A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow.

inspection auscultation superficial palpation deep palpation

A nurse is performing a neurological assessment for a client who has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?

instruct the client to look up and down without moving his head

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status?

instruct the client to wiggle his toes

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status? -measure the circumference of the thigh -palpate the femoral pulse -monitor the client's calf for edema -instruct the client to wiggle his toes

instruct the client to wiggle his toes

A nurse in a clinic is caring for an older adult client who reports thirst, a dry mouth, and flaky skin on her upper back. Which of the following is an appropriate next step?

pinch up a fold of skin to check for turgor

what is the preferred route to obtain temperature for patients that are comatose or infants less than 6mos?

rectal

A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect? -bradypnea -solmnolence -pallor -tachycardia

tachycardia

A nurse is observing a newly licensed nurse who is performing a focused skin assessment on a client who reports a skin condition. Which of the following questions by the newly licensed nurse requires intervention/ -"does your skin condition keep you awake at night?" -"have you had any changes in your diet?" -"how do you handle stress?" -"how does your skin condition make you feel?"

"how do you handle stress?"

cardiovascular assessment focused interview questions (5)

any known heart conditions? any chest pain? any shortness of breath or dyspnea? any swelling in your legs or weight changes? any pain or cramping in your legs?

dermatome definition:

area of skin directly correlated to a spinal nerve

A nurse is assessing a client who has a left forearm fracture. Which of the following indicates impaired arterial blood flow below the area of injury? -bounding radial pulse -cool hands and fingers -ecchymosis of the surrounding skin -increasing edema

cool hands and fingers

A nurse is caring for a client who has atrial fibrillation and reports a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?

irregular heart rhythm, with a difference between apical and radial pulse rates

A nurse is providing care for a surgeon on a med-surge unit. A nurse from another unit asks the nurse about the surgeon's medical diagnosis. The nurse responds that he is unable to provide the information requested. The nurse is displaying which of the ethical principles?

justice

A nurse is providing care for a surgeon on a medical-surgical unit. A nurse from another unit asks the nurse about the surgeon's medical diagnosis. The nurse responds that he is unable to provide the information requested. The nurse is displaying which of the following ethical principles?

justice

A nurse in a clinic is caring for an older adult client who reports thirst, a dry mouth, and flaky skin on her upper back. Which of the following is an appropriate next step? -perform examination of the back before the general inspection of the skin -pinch up a fold of skin to check for turgor -use a penlight to examine the back in greater detail

pinch up a fold of skin to check for turgor

A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?

place suction equipment at the client's bedside (client is at risk of aspiration)

what are the three key factors of a suicide risk assessment?

plan, means, intent

An acute care nurse receives shift report for a client who has increased ICP. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?

plantar flexion of the legs

A nurse is performing an admission assessment on a client. Which of the following findings should the nurse identify as an indication that the client is dehydrated? -low body temperature -jugular vein distention -skin tenting present -hypertension

skin tenting present

A nurse is caring for a child with an outer ear infection. Which of the following assessment findings should the nurse expect? -tragal tenderness -red, bulging ear drum -mastoid process tenderness

tragal tenderness

heart murmurs are a result of...

valve turbulence - valve not fully opening/closing creates "woosh" sound... murmurs sound crisp or like clicking

fissure definition:

Liner crack into the dermis (i.e. athletes foot)

what is a "coffee ground emesis"?

when blood combines with stomach acid... black and coagulated vomit

what heart sound is created by S1

"lub" - bicuspid/tricuspid valves closing

A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? -poor skin turgor -bradycardia -hypotension -flat neck veins -hypertension

-poor skin turgor -hypotension -flat neck veins

A nurse is performing a cardiac assessment on a client and auscultates an S3 sound. The nurse should recognize that this sound represents which of the following heart conditions?

ventricular gallop

Which cranial nerves are assessed via EOMs?

III, IV, VI

abdomen assessment focused interview questions (5)

are you experiencing and abdominal pain... can you show me where the pain is? have you had any nausea or vomiting? have you had any stool changes or diarrhea? when did you last eat or drink? when was your last bowel movement?

A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss? -body weight -skin integrity -blood pressure

body weight

A nurse is performing a cardiac assessment on a client and auscultates an S3 sound. The nurse should recognize that this sound represents which of the following heart conditions? -atrial gallop -ventricular gallop -closure of the mitral valve -closure of the pulmonic valve

ventricular gallop

When auscultating breath sounds, what is an appropriate term for softly coarse, blowing breath sounds typically heard throughout most of the chest?

vesicular

A nurse asks a client how he is feeling. The client states "I'm feeling a bit nervous today." Which of the following responses should the nurse make?

Please explain what you mean by the word "nervous"?

Of the following assessment, what should the nurse report to the provider? A 43-year-old male has presented today described a 1 day history of nausea and vomiting. On exam, he is awake and alert, speaking in complete sentences. Skin is unifrom in color, even texture, with no tenting. Heart sounds show regular rate and rythym. S1 and S2 are easily identifiable. No murmurs. S3 present. Abdomen is distended, rigid. Bowel sounds are low pitched with borborygmi. There is diffuse generalized tenderness and guarding. No CVA tenderness.

S3 present abdomen is distended, rigid there is diffuse generalized tenderness and guarding

A nurse on a med-surge unit is performing an admission of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings? -respiratory alkalosis -increased anteroposterior diameter of the chest -petechiae on the chest

increased anteroposterior diameter of the chest

A 24-year-old client has a blood pressure of 95/70, and asks the nurse whether the blood pressure is okay. Below, identify all assessment findings that are consistent with adequate tissue perfusion. (3)

intact mental status, without weakness brisk capillary refill extremities show symmetrical warmth and color

Shock is characterized by poor tissue perfusion, resulting in tissue ischemia. A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding? -hypertension -flushed skin -mental status change or confusion -bradypnea

mental status change or confusion

A client smoking in the bathroom has dropped a cigarette butt into the wastepaper basket, which begins to smolder. Which of the following actions is the nurses' priority?

move any clients in the immediate vicinity

During an assessment interview, a client tells the nurse that she is experiencing difficulty swallowing. In addition to a detailed HEENT exam, what other symptom assessment should the nurse anticipate performing?

neurological

A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve VII?

observe for facial symmetry while the client smiles

A nurse is preparing to perform a cranial nerve examination for a client. Which of the following actions should the nurse take to check cranial nerve XI?

observe for the ability of the client to turn their head side to side

A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

oral mucosa

A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis? -oral mucosa -conjunctivae -ear lobes soles of the feet

oral mucosa

A charge nurse is observing a nurse auscultating a client' bowel sounds. Which of the following actions requires intervention by the charge nurse?

palpates the abdomen prior to performing auscultation

A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (3)

poor skin turgor hypotension flat neck veins (also possible: tachycardia, dark concentrated urine)

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

prior to percussing the abdomen

A nurse is assessing a client's bowel sounds. At which point in the assessment should the nurse auscultate the client's abdomen?

prior to percussing the abdomen

A nurse is caring for a client who reports abdominal pain. The nurse asks the client to describe what the pain feels like. The nurse is using which of the following components of the PQRST?

quality

A nurse is assessing a client who has peritonitis (inflammation of the outer lining of abdominal organs). Which of the following findings should the nurse expect?

rigid abdomen

A nurse is assessing a client who has peritonitis (inflammation of the outer lining of the abdominal organs). Which of the following findings should the nurse expect? -increased urine output -rigid abdomen -frequent bowel movements

rigid abdomen

A nurse is assessing a new client who has a new skin lesion that has a wavy, S-shaped border. The nurse should document the lesion using which of the following descriptions?

serpiginous

the client says, "this only happens when i get too little sleep." Which of the eight critical variables does this statement represent? -setting -quality -location -associated factors

setting

what are possible acute pain reactions? (5)

sweating, grimacing, guarding, increased BP, increased HR