Final Exam Flashcards
A new nurse on the long-term care unit is learning how to assess a client’s risk for skin breakdown. What would be the most likely instrument this nurse would use?
Braden scale
T/F: When using an otoscope to assess the inner ear the nurse should hold the patient’s ear at the helix, lifting up and back for best visualization.
True
A client has a 7mm lesion with irregular borders and color variation that has grown over the last several weeks. The nurse knows that this lesion could possibly be what type of cancer?
A. Angioma
B. Melanoma
C. Dermatoma
D. Nevus
B. Melanoma
The nurse recognizes that the 60-year-old patient may have difficulty reading fine print because of
A. amblyopia
B. the loss of accommodation
C. asthenopia
D. the unequal size of the pupils
B. the loss of accommodation
Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?
A. subcutaneous layer
B. connective layer
C. dermis
D. epidermis
C. dermis
What does HOh stand for?
Hard of hearing
What does PERRLA stand for?
Pupils Equal Round Reactive Light Accommodation
Peripheral vision is evaluated by the nurse using the
A. confrontation test
B. corneal light test
C. cardinal fields of gaze test
D. cover test
A. confrontation test
An elderly client comes to the clinic for evaluation. During the skin assessment, the nurse noted considerable skin tenting. Why does this finding require further assessment?
A. tenting indicates dehydration
B. tenting indicates vitamin B12 deficiency
C. tenting indicates dramatic weight loss
D. tenting indicates malnutrition
A. tenting indicates dehydration
A client tells a nurse about a raised lesion on the client’s leg. What is the nurse’s first nursing action?
A. move to the next body system
B. document the statement
C. palpate the area
D. inspect the area
D. inspect the area
What characteristic nail color should the nurse recognize as an indication of hypoxia?
A. jaundice
B. greenish
C. cyanotic
D. pink
C. cyanotic
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?
A. the right lung is approximately one-third larger than the left lung.
B. the lungs are structurally symmetrical but functionally different.
C. the right lung has three lobes, while the left lung has two lobes.
D. the lower lobes of both lungs are primarily located toward the anterior chest wall.
C. the right lung has three lobes, while the left lung has two lobes.
A client comes to the clinic with reports of a reddened, tender lump on the left breast. What would the nurse document about the lump?
A. size
B. pallor
C. nipple size
D. symmetry of the chest
A. size
Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields?
A. listen at one site for inspiration, then move to the next site for expiration.
B. listen to the lungs starting in the apices.
C. instruct the client to breathe in and out rapidly through the mouth.
D. use the diaphragm then the bell in each location.
B. listen to the lungs starting in the apices.
The nurse is preparing to palpate the breasts of a female client. Which technique would be most appropriate?
A. use the flat pads of three fingers.
B. use the fingertips of both hands.
C. palpate over the client’s own hand.
D. use the palm of one hand.
A. use the flat pads of three fingers.
T/F: a client in the ED tells a nurse that she feels short of breath. The nurse would document this finding as dyspnea.
True
What techniques can be performed when palpating the breasts? Select all that apply.
A. Vertical pattern
B. Wedge pattern
C. Side to side pattern
D. Circular pattern
E. Rectangular pattern
A. Vertical pattern
B. Wedge pattern
D. Circular pattern
A nurse is inspecting a client’s nipples. Which of the following findings should the nurse regard as a cause for concern?
A. Supernumerary nipples
B. A recently retracted nipple that was previously everted.
C. Nipples that have been flat for many years.
D. Nipples that are nearly equal in size.
B. A recently retracted nipple that was previously everted.
T/F: The nurse should recognize that the presence of a wheeze can result from air passing through constricted passageways.
True
Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would most likely suspect the client is compensating for what pathophysiological disorder?
A. Diabetes mellitus
B. Heart failure
C. COPD
D. System lupus erythematosus
C. COPD
A client is admitted to the health care facility with reports of chest pain, elevated blood pressure, and shortness of breath with activity. The nurse palpates the carotid arteries as 1+ bilaterally and a weak radial pulse. A grade 3 systolic murmur is auscultated. Which nursing diagnosis can the nurse confirm based on this data?
Ineffective tissue perfusion
The nurse manager on a cardiac unit should immediately intervene when observing which staff nurse’s assessment technique?
Palpating carotid pulses simultaneously
A 62 year old client visits the clinic and tells the nurse that she feels chest pain and pain down her left arm. The nurse should refer the client to a physician for possible..
Myocardial infarction
A client complains of difficulty sleeping, stating he has to sit up with the help of several pillows and cannot breathe when lying flat. This client has a condition known as what?
Orthopnea
Which formula will the nurse use to calculate cardiac output?
heart rate x stroke volume
While performing an admission assessment, the nurse auscultates a high-pitched, scratching, and grating sound at the left lower sternal border. The nurse should use what term to document the sound?
Pericardial friction rub
The sternal angle at the right 2nd rib space is also known as what?
The aoric area
The nurse performs an admission assessment on an adult client admitted through the ED with a myocardial infarction. The nurse auscultates a swooshing sound over the right carotid artery. What phrase should the nurse use to correctly document this finding?
“Right carotid bruit auscultated.”
When describing the cardiac cycle to a group of students, the instructor correlates heart sounds with events of the cycle. Which heart sound would the instructor explain as being associated with systole?
S1
During the assessment, the nurse identifies warm thick skin that is swollen and reddish-blue. The nurse also notes an ulcer at the ankle that the client describes pain at the ulcer site as achy. The nurse suspects the client may have what?
A. Intermittent claudication
B. Hypertrophic changes
C. Arterial insufficiency
D. Venous insufficiency
D. Venous insufficiency
T/F: One extremity cooler than the other indicates arterial insufficiency.
True
While performing an assessment, the nurse presses the tissue on the legs and there is increased pitting with a 6mm depression. How would the nurse document this?
A. 3+ pitting edema
B. 1+ pitting edema
C. 2+ pitting edema
D. 4+ pitting edema
A. 3+ pitting edema
When assessing the lower extremities, it is critical that the examiner:
A. compares side to side
B. evaluate the venous system and the arterial system
C. starts at the feet
D. starts at the femoral area
A. compares side to side
What pulse is located in the groove between the medial malleolus and the Achilles tendon?
A. posterior tibial
B. popliteal
C. femoral
D. dorsalis pedis
A. posterior tibial
A client reports to the ER complaining of pain in their left calf. Upon assessment a nurse notes the reported area is edematous, red, and warm to the touch. The nurse suspects the client may have what?
A. Deep vein thrombosis (DVT)
B. Varicose veins
C. Lymphedema
D. Pulmonary embolism (PE)
A. Deep vein thrombosis (DVT)
The nurse assessing a clients skin identifies an ulcer. What would indicate to the nurse it is an arterial ulcer?
A. The extremity has an easily palpable, strong pulse.
B. The ulcer is superficial and pink.
C. The ulcer is necrotic.
D. The borders are irregular.
C. The ulcer is necrotic.
The six Ps of arterial occlusion include which of the following? Select all that apply.
A. Pain
B. Pilonidal
C. Pallor
D. Pulselessness
E. Pilocarpine
F. Paresthesia
A. Pain
C. Pallor
D. Pulselessness
F. Paresthesia
T/F: Maintaining fluid balance is one function of the lymphatic system.
True
A client comes to the clinic reporting pain in her legs while walking. The client states the pain goes away when resting. The nurse suspects the client is experiencing what?
A. Deep vein thrombosis
B. Varicose veins
C. Intermittent claudication
D. Pulmonary embolism
C. Intermittent claudication
When assessing risk of colon cancer, which of the following health-history components should the nurse prioritize?
Family history; dietary habits
The nurse is auscultating a client’s abdomen and is unable to discern any bowel sounds. How should the nurse proceed with assessment?
Listen for five minutes before documenting an absence of bowel sounds.
Cody is a teenager with a history of leukemia and an enlarged spleen. Today he presents with fairly significant left upper quadrant pain. On examination of this area a rough grating noise is heard. What is this sound?
It is a splenic rub
What is the second step of physical assessment when assessing the abdomen?
Auscultation
A patient with a history of kidney stones presents with complaints of pain, hematuria, and nausea with vomiting. What assessment technique will elicit kidney pain?
Blunt percussion of CVA tenderness
A client presents complaining of nausea, vomiting, and acute abdominal pain. What is the nurse’s first action?
Ask the client when the pain began
An emergency department nurse is caring for a teenage client who has severe pain in the umbilical area. Documentation shows that the client exhibits “Rovsing’s sign.” What medical diagnosis is associated with the assessment finding?
Appendicitis
As part of an abdominal assessment, the nurse must palpate a client’s liver. In which quadrant is this organ located?
Right upper quadrant
The nurse suspects an abdominal aortic aneurysm when what is assessed?
Abdominal bruit
How many quadrants is the abdomen divided into during an assessment?
4
When evaluating a client’s risk for cerebrovascular accident, which client would the nurse identify as being at highest risk?
A. 35-year-old African American who has sleep apnea
c
C. 55-year-old Caucasian male who has two beers a week
D. 42-year-old Caucasian woman who smokes
B. 68-year-old African American male with hypertension
Which of the following tests would be most appropriate for the nurse to use when assessing motor function of the trigeminal nerve?
A. Assess dilation of pupils with direct light
B. Palpate the temporal and masseter muscles while the client clenches teeth
C. Ask the client to differentiate sharp and dull sensations on the face
D. Have the client smile, frown, and wrinkle the forehead
B. Palpate the temporal and masseter muscles while the client clenches teeth
As people age, several neurological changes occur. Neurons, brain size, and neurotransmitters decrease. What are some of the results of aging on the neurological system? Select all that apply.
A. More frequent seizures
B. Slower thought processing
C. Inability to process nutrients
D. Delayed reflexes
E. Reduced response to stimuli
B. Slower thought processing
D. Delayed reflexes
E. Reduced response to stimuli
A client says that an object placed in the hand is a pair of scissors when the object is a paper clip. Which aspect of the client’s neurologic system should the nurse identify as being compromised?
A. motor
B. sensory
C. responsiveness
D. position sense
B. sensory
When assessing cranial nerves IX and X, which of the following would the nurse consider as an abnormal finding?
A. impaired swallowing
B. asymmetrical tongue movement
C. upward movement of the palate
D. contraction of the pharyngeal muscle
A. impaired swallowing
Lifestyle can play a big part in developing risk factors for stroke. Which of the following can greatly reduce a client’s risk for stroke? Select all that play.
A. Quitting smoking
B. Eating a high-sodium diet
C. Following a sedentary lifestyle
D. Maintaining a healthy weight
E. Regularly exercising
A. Quitting smoking
D. Maintaining a healthy weight
E. Regularly exercising
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. Ask a client to identify scents.
B. Test extraocular eye movements.
C. Use a Snellen chart to test visual acuity.
D. Perform the Weber test
Ask a client to identify scents.
A nurse is preparing to assess a client’s cerebellar function. What aspect of neurological function should the nurse address?
A. Mental status exam
B. Balance
C. Remote memory
D. Sensation
B. Balance
The nurse enters a client’s room to administer a prescribed anticoagulant for atrial fibrillation. The client exhibits new onset facial drooping and slurred speech. What is the nurse’s priority action?
A. Ask the client to raise both arms in front of the client’s body.
B. Assess the client’s bleeding time before medication administration.
C. Assess the client’s vital signs and cranial nerves.
D. Administer the PO anticoagulant immediately.
A. Ask the client to raise both arms in front of the client’s body.
A client’s patellar reflex is normal for the right side but diminished on the left. Using the scale for grading reflexes, how should the nurse document this finding?
A. Right knee +2; left knee +1
B. Right knee +1; left knee 0
C. Right knee +4; left knee +3
D. Right knee +2; left knee +1
D. Right knee +2; left knee +1
The nurse does a health history. The client states he has lost 30 pounds in the last couple months without really trying. The client also states he feels warm all the time and sometimes feels like he has heart palpitations. The nurse would anticipate orders to evaluate the client for:
A. Hyperproteinemia
B. Hyperbilirubinemia
C. Hypernatremia
D. Hyperthyroidism
D. Hyperthyroidism
T/F: Patients can aspirate even if they have an intact gag reflex.
True
A client diagnosed with peritonsillar abscess exhibits 4+ tonsils and is not able to eat or drink. What is the nurse’s priority concern for this client?
A. Obtain a throat culture
B. Ensure a patent airway
C. Begin antibiotics immediately
D. Correct clients dehydration
B. Ensure a patent airway
The nursing instructor is discussing the normal functioning of the nose and sinuses with the nursing class. What would be the best description of the major factors related to the normal functioning of these structures? Select all that apply.
A. Deep cervical and retropharyngeal nodes
B. Normal quality and quantity of the mucous
C. Patency of the sinus ostia
D. An abundant lymph supply
E. Normal cilia function
B. Normal quality and quantity of the mucous
C. Patency of the sinus ostia
E. Normal cilia function
T/F: Kiesselbach plexus is the most common site of nosebleeds
True
Which type of vessels filter pathogens from the body and drain the fluid that has moved outside of the circulation back into the vessels?
A. Arteries
B. Veins
C. Lymphatic
D. Aortic
C. Lymphatic
What is the purpose of the tongue? Select all that apply.
A. Helps with the identification of sweet, sour, salty, and bitter tastes
B. Aids in the production of saliva
C. Provides resonance to the voice
D. Manipulates solids and liquids when eating and drinking
E. Assists in speech production
A. Helps with the identification of sweet, sour, salty, and bitter tastes
D. Manipulates solids and liquids when eating and drinking
E. Assists in speech production
The client has experienced a stroke and has dysphagia. The nurse knows this is what?
A. Difficulty swallowing
B. Painful swallowing
C. Lack of gag reflex
D. Difficulty talking
A. Difficulty swallowing
A white coating of the tongue may be oral ________ and is common in patients taking antibiotics.
candidiasis
A nurse is preparing an educational event for the parents of children with respiratory disorders. What would the nurse tell the parents about allergies?
A. If a parent has allergies, the child has a 25% chance of developing them as well.
B. There are few effective treatments for allergies.
C. Allergy can affect any target organ in the body.
D. Children will outgrow their allergies.
C. Allergy can affect any target organ in the body.
Moving a part of the body away from the midline is called?
Abduction
What term is abbreviated to “ROM?”
Range of Motion
Decreasing the angle between bones is called
Flexion
The nurse is developing a plan of care for a client found to have a strength problem. What would be an appropriate nursing diagnosis for this client?
A. Activity intolerance
B. Self-care deficit
C. Impaired physical mobility
D. Impaired walking
C. Impaired physical mobility
An older adult client has been admitted to the unit. The client has problems with fine motor movement. What would be important to do for this client?
A. Open all packages and arrange the meal tray while communicating actions to the client
B. Teach the client to call for assistance when getting up to bathroom
C. Evaluate for assistance devices
D. Assess gross motor function
A. Open all packages and arrange the meal tray while communicating
T/F: The Romberg test is one assessment that can be completed to assess balance.
True
When assessing a client’s strength, it is necessary to
A. Compare one side to the other
B. Assess the extremities at the same time
C. Compare upper and lower extremities
D. Assess upper and lower extremities at the same time
A. Compare one side to the other
Loss of bone density that occurs with greatest frequency in postmenopausal women is called?
Osteoporosis
A client presents to the emergency department after falling off a ladder while doing some outside painting at home. The client’s ankle appears swollen, out of alignment, and is painful to touch. What is the nurse’s first action?
A. Encourage early weight bearing and ambulation.
B. Apply an ice pack to the affected extremity.
C. Check for a pulse, color, temperature, and capillary refill.
D. Splint and immobilize the affected extremity
C. Check for a pulse, color, temperature, and capillary refill.
A client comes to the clinic and reports a sore knee. The nurse notes popping and cracking noises when the client attempts to bend the knee. The client exhibits signs of pain by facial expression. The nurse knows that the popping and cracking noises should be charted as what?
A. Crepitus
B. Grating noise
C. Tactile emphysema
D. Popping and cracking noises
A. Crepitus
Upon assessment of an older adult, the nurse notes the client’s skin to have a yellow color. The nurse recognizes and documents this skin color as which of the following?
A. Ecchymosis
B. Pallor
C. Cyanosis
D. Jaundice
D. Jaundice
