Exam Review
- When the nurse is assessing a client's mental status as part of the neurological examination, which question would be most appropriate to ask?A)"Do you feel like crying often?"B)"Do you have a history of psychotic disorder?"C)"Can you tell me about your mood today?"D)"Can you tell me where you are right now?"
- A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?A)Instruct the patient on Tripod positioningB)Restrict the client's fluid intake to less than 2 L/day.C)Provide the client with a low-protein diet.D)Have the client use the early-morning hours for exercise and activity.
- A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?A)Instruct the patient on Tripod positioningB)Restrict the client's fluid intake to less than 2 U/day.C)Provide the client with a low-protein diet.D)Have the client use the early-morning hours for exercise and activity.
- The nurse suspects an older adult client has congestive heart failure. Which of the following did the nurse most likely assess in the client?A)Carotid bruitsB)S4 heart soundC)Harsh holosystolic murmur at the apexD)S3 heart sound
Exam Review
- A nursing student asked the respiratory floor nurse why the adventitious wheezing breath sounds are present in asthmatic patients. The nurse should respond:A)this is an abnormal breath sound due to bronchial airways being narrowed, bronchoconstrictionB)this is a normal breath sound due to normal gas exchangedC)this is an abnormal breath sound due to bronchial airways being dilated, bronchodilationD)this is a normal breath sound due to the alveoli being fluid-filled
- A nurse is collecting assessment data on a new client. The client states she does not have a menses. What term will the nurse use in her documentation to describe the absence of menstrual flow?A)MenorrhagiaB)DysmenorrheaC)AmenorrheaD)Metrorrhagia
- A Community nurse is doing a class teaching measures to prevent peripheral arterial disease. Select all that apply teaching for this topic. (Select All that Apply.)(SATA)A)Decreased exercisesB)Diabetes managementC)Smoking cessationD)Hyperlipidemia control
- A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)Correct Answer:"{\"xRanges\":[104.828125,113.828125],\"yRanges\":[122.5,131.5]}"
Exam Review
- A nurse is performing a pressure injury risk assessment for a client. Which of the following findings increases the client's risk of a pressure injury?(SATA)A)BMI of 20B)Peripheral neuropathyC)ImmobilityD)Hypoperfusion
- A patient is diagnosed with a Pneumothorax on the right lung. During the assessment, when percussing this area the nurse expects to find the percussion note as:A)FlatnessB)DullnessC)ResonanceD)Hyperresonance
- Which of the following would the nurse expect to be done to assess the size of the prostate?A)Pelvic examinationB)TransilluminationC)Bladder percussionD)Digital rectal examination
- During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. The nurse should document which problem?A)angioedemaB)actinic cheilitisC)angular cheilitisD)herpes simplex
Exam Review
- Assessment of the client 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)ObtundedB)StuporC)ComaD)Lethargy
- During a respiratory physical assessment, the nurse directs the patient to say and repeat the letter E for the transmitted voice sounds assessment. The nurse by auscultation hears the letter A instead of E. This is known as:A)EgophonyB)normal voice transmission.C)Air filled lungsD)Bronchophony
- A nurse is teaching a newly licensed nurse about evaluating a cardiac rhythm. Which of the following options should the nurse identify as the P wave in the ECG complex? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
- A family member brought a senior to the clinic. The family member explained to the nurse that the patient suddenly from one day to the other, started with confusion, and agitation. The family states the patient used to be orientated and with very calm behavior. The nurse suspects that this patient is experiencing:A)DeliriumB)SundowningC)AlzheimersD)Dementia
Exam Review
- A 54 year-old client diagnosed with Bipolar disorder is clenching his jaw closed to avoid taking a prescribed oral medication. The nurse can use this observation to confirm the client is demonstrating motor function of which cranial nerve?A)VagusB)FacialC)GlossopharygealD)Trigeminal
- When assessing an older adult client, the nurse notes which age-related changes of the cardiovascular system that increase the risk for falls?A)stiffening of the large arteriesB)rise in the systolic blood pressureC)postural orthostatic hypotensionD)Decline of pacemaker cells in the sino-atrial node
- 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 these signs?A)Bell's palsyB)MyxedemaC)Cushing's syndromeD)Scleroderma
- How would the nurse assess CN VIII Acoustic, vestibulocochlear: Select all that ApplyA)Weber testB)MagazineC)Rhine testD)Whispered voice test
Exam Review
- The nurse is planning to inspect a client's apical heart impulses. What should the nurse do to ensure an accurate assessment of this organ?A)Assist the client to a standing position.B)Focus a penlight on the client's chest.C)Use tangential lightingD)Use perpendicular lighting.
- The nurse assesses a client who reports chronic pain with chewing. The nurse should assess which body area to investigate the client's problem further?A)glenohumeral jointB)sternoclavicular jointC)temporomandibular jointD)acromioclavicular joint
- A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point. (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)
- A patient came with a right ear sensorineural hearing loss. What should the nurse expect while performing the Weber test?A)lateralization of the sound/vibration to both ears equallyB)lateralization of the sound/vibration to the left ear.C)bone conduction(BC) is greater than air conduction (AC)D)lateralization of the sound/vibration to the right ear.