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
When inspecting the patient’s skin, the nurse should look for ___________ , which may include scabies, lice, and fleas.
infestations
A high school football player presents to the hospital with dizziness, headache, sleepiness, increased tenting of the skin, and decreased turgor following an intensive practice in the summer heat. Which of the following nursing diagnoses can the nurse formulate based on this information?
A. Deficient Fluid Volume
B. Activity Intolerance
C. Risk for Imbalanced Fluid Volume
D. Acute Confusion
A. Deficient Fluid Volume
T/F: If the patient’s skin color is cyanotic or pale, breathing is difficult, posture is strained, facial expression is anxious, or overall appearance indicates distress, the nurse focuses on the immediate problem.
True
When conducting a focused health assessment, the nurse asks questions specifically targeting the client’s:
A. gender
B. specific issues and symptoms
C. culture
D. sexual Orientation
B. specific issues and symptoms
Nurses assess ability to perform self-care activities, or __________ .
Activities of daily living (ADLs)
The nurse is conducting a head-to-toe assessment on a client. Which observation(s) by the nurse would be cause for concern? Select all that apply.
A. Infestations
B. Goose bumps
C. Rashes
D. Freckles
E. Lesions
A. Infestations
C. Rashes
E. Lesions
The nurse usually performs a complete physical examination with elements in the following order:
A. Eyes, heart, abdomen, legs
B. Face, heart, legs, arms
C. Ears, back. lungs, arms
D. Head, abdomen, lungs, legs
A. Eyes, heart, abdomen, legs
A nurse who works on a day-surgery unit conducts a thorough, head to toe assessment of each client prior to the client’s scheduled surgery. The nurse would document an unexpected finding if unable to palpate a client’s:
A. Lymph nodes
B. Thyroid Gland
C. Peripheral pulses
D. Liver
C. Peripheral pulses
T/F: The physical examination begins with the head-to-toe assessment.
False
The nurse is concerned that an older client is developing delirium. What findings caused the nurse to make this clinical determination? Select all that apply.
A. Combative behavior
B. Rambling speech
C. Sleep disturbances
D. Easily distracted by unimportant things
E. Inability to recall recent events
A. Combative behavior
B. Rambling speech
C. Sleep disturbances
D. Easily distracted by unimportant things
The RN may delegate which care component to a nursing assistant?
A. Check client’s pain level
B. Evaluating vital signs
C. Ambulation assistance
D. Wound care and assessment
C. Ambulation assistance
Some symptoms are common in elderly clients. Which of the following is less likely to be a common problem in old age?
A. Falls.
B. Fever
C. Weakness.
D. Confusion.
B. Fever
T/F: Before interviewing the older adult, the nurse should set up the room and create an environment that facilitates hearing and understanding of communication.
True
A nurse assesses a client’s blood pressure and the findings suggest orthostatic hypotension. Which area should the nurse emphasize during client education?
A. Vitamin supplementation
B. Diet high in iron
C. Prevention of falls
D. Daily exercise routine
C. Prevention of falls
The nurse enters a client’s room to administer scheduled medications through a barcode system. The client is not wearing an armband. What is the nurse’s best action?
A. Scan the barcode on the client’s chart, then administer the medications.
B. Ask the client for name and birth date, then administer the medications.
C. Confirm the client’s identity with visitors who are present.
D. Leave the room to obtain another armband for the client.
D. Leave the room to obtain another armband for the client.
The RN working on a surgical unit should question which of these orders before completing it?
A. Check intracranial pressure
B. Reapply a staple in an incision
C. Change a central line dressing
D. Administer a narcotic infusion
B. Reapply a staple in an incision
When assessing the skin, hair, and nails of the older adult, the nurse needs to know the normal effects of aging on these structures. Which of the following are normal effects of aging on the integumentary system? Select all that apply
A. The epidermis thins
B. The number of sweat and sebaceous glands increases
C. Nails become thin and brittle with increased growth
D. The epidermis thickens
E. Nails become thick and brittle with slow growth
F. Wound healing slows
A. The epidermis thins
E. Nails become thick and brittle with slow growth
F. Wound healing slows
The nurse has entered a client’s room to begin a head-to-toe assessment. The client appears anxious, is pale, and is struggling to breathe. What is the nurse’s priority action?
A. Count respirations.
B. Ensure a patent airway.
C. Check for pupil reaction.
D. Assess blood pressure.
B. Ensure a patent airway.
Where is it recommended to start when you auscultate the abdomen?
Start at the point of the ileocecal valve, slightly right and below the umbilicus, and proceed clockwise.
To assess an adult client’s skin turgor, the nurse should
use two fingers to pinch the skin under the clavicle
A nurse performs a focused assessment on a new client. The nurse observes pustules and erythema around the client’s hair follicles. The nurse recognizes these are signs and symptoms of which of the following disorders?
folliculitis
A nurse receives report from the shift nurse that a client has new onset of peripheral cyanosis. Where should the nurse focus the assessment of the skin to detect the presence of this condition?
Fingers and toes
A nurse inspects a client’s skin and notices several flat, brown color change areas on the forearms. What is the proper term for documentation of this finding by the nurse?
Macule
A client with a zosteriform rash has a rash that
is distributed along a dermatome
Hair follicles, sebaceous glands, and sweat glands originate from the
dermis
A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale?
The client’s ability to change position
A client comes to the clinic reporting red “itchy” skin. The nurse should assess the client for which of the following causes of pruritus? Select all that apply.
A. aginig
B. allergies
C. new medications
D. liver dysfunction
E. peripheral neuropathy
A. aginig
B. allergies
C. new medications
D. liver dysfunction
A female client is noted to have excessive hair on her face and chest. The nurse plans further evaluation of which body system?
Endocrine
When documenting that a client has freckles, the appropriate term to use is
macules
Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?
Dermis
Mrs. Anderson presents with an itchy raised rash that appears and disappears in various locations. Each lesion lasts for many minutes. Which most likely accounts for this rash?
Urticaria or hives
The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the
areola of the breast
An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what?
sebum production
A nurse has been asked to assess an older adult resident of a long-term care facility. During assessment of the resident’s skin, the nurse notes a break in the skin, erythema, and a small amount of serosanguineous drainage over the resident’s sacrum. Inspection reveals that the area appears blister-like. The nurse should interpret this finding as indicating which stage of pressure ulcer?
Stage II
A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions?
Psoriasis, fungal infections, trauma
The nurse is assessing a dark-skinned client whose forearms and hands have distinct regions of depigmentation. The nurse should document the presence of what health problem?
Vitiligo
The nurse notes that a client’s nails are greater than a 160-degree angle. What should the nurse assess as a priority for this client?
Pulse oximetry
A 19-year-old construction worker presents for evaluation of a rash. He says that it started on his back with a multitude of spots and is also on his arms, chest, and neck. It itches a lot. He has been sweating more than before, because being outdoors is part of his job. Physical examination reveals dark tan and reddish patches with sharp borders and fine scales, scattered more prominently around the upper back, chest, neck, and upper arms as well as under the arms. Based on this description, what is the most likely diagnosis?
Tinea versicolor
A nurse is instructing a client on how to assess himself for herpes simplex lesions by their configuration. Which configuration should the nurse tell the client to look for?
Clustered
A 73-year-old woman comes to the office for evaluation of new onset of tremors. She is not taking any medications, herbs, or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow, shuffling steps. She has decreased facial mobility with a blunt expression without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the client’s symptoms?
Parkinson’s disease
Assessment of an adult female client’s face reveals a moon shape, increased hair distribution, and a reddened tone to the client’s cheeks. What collaborative problem is most clearly suggested to the nurse by these assessment data?
Cushing’s syndrome
A nurse is palpating the head and neck of a newly referred client. Which of the following would the nurse suspect if assessment reveals that the client’s skull and facial bones are larger and thicker than normal?
Acromegaly
Which of the following would the nurse document as an abnormal finding with lymph node assessment?
- Mobile
- Tender
- Soft
- Undetectable
Tender
The nurse is caring for a client who comes to the clinic reporting a lump by her ear. What are the symptoms of a cancerous lymph node?
The node is fixed and rubbery
Palpation of a 15-year-old boy’s submandibular lymph nodes reveals them to be enlarged and tender. What is the nurse’s most reasonable interpretation of this assessment finding?
There is an infection in the area that these nodes drain.
The nurse is preparing to assess the lymph nodes of an adult client. The nurse should instruct the client to
sit in an upright position.
A nurse is assessing the head and neck of an adult client. Which vertebra should the nurse identify as a landmark in order to locate the client’s other vertebrae?
C7
A nurse is assessing a client with hyperthyroidism for the presence of a bruit. Which assessment technique should the nurse use?
Auscultation
A nurse is examining a client’s neck and is preparing to palpate the thyroid gland. The nurse would most likely expect to palpate how many lobes?
2
When examining a client’s thyroid gland, the nurse ensures that which equipment is readily available?
Cup of water
The nurse is assessing a client’s thyroid by having the client swallow a small sip of water. What will the nurse document as an expected finding?
The thyroid cartilage and cricoid cartilage move upward symmetrically.
The nurse is palpating a client’s cervical vertebrae. Which vertebra can be easily palpated when the neck is flexed and should help the nurse locate the other vertebrae?
C7
During the physical examination of a client, a nurse notes that a client’s trachea has been pushed toward the right side. The nurse recognizes that the pathophysiologic cause for this finding is related to what disease process?
Atelectasis
A nurse examines a client with complaints of a sore throat and finds that the tonsils are enlarged and touching one another. Using a grading scale of 1+ to 4+, how should the nurse appropriately document the tonsils?
4+
What instructions should the nurse provide to the client taking a sublingual medication?
Put the medication underneath your tongue.
During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client’s lips and surrounding skin. The nurse would document this finding as being:
Herpes simplex
During an oral assessment, the nurse identifies that client has white patches in his mouth. How would this be documented in the medical record?
Leukoplakia
A nurse is working with a client who has an impaired ability to move the tongue. He explains that he was in an automobile accident many years ago and suffered nerve damage that resulted in this condition. Which nerve should the nurse suspect was damaged in this client?
Cranial nerve XII (hypoglossal)
The submandibular glands open under the tongue through openings called
Wharton ducts
When visualizing the structures of the nose, the nurse recalls that air travels from the anterior nares to the trachea through the:
Vestibule, nasal passages, and nasopharynx
A client is found to have a smooth, glossy tongue. What vitamin deficiency might this indicate?
Vitamin B12 deficiency
A client is admitted to the health care facility with a diagnosis of left lower lobe pneumonia. What change in egophony should the nurse expect to find in the left lower lobe?
Sound is louder and sounds like “A”.
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?
The right lung has three lobes, while the left has two lobes.
The nurse is caring for a client who is 48 hours postop from the repair of a fractured hip. She has a sudden onset of dyspnea without pain. What disease process would the nurse suspect?
Pulmonary embolism
What is the best guide to make vertical locations on the chest?
Sternal angle
Auscultation of a 23-year-old client’s lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing?
Narrowing or partial obstruction of an airway passage
Which action by a nurse demonstrates proper technique for assessment of chest expansion?
Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath.
The apex of each lung is located at the
area slightly above the clavicle
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
How should a nurse assess a client for pulse rate deficit?
Assess for a difference between the apical and radial pulse.
A client is admitted for the new onset of heart failure. The nurse recognizes that which finding is the earliest sign of heart failure?
Auscultation of an S3 heart sound
In auscultating a client’s heart sounds, a nurse hears a swooshing sound over the pre cordium. The nurse recognizes this sound as which of the following?
Murmur
The nurse suspects an abdominal aortic aneurysm when what is assessed?
Abdominal bruit
The peritoneum is a serous membrane that contains what?
A parietal layer
The nurse plans to assess an adult client’s kidneys for tenderness. The nurse should assess the area at the
costovertebral angle
The nurse is auscultating the abdomen and notes a swishing sound in the abdominal area. The nurse would document this sounds as a what?
Bruit
When assessing for appendicitis, what signs might the nurse look for?
Rovsing sign and cutaneous hyperesthesia
Assessment used to assess for rebound tenderness to check for peritonitis; may include appendicitis or infection. Away from the painful area, push down your hand at a 90-degree angle slowly and deeply. Quickly release pressure.
Blumberg sign
Increased bowel sounds that occur with diarrhea and early intestinal obstruction
Borborygmi
Collection of fluid in the abdomen
Ascites
Pain that results from inflammation of the peritoneum. Usually severe and localized over the involved structure
Parietal pain
Pain that occurs in more distant sites innervated at approximately the same spinal level as the disordered structure.
Referred pain
Pain that occurs when hollow organs are distended, stretched, or contract forcefully. Difficult to localize.
Visceral pain
Hold fingers beneath the liver border, apply mild pressure and ask the patient to take a deep breath. Assessing for gallbladder inflammation.
Murphy sign
With patient lying supine, lift the right leg straight up, keeping the knee straight. Push down over the lower part of the right thigh while the patient pushes up. This is performed when appendicitis is suspected.
Iliopsoas muscle test
T/F: As a person ages, there is a decrease in thirst sensation, production of saliva, gastric motility, peristalsis, liver, and renal function.
True
T/F: On average, waste products of food ingested today are eliminated 48 hours later.
True
________ bowel sounds occur more than 30 gurgles per minute.
Hyperactive
Where in the abdomen would you listen for bruits?
Over the aorta in the epigastric region and over the renal and iliac arteries.
Where in the abdomen would you listen for venous hums?
In the epigastric region near the liver and over the umbilicus.
Where in the abdomen would you listen for friction rubs?
Over the liver and spleen.
In what quadrant is the liver?
RUQ
In what quadrant is the gallbladder
RUQ
In what quadrant is the pancreas?
LUQ
In what quadrant is the spleen?
LUQ
In what quadrant is the appendix?
RLQ
When the muscles have absolutely no resistance to movement
flaccid/atonic
Muscle tone seems to be only decreased or “flabby”
hypotonia
Increased resistance of the muscles to passive stretch
hypertonia
Characterized by a steady persistent resistance to passive stretch in both flexor and extensor muscle groups
rigidity
Unsteady, wavering movement with inability to touch the target
Ataxia
Lack of awareness and attention to one side of the body
Neglect
Medical term for nosebleed
Epistaxis
Turning the sole of the foot outward
Eversion
Movement of a part away from the center of the body
Abduction
Maneuver that decreases the angle between bones or brings bones together
Flexion
Turning the sole of the foot inward
Inversion
Movement of a part toward the center of the body
Adduction
Movement of a joint whereby one part of the body is moved away from another. Increases the angle to a straight line or 0 degrees.
Extension
Turning a structure to face upward
Supination
Turning a structure to face downward
Pronation
Extension beyond the neutral position
Hyperextension
T/F: The musculoskeletal system is composed of skeletal muscle and five types of connective tissues: bone, cartilage, ligaments, tendons, and articulations.
True
_______ occurs in all people, but it is most evident in women with small bony frames. Women experience rapid loss of bone density for the first 5 to 7 years after menopause.
Osteoporosis
Bone marrow cavities serve as sites of _________, or the manufacturing of blood cells.
hematopoiesis
________ is the lateral curvature of the spine, usually affecting both the thoracic and lumbar parts, with a deviation in one direction in the thoracic spine and in the other direction in the lumbar spine.
Scoliosis
_________ is an exaggerated forward curvature of the spine that may occur in older adults.
Kyphosis
Name the type and number of each vertebrae:
7 - cervical
12 - thoracic
5 - lumbar
5 - sacral
3 to 4 - coccygeal
The shortening of tendons, fascia, or muscles.
Contracture
Wasting or shrinking of the muscle as a result of disuse.
Atrophy
