PRNU 113 FINAL
A normal finding of accommodation is: a) Pupils constrict when focus changes from far to near object b) The patient is able to see examiner's finger in their peripheral vision. c) The red light reflex is bilaterally symmetrical. d) When the light shines on one pupil, both pupils constrict.
a
A nurse has completed an assessment of a client's lymph nodes. What data would the nurse document as an abnormal finding? A)Tender B)Diameter: 0.75 cm C)Discrete D)Mobile
a
A nurse in the emergency department is caring for a client diagnosed with pneumonia. In addition to assessing their lungs, the nurse also assesses the clients nails inspecting for: a) Clubbing, pitting, and grooving b) Contour, consistency, and color c) Length and clumping d) Texture, strength, and translucency
a
A patient has a heart rate of 36. What is one possible cause? a) Failure of the SA node to fire b) Break in the Bundle of HIS c) Failure of the Purkinje fibers to connect d) Failure of the AV nodes to fire
a
An adult client has sought care because he has a 2-day history of stool that is "black like road tar." How should the nurse bestrespond to this aspect of the client's history? A)Refer the client for treatment of a possible gastrointestinal bleed. B)Refer the client to a dietitian for treatment of a possible vitamin deficiency. C)Encourage the client to increase his intake of fluids and soluble fiber. D)Tell the client to use an over-the-counter laxative for the next 2 to 3 days.
a
Ascites is defined as: a) An abnormal accumulation of serous fluid in the abdomen b) An abnormal enlargement of the spleen c) A bowel obstruction due to a fecal blockage d) A loss of peristaltic activity in the bowel
a
During a health visit, a client says, "I know that arteries and veins are both blood vessels, but what's the difference?" Which statement would the nurse include in the response? A)"Arteries have thicker walls than veins." B)"Arteries carry 70% of the body's blood volume." C)"Arteries have a lower pressure than veins." D)"Arteries carry waste from the tissues."
a
During an assessment, the nurse determines that a client sees more than one primary care provider and has obtained prescriptions from each provider. Which method would be most appropriate to determine a client's current medication regimen? A)Ask the client to bring all the medications and supplements to an interview. B)Ask the caregiver whether the client is taking prescribed medications. C)Ask the client about the use of any over-the-counter medications. D)Ask the client to identify which medications taken every day.
a
The nurse is assessing CN V (trigeminal nerve) in a newly admitted client. What instruction should the nurse provide to the client during this phase of assessment? A)"Clench your teeth together tightly." B)"Close your left eye and look at me with your right." C)"Look straight at me while I shine this light in your eye." D)"Open your mouth wide and say "ah."
a
The nurse is assessing a client who is in uncompensated right-sided heart failure. What assessment finding should the nurse anticipate? A)Increased jugular venous pressure B)Bradycardia C)Decreased blood pressure D)Dysrhythmias
a
The nurse is assessing a client's respiratory rate and rhythm during the beginning of a shift. The client's rate is 29 breaths/min. How should the nurse respond to this assessment finding? A)Ask the client if she has recently exerted herself. B)Report the finding to the client's primary care provider. C)Ask the client if she has smoked recently. D)Palpate the client's anterior and posterior thorax.
a
The nurse is assessing the skin condition and color of an African American client. What would the nurse document as an abnormal finding? A)Ashen gray skin color B)Lack of visible pores C)Light to medium dark brown skin D)Evenly distributed color
a
The nurse is assessing their patient's lungs and detects areas of atelectasis. How did they come to this determination? They heard: a) Diminished breath sounds over the affected area b) Hyper resonance over the affected area c) Coarse rhonchi over the affected area d) Wheezing upon expiration
a
The nurse is performing light palpation of the client's abdomen. How can the nurse bestprevent voluntary guarding during this phase of assessment? A)Ask the client to breathe slowly and deeply. B)Perform auscultation prior to palpation. C)Explain the procedure to the client before palpating. D)Position the client sitting upright
a
The nurse is using the COLDSPA mnemonic during a client's head-to-toe assessment. This tool will allow the nurse to address which component of the assessment? a) The client's present health concern b) The review of the client's body systems c) The client's personal health history d) The client's health practices profile
a
What heart sound is heard in the 2nd LICS? a) Pulmonic vein closure b) Erb's point c) Pulmonic valve snap d) Aortic valve snap
a
What would the nurse interpret as a positive response to the Phalen test for a client suspected of having carpal tunnel syndrome? A)Numbness B)Atrophy of the thenar prominence C)No tingling D)Hard, painless Bouchard nodes
a
When assessing a client for possible oral cancer, the nurse should most closely inspect which area? A)Area under the tongue B)Along the gum line C)Hard palate D)Buccal mucosa
a
When assessing the temperature of the feet of an older client with diabetes, the nurse would use which part of the hand to obtain the most accurate assessment data? A)Dorsal surface B)Fingerpad surface C)Ulnar surface D)Palmar surface
a
Which assessment technique is most commonly used by nurses? a) Inspection b) Palpation c) Auscultation d) Percussion
a
Which is NOT true of lymph nodes? a) Lymph nodes rarely return to normal once enlarged b) Fixed, enlarged lymph nodes are a concern for possible malignancy c) Lymph nodes are rarely enlarged in healthy adults d) Tender enlarged lymph nodes suggest infection nearby
a
Which of the following is an example of an open-ended question? a) "What were you doing when you felt the pain?" b) "Do you have someone to help you at home?" c) "How many times a day do you take that medication?" d) "Have you ever experienced pain like this before?"
a
While auscultating the client's heart at the third intercostal space and on the left sternal border, the nurse notes a high-pitched, scratchy sound that increases with exhalation with the client leaning forward. How would the nurse document the findings? A)Pericardial friction rub B)Midsystolic click C)Summation gallop D)Aortic ejection click
a
Your 50 year old patient just took a large dose of a laxative prior to a health screening diagnostic test (colonoscopy). What would you expect to hear when auscultating his abdomen? a) Borborygmus b) Loud cursing c) Absent bowel sounds d) Abdominal bruit
a
A client expresses concern that a new lesion may be melanoma (skin cancer). Which finding suggests malignant melanoma? a) Non-blanching of the skin in that area b) Irregular borders and shape c) Brown color of the lesion d) Diameter less than 5 mm
b
A client's bladder is found to be distended. At which location should the nurse begin palpating? A)At the umbilicus B)At the symphysis pubis C)In the right lower quadrant D)In the left lower quadrant
b
A nurse is assessing a client who is exhibiting decorticate posturing. What would the nurse observe? A)Extended upper extremities B)Internally rotated lower extremities C)Pronated forearms D)Flexed hands at the side of the body
b
A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN I. What would the nurse do? A)Use a Snellen chart to test visual acuity. B)Ask a client to identify scents. C)Test extraocular eye movements. D)Perform the Weber test.
b
A nurse is preparing to palpate a client's preauricular lymph nodes. A what anatomical location should the nurse place the pads of their fingers? a) Behind the tip of the mandible b) In front of the ear c) Behind the ear d) At the base of the skull
b
After completing the vitals of a client, the nurse obtains a temperature reading of 39.5 C. In addition, the nurse may also note: a) A pulse oximetry reading of 96%. b) A heart rate greater than 100 bpm. c) A respiratory rate of 12 - 20 breaths/minute. d) A blood pressure of 120/70.
b
After teaching a group of students about the bones and their functions, the instructor determines that the teaching was successful when the students state that blood cells are produced in which of the following? A)Compact bone B)Red marrow C)Yellow marrow D)Spongy bone
b
Assessment of a client's mouth reveals a lesion on the client's buccal membrane that is approximately 0.5 cm in diameter, bleeds easily, and according to the client has been there for about 3 months. What next step should the nurse implement? a) Swab the lesion and send to the laboratory for further analysis b) Refer the client to his/her PCP for priority treatment c) Explain to the patient that in time such a lesion generally will heal d) Salt water rinsing is the recommended treatment of choice
b
During an eye assessment, the nurse is testing a client's visual acuity using a Snellenchart. In order to prepare the client for this component of assessment, what instruction should the nurse provide? A)"Hold this chart and start to read out the letters after covering one of your eyes." B)"Cover one of your eyes and then read out the letters on the chart, starting from the top." C)"Please stand at a comfortable distance from the chart and I'll get you to read each letter." D)"I'm going to ask you to slowly walk forward until the last line of the chart become clear."
b
The nurse assesses a client's carotid pulse and finds it to be of normal amplitude. How would the nurse document this finding in the client's electronic medical record? A)1+ B)2+ C)3+ D)4+
b
The nurse collects vital signs on a hospital client who has recently been experiencing pain. Which finding would indicate the client is currently experiencing pain? A)Blood pressure of 120/70 mm Hg B)Heart rate of 110 beats/min C)Respiratory rate of 18 breaths/min D)Temperature of 37.3°C (99.1°F)
b
The nurse is obtaining a client's blood pressure. Which additional information should be included with the actual pressure reading? a) The person who took the blood pressure b) Whether the patient was sitting or lying during the procedure c) Client's knowledge of normal blood pressure values d) Reason for seeking health care
b
The nurse is performing a head-to-toe assessment of an 18-year-old woman. When asking the woman about her pain, she states: "My stomach is really killing me right now." How will the nurse next respond to this client's statement? a) Ask the woman if she would like a pain medication. b) Ask the woman to rate her pain on a scale of 0 - 10. c) Ask the woman if her PCP is aware of her having pain. d) Ask the woman if she would like to take a break.
b
The nurse palpates the client's jaw movements, placing two fingers in front of each ear and asks the client to slowly open and close their mouth. In addition, the nurse will instruct the client to: a) Swallow a cup of water b) Move their jaw side to side c) Clench their teeth together d) Smile and puff out their cheeks
b
The patient's pulse is documented as 2+. This finding relates to which pulse characteristic? a) Rate b) Amplitude c) Rhythm d) Regularity
b
The presence of faint pedal pulses in aclient has prompted the nurse to perform a position change test for arterial insufficiency. What finding would suggest that the client may have arterial insufficiency? A)The client's legs are tender on palpation when in a dependent position. B)The client's legs are visibly pale when elevated above the examination table. C)The client's legs return to a pink color in 5 seconds. D)The client's legs develop pitting edema when he or she dangles them over the bedside.
b
The unit nurse is admitting a client with a history of pancreatitis, liver cirrhosis, poor dentition, and malnutrition. They were just admitted for injuries sustained in a motor vehicle accident where alcohol is suspected. Which statement requires further validation? a) The client's blood pressure is 148/88 mm Hg b) The client swears they only drink one or two martinis a week c) The client states "My skin is yellow on account of my liver d) The client is oriented to person, place, but not time
b
What cranial nerve is compromised when a patient has Bells Palsey (facial drooping)? a) CN X (Vagus) b) CN VII (facial) c) CN IV (trochlear) d) CN II (optic)
b
What does Kyphosis refer to? a) Exaggerated curvature of the cervical spine b) Exaggerated curvature of the thoracic spine c) Exaggerated curvature of the lumbar spine d) Exaggerated curvature of the sacral spine
b
When assessing a client's pain, the nurse understands that pain: a) Is measureable by objective means b) Is determined by the client's perception c) Rarely results in physiologic or psychological changes d) Is a sensory experience related only to tissue damage
b
When describing the importance of documenting initial assessment data to a group of new nurses, what would the nurse emphasize as the primary reason? A)It satisfies legal standards established by health care organizations and institutions. B)It becomes the foundation for the entire nursing process. C)Incorrect conclusions may be made without documentation of the nurse's opinions. D)Health care institutions have established policies regarding documentation.
b
Where can the action of the aortic valve best be auscultated? a) Left sternal border, 2nd intercostal space b) Right sternal border, 2nd intercostal space c) Right sternal border, 4th intercostal space d) 5th intercostal space, midclavicular line
b
Which body system does the nurse assess primarily by inspection? a) Abdominal b) Integumentary c) Cardiac d) Respiratory
b
Which client situation would the nurse interpret as requiring an emergency assessment? A)A client needing an employment physical B)A client who overdosed on acetaminophen C)A distraught client who wants a pregnancy test D)A pediatric client with severe sunburn
b
Which cranial nerves are associated with changes in TASTE? a) CN VIII (acoustic) and CN X (Vagus) b) CN VII (facial) and CN IX (glossopharyngeal) c) CN V (trigeminal) and XII (hypoglossal) d) CN IX (glossopharyngeal) and XI (spinal accessory)
b
Which is the best technique for assessing the carotid pulse? a) Press firmly on both arteries for comparison b) Assess each separately then compare findings c) Press gently medially at the base of the neck d) Simultaneously to ensure accuracy of findings
b
Which statement below is an example of clarification? a) "You sleep four hours a night." b) "What do you mean by sore?" c) "Let me tell you what I think is going on." d) "Uh huh."
b
A client has presented to the emergency department (ED) with complaints of abdominal pain. Which member of the care team would most likely be responsible for collecting the subjective data on the client during the initial comprehensive assessment? A)Diagnostic technician B)Gastroenterologist C)ED nurse D)Admissions clerk
c
A client presents with small, elevated superficial lesions filled with purulent fluid. The nurse documents these lesions as: a) Vesicles b) Cysts c) Pustules d) Wheals
c
A client tells the clinic nurse that she has sought care because she has been experiencing excessive tearing of her eyes. Which assessment should the nurse next perform? A)Perform the eye positions test. B)Test pupillary reaction to light. C)Assess the nasolacrimal sac. D)Inspect the palpebral conjunctiva
c
A community health nurse is planning a health promotion campaign that will focus on cancer prevention. Which educational intervention should the nurse select in order to mostinfluence participants' risks ofhead and neck cancers? A)Teaching about monthly self-examination B)Teaching about genetic screening C)A smoking cessation program D)A nutritional health program
c
A group of students is preparing for their clinical experience, during which they are required to demonstrate the techniques for assessing the abdomen. The students demonstrate understanding of the proper sequence when they demonstrate the techniques in which order? A)Palpate, percuss, inspect, auscultate B)Auscultate, inspect, palpate, percuss C)Inspect, auscultate, percuss, palpate D)Percuss, inspect, auscultate, palpate
c
A nurse in the emergency department assesses a client's pupillary reaction and observes pinpoint pupils. The nurse interprets this finding as suggesting which of the following? A)Macular degeneration B)Recent peripheral nervous system injury C)Narcotic use D)Recent eye trauma
c
A nurse is assessing a patient's heart rate by palpating the carotid artery. Which technique should the nurse implement when assessing the pulse at this site? a) Monitor for a full minute b) Palpate just below the ear on each side c) Press gently when palpating this site d) Massage the site gently before you palpate
c
A nurse is completing the intake assessment of an older adult who has just relocated to a long-term care facility. Which nursing action would be most important to ensure accurate data when gathering the resident's information? A)Determining client needs B)Documenting the data C)Validating the data D)Identifying client support systems
c
A nurse is performing an otoscopic examination of a client's right tympanic membrane. At which location would the nurse document seeing the cone of light if it were in the appropriate place? A)In the 7 o'clock position B)In the upper left quadrant C)In the 5 o'clock position D)In the center of the membrane
c
A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client database, which of the following actions should the nurse prioritize? A)Making clinical inferences B)Identifying potential health problems C)Establishing a trusting relationship D)Determining the client's strengths
c
A nurse is ready to take the client's BP but is unable to find the brachial pulse of the client. Which pulse should the nurse then check to determine adequate blood flow in this patient? a) Femoral b) Dorsalis pedis c) Radial d) Politeal
c
A nurse is reviewing a colleague's documentation of a client assessment. The nurse reads that the client's radial pulse was 2+. How should the nurse interpret this assessment finding? A)The client's radial pulse could not be manually occluded. B)The client's radial pulse occluded easily. C)The client's radial pulse occluded with moderate pressure. D)The client's radial pulse occluded with very firm pressure
c
A nurse is unable to palpate a client's radial and ulnar pulses. What is the mostappropriate nursing action? A)Refer the client for medical follow-up. B)Document the finding. C)Palpate the brachial pulse. D)Auscultate the apical pulse.
c
A patient presents with "pain in the legs that is worse with activity, relieved with rest" (Intermittent claudication). His legs are hairless and cool to touch bilaterally. The capillary refill is greater than 4 seconds. What does the nurse suspect? a) Venous insufficiency b) Deep venous thrombosis c) Arterial insufficiency d) Papilla edema
c
A woman appears restless and is wringing her hands prior to having a clinical breast examination performed. Which statement by the nurse would be most appropriate? A)"I know you are worried, but your risk for cancer is low." B)"You need to pay attention to these instructions so we can finish as quickly as possible." C)"You seem to be anxious. Can you tell me what you are thinking?" D)"You appear restless but I can assure you that your doctor is very good."
c
Assessment of a client who has suffered a recent stroke reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the client's level of consciousness as which of the following? A)Obtunded B)Stupor C)Coma D)Lethargy
c
During a health fair a nurse is educating the benefits of primary prevention for skin cancer. Which recommendation is stressed to reduce skin cancer risk? a) Perform self-examination of skin monthly b) Use a tanning booth instead of sunning outside if a tan is desired c) Wear protective clothing and sunscreen while in direct sunlight d) Use a natural coconut oil for tanning
c
The nurse assesses for adduction of the hip by asking the client to: a) Raise one leg at a time, bending the knee, while lying supine b) Raise one leg at a time, bending the knee, while lying prone c) Move one leg at a time medially, toward the midline. d) Move one leg at a time laterally, away from the midline
c
The nurse is assessing the bowel sounds of a patient who has had surgery. Which technique should the nurse use to obtain accurate assessment data when auscultating the patient's abdomen? a) Listen for several minutes in each quadrant of the abdomen b) Auscultate the areas noted as painful by the patient first. c) Perform auscultation before palpation of the abdomen d) Start auscultating in the LLQ and work clockwise
c
The nurse is documenting initial findings of a comprehensive health assessment. Which statement best describes data gained during the general survey? a) Hair neat and clean with white a gray streaks, no scalp lesions noted b) Sclera white, conjunctiva slightly reddened without lesions c) Client alert and cooperative, sitting comfortably on chair with hands in lap d) Head symmetrically round, neck non-tender with full ROM
c
What action by the patient will help relax their abdominal muscles and facilitate abdominal palpation? a) Holding their breath b) Grasping both hands across their chest and pulling c) Taking slow deep breaths through their mouth d) Raising their arms above their head
c
When auscultating the heart of a client with pericarditis, the nurse would expect to hear which sound? a) A S3 heart sound b) A S4 heart sound c) A friction rub d) A systolic murmur
c
When preparing to assess a client's thoracic cage, the nurse should locate which landmark when determining where to begin the assessment of the ribs and intercostal spaces? A)Scapula B)Suprasternal notch C)Sternal angle D)Sternal border
c
Which piece of assessment data requires the nurse to further assess the client? a) 18 year old woman with a pulse rate of 140 who just ran up the stairs b) 50 year old man with a blood pressure of 108/60 mm Hg first thing in the morning c) 65 year old man with a respiratory rate of 10 while awake in bed d) 40 year old woman with a pulse of 96 with a cold
c
While inspecting the skin of an older adult client, the nurse observes multiple, small, flat, reddish-purple macules. What term will the nurse use to document this finding? a) Purpura b) Striae c) Petechiae d) Angioma
c
A client complains of temporomandibular joint (TMJ) pain. What would the nurse most likely assess? A)Joint dislocation B)History of fracture C)History of dental abscess D)Difficulty chewing
d
A client has sustained an injury to the cerebellum. Which area should be the nurse's primary focus for assessment? A)Vital signs B)Respiratory status C)Cardiac function D)Coordination
d
A client presents to an ambulatory clinic with purulent, bloody drainage of the ear. What would the nurse assess first? A)Palpate the client's tragus. B)Perform hearing assessments. C)Assess the client's tympanic membrane. D)Inspect the client's external ear canal
d
A nurse asks a client to bring his hands together behind his head with his elbows flexed. What is the nurse testing? A)Abduction B)Adduction C)Internal rotation D)External rotation
d
An 88-year-old client has been admitted to the acute medical unit for the treatment of a urinary tract infection that is thought to be progressing to urosepsis. When assessing the client's orientation, how should the nurse bestgauge the client's orientation to time? A)"Can you tell me approximately what time it is right now?" B)"Are you able to tell me today's date?" C)"Can you tell me the date and the day of the week?" D)"Are you able to tell the month and the year that we're in?"
d
An adult patient's vital signs are: Temperature 37.8C, Pulse 88 and regular, Respirations 16 and shallow, Blood Pressure 180/102 mm Hg. Which vital sign should be reported? a) Temperature b) Pulse c) Respirations d) Blood pressure
d
During a client's vascular assessment, the nurse is palpating the pulse just under the client's inguinal ligament. The nurse is assessing which pulse? A)Temporal B)Brachial C)Popliteal D)Femoral
d
During assessment of a client's lower extremities, the nurse is having difficulty palpating the dorsalis pedis pulse. Which action is appropriate for the nurse to perform next? a) Assess for a popliteal pulse b) Document that the pulse is absent c) Wait a few minutes and try again d) Use a Doppler to detect the presence of a pulse
d
During the health interview, a client tells the nurse that he "can't breathe all that well" at night when he is lying down and that this significantly disrupts his sleep. The nurse should assess this client further for what health problem? A)Pneumonia B)Tuberculosis C)Bronchitis D)Heart failure
d
During the taking of a health history, a client tells the nurse that he rarely sleeps more than 4 hours a night and hasn't experienced any problems as a result. An appropriate response from the nurse would be: a) "Only four hours of sleep a night? That can't be true, is it?" b) "That's awful, you must be tired!" c) "Okay, good to know" d) "Did I hear you correctly? You sleep only four hours a night?"
d
The nurse demonstrates the correct technique for assessing the psoas sign by which action? A)Applying deep palpation pressure to the client's right lower quadrant, then suddenly releasing B)Tapping finger pads over the client's abdominal wall, feeling for a floating mass C)Percussing over the client's symphysis pubis with the client supine and then sitting upright D)Flexing the client's right hip, applying downward pressure on the right thigh
d
The nurse is assessing a 69-year-old woman's risks for lung disease. The woman states, "It shouldn't be a problem for me. My husband smokes quite heavily but I've been a lifelong nonsmoker." The nurse should recognize the need to teach the client about what topic? A)Strategies for making her husband quit smoking B)Genetic causes of lung cancer C)Age-related changes to respiratory function D)Health risks of secondhand smoke
d
The nurse is assessing a client's heart and great vessels. Which technique would facilitate the examination of the client's jugular venous pulse? a) Perform the exam with the patient in the prone position b) Have the client look straight ahead with chin slightly tucked c) Be sure to have the client sitting up at a 90 degree angle d) Inspect for pulsation at or around the suprasternal notch and clavicles
d
The nurse is assessing if a patient is oriented. They generally ask: a) The patient's name, current address, day of the week b) The interviewers name, current location, time c) The patient's wife's name, home address, time d) The patient's name, current location, day of the week
d
The nurse is assessing the various lobes of the client's lungs. To gather accurate data, the nurse must assess which lobe anteriorly? A)Left upper lobe B)Left lower lobe C)Right upper lobe D)Right middle lobe
d
The nurse is inspecting a new client's abdomen and notes the presence of a tight, distended abdomen and visible arterioles on the abdominal skin surface. What would the nurse do next? A)Review the client's blood work for low platelets and hemoglobin. B)Assess the client for signs and symptoms of fluid volume overload. C)Assess the client's nutritional status. D)Assess the client for other signs and symptoms of liver disease
d
The nurse is preparing to assess a client's apical impulse. The nurse should palpate at which location? A)Second intercostal space, left sternal border B)Third intercostal space, left axillary line C)Fourth intercostalspace, left sternal border D)Fifth intercostal space, left midclavicular line
d
The nurse isexamining a client's breasts and notes the presence of pronounced dimpling. How should the nurse bestrespond to this assessment finding? A)Confirm whether the client has breast implants in place. B)Ask the client about any history of mastitis(breast infection). C)Explain to the client that this is a normal, age-related change. D)Promptly refer the client for further medical assessment
d
The nurse who detects an irregularity in the rhythm of a client's radial pulse will: a) Use a stethoscope to check the brachial pulse b) Repeat the procedure on the opposite wrist. c) Record this as a normal finding for this client d) Assess the client's apical pulse for a full minute
d
The nurse's inspection of a client's extremities reveals a deep, circular, painful wound on the client's great toe. What should the nurse suspect as the etiology of the client's wound? A)Blood is returning from the client's toe more slowly than normal. B)There is a blockage or infection in the client's lymphatic system. C)There is a disruption in osmotic pressure in the client's extremities. D)The client's toe is receiving an inadequate supply of blood
d
The posterior tibialis pulse is palpated: a) Behind the knee b) Just lateral to the extensor tendon of the great toe c) Slightly below and behind the neck d) Slightly below and behind the medial malleolus of the ankle
d
The school nurse assesses unequal shoulder and scapula height in an adolescent. What would the nurse assess next? A)Lateral aspect of the thorax B)Lung volume C)Hip levels D)Spinal column
d
When preparing to assess a client's thoracic cage, the nurse should ask the patient to do all of the following EXCEPT: a) Have the patient sit upright as much as possible b) Instruct the patient to take slow deep breaths through their mouth c) Place their hands together in front of their chest and "pull" d) If needed, allow for rest period in between anterior and posterior exam
d
Which of the following would be mostimportant for the nurse to do when assessing a client's blood pressure? A)Hold the client's arm slightly flexed with palm down. B)Deflate the cuff about 5 mm Hg per second. C)Palpate the pulsations of the ulnar artery. D)Inflate the cuff 30 mm Hg above where the radial pulse disappears.
d
While assessing the health of a client's respiratory system, the nurse is palpating for fremitus. What instruction should the nurse provide to the client during this component of assessment? A)"When I say so, please exhale forcefully and hold the breath." B)"Say the letter "e" and keep saying it until I tell you to stop." C)"Breathe in as deeply as you can and hold your breath until I say to stop." D)"Please say the number "ninety-nine" for me."
d
Which test would be most appropriate for the nurse to perform when a client complains of low back pain? A)Straight leg test B)Muscle leg strength C)Lateral bending of cervical spine D)Internal rotation of the shoulders
a
When palpating the abdomen, the nurse notices an organ enlargement and potential mass at the right costal margin, midclavicular line. Which organ is most likely involved? a) Spleen b) Kidney c) Sigmoid colon d) Liver
d
Which is generally not part of a nursing physical assessment? a) Posture and gait b) Balance and strength c) Hygiene and grooming d) Blood and urine values
d
A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present, and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. How would the nurse document this finding? A)Positive Rovsing sign B)Psoas sign present C)Obturator sign positive D)Positive skin hypersensitivity test
a
A client has sustained a brain stem injury and is being treated in the intensive care unit. What would the nurse need to consider when assessing this client's respiratory status? A)The client will have a loss of involuntary respiratory control. B)The client will respond negatively to increased stimuli. C)The client will have greatly increased respiratory effort. D)The client will exhibit Cheyne-Stokes respirations.
a
