pn NCLEX Health assessment/physical exam
upon palpation of the fontanelle of a three month old newborn, the nurse notes that the anterior fontanelle has not closed and is soft and flat. Which action should the nurse take
document the findings
the nurse notes documentation that a client has conductive hearing loss. The nurse understands that which is a cause of this type of hearing loss
a physical obstruction to the transmission of sound waves
while collecting data related to the cardiac system on a client diagnosed with an incompetent heart valve, the nurse auscultate say murmur. Which best describes the sound of a heart murmur
gentle, blowing or swishing noise
a nursing student enrolled in a physical assessment courses asked to describe the probable signs of pregnancy. Which are probable signs indicating possible pregnancy
hager's Chadwicks McDonald's
the nurse is preparing the client for eye testing, and the examiner is planning to test the eyes using the confrontational method. What should the nurse tell the client about the purpose of the test
examines visual fields or peripheral vision
the nurse is collecting medication information from a client, and the client states that she is taking garlic as an herbal supplement. The nurse understands that the client is most likely treating which condition
hyperlipidemia
to assess for the presence of the posterior tibialis pulse the nurse should palpate which area
in the groove behind the medial malleolus and the Achilles tendon
the nurse is preparing to collect data by examining the abdomen. The nurse should begin the assessment by performing which action first
inspection
the nurse is preparing to perform an abdominal examination. The initial step should be which
inspection
the nurse is preparing to perform an abdominal assessment on a client. The nurse places the client in which best position to perform the assessment
2
when collecting physical assessment data, the nurse understands that the spleen is located in which abdominal quadrant
2
the nurse is preparing to auscultate a client's abdomen for bowel sounds. The nurse listens for bowel sounds in which abdominal quadrant first
3
the nurse provides information to a client regarding breast self-examination. Which client statement indicates a need for further teaching
I don't need to do that, I'm too old for that
the nurse is reviewing the client's health record and notes that the client elicited a positive Romberg sign. The nurse understands that this indicates which finding
a significant sway when the client stands erect with feet together, arms at the side and eyes closed
the nurse is preparing to assist the healthcare provider to test the extraocular movements in a client for muscle weakness in the eyes. The nurse anticipates that which physical assessment technique will be done to assess for muscle weakness in the eye
testing the six cardinal positions of gaze
the nurse notes that the physical assessment findings for a client with mebingeal irritation indicate a positive Brudzinski sign. the nurse understands that which observation was made
the client passively flexes the hip and knee in response to Netflix Ian and reports pain in the vertebral column
the nurse is asked to test the visual Acuity of a client using a Snellen chart. The nurse prepares to perform the test, knowing that which identifies the accurate procedure for this visual Acuity test
the right eye is tested, followed by the left eye, and then both eyes are tested
a client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. how should the nurse interpret this result
they client can read at a distance of 20 feet with a clot with normal vision can read at 60 feet
the nurse is checking the apical heart rate of a client with a complaint of angina. The nurse places the stethoscope in which anatomical area
4
the nurse notes documentation that a client is exhibiting Cheyenne Stokes respirations. On data collection of the client, the nurse expects to note which finding
Rhythmic respirations with periods of apnea
the nurse is reinforcing instructions for a client and how to perform a testicular self-examination. The nurse explains that which is the best time to perform this exam
after a shower or bath
which observation indicates that the nurse is performing a whispered voice hearing assessment test procedure correctly
ask the client to block one ear at a time
they Clinic nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of data collection
auscultating lung sounds obtaining the client's temperature obtaining information about the client's respirations
the nurse is auscultating bowel sounds. Which are appropriate data collection methods
divide the abdomen into four quadrants at the umbilicus do not feed the client if no sounds are audible in 5 minutes listen and each quadrant for gurgling sounds indicating movement
a client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventititious lung sounds should the nurse expect to note documented in the health record when collecting data related to the respiratory system for this client
wheezes