Exam Review
- Patient Data Exhibits Click to indicate which findings are indicative of rheumatoid arthritis or are not applicable to that disease. Each row must have only one response option selected.
Rheumatoid Arthritis Not Applicable Joint swelling ✓ Pain increases with motion ✓ Morning stiffness quickly resolves ✓ Fatigue and fever ✓ Small joints of the hand ✓ Symmetrical involvement ✓ Heberden nodes ✓ - A mother brings her obese adolescent daughter to the clinic because for the last 6 months her daughter sleeps every day after school, has lost weight, and has not had a period for 3 months. After sending the mother to the waiting room, which assessment is most important for the nurse to implement?A)Request a 24-hour dietary recall.B)Question her about thoughts of self harm.C)Ask the teen if she is sexually active.D)Inquire about the use of illicit drugs.
- Which assessment technique should the nurse use to confirm the presence of papilledema in a client with a rapidly decreasing level of consciousness?A)Percussion.B)Palpation.C)Inspection.D)Auscultation.
- The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding?A)Glucose.B)White blood cell count (WBC).C)Blood urea nitrogen (BUN).D)Hematocrit.
Exam Review
- The nurse begins a client's musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible finding(s)? Select all that apply.(SATA)A)Contracture.B)Crepitus.C)Osteopenia.D)Atrophy.E)Kyphosis.
- A woman comes to the clinic for her first prenatal visit. The nurse is conducting a health history and the woman begins to cry when asked about previous pregnancies. Which response is best for the nurse to provide?A)"Why don't I come back in a few minutes after you are more composed."B)Allow the client to compose herself then change the subject.C)Offer a tissue and sit quietly until the crying subsides.D)"I'm so sorry that I made you cry. I didn't mean to upset you."
- While completing a health assessment for a client with peripheral vascular disease (PVD), which assessment technique is most important for the nurse to implement?A)Document thickened toe nails.B)Palpate and document quality of distal pulses.C)Measure ankle-brachial index (ABI).D)Measure and record dependent ankle edema.
- When assessing a 24-year-old body-builder, the nurse is unable to palpate an apical pulse. Which action should the nurse implement?A)Dim the lights in the examination room.B)Question the client about steroid use.C)Continue with the cardiac examination.D)Position the client in high Fowler's position.
Exam Review
- The nurse is evaluating a client's hearing who reports hearing best in the left ear although words are muffled during conversation at a social gathering. Based on this finding, which assessment should the nurse implement?A)Inspect the external ear canals.B)Ask client if he has tinnitus.C)Determine ability to maintain balance with eyes closed.D)Differentiate ability to hear high and low pitched sounds.
- The nurse examines a client admitted with a deep, constant pain in the abdomen that radiates to the back. Which finding is most important for the nurse to report to the healthcare provider (HCP)?A)An audible abdominal bruit.B)Hypoactive bowel sounds in all quadrants.C)A bulge over umbilicus when coughing.D)Intermittent pain on deep inspiration.
- Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.✓Auscultate the lungs for adventitious breath sounds✓Inspect the chest for asymmetrical expansion✓Lobar pneumonia✓Respiratory rate and pulse✓CyanosisActions to Take Choices✓Auscultate the lungs for adventitious breath sounds✕Assess for tactile fremitus✕Assess for prolonged expiration✕Assess for muffled heart sounds✓Inspect the chest for asymmetrical expansionPotential Conditions Choices✓Lobar pneumonia✕Acute bronchitis✕Pleural effusion✕AtelectasisParameters to Monitor Choices✓Respiratory rate and pulse✕Crackles✓Cyanosis✕Wheezing✕Loud bronchial breathing
- An older adult client reports noticing an increased difficulty hearing over the past year. The client explains that words often sound garbled and the end of sentences are often missed. Which follow up question is best for the nurse to ask?A)"Have you ever considered being evaluated for a hearing aid?"B)"Do you have a history of ear infections?"C)"Is this hearing loss accompanied by any loss of balance?"D)"How is this hearing loss interfering with your daily activities of living?"
Exam Review
- The nurse is examining the abdomen of an older adult male client who expresses suprapubic tenderness on palpation. The client reports that it sometimes feels like there is still pressure in that area after urination. Which additional finding should the nurse expect with continued interview of the client?A)An overactive bladderB)A cloudy discharge.C)A weak urinary stream.D)Black tarry stools.
- The nurse has just completed palpation maneuvers for lymph nodes on an older adult female client. Which findings are considered normal for this older adult client?A)Axillary nodes feel soft and fatty.B)Inguinal nodes are enlarged and warm to the touch.C)Nodes feel ropey and rubbery.D)Nodes are nonpalpable.
- The nurse determines that a male client has smoked 2 packs of cigarettes daily for the past 20 years. In calculating his smoking history, how many pack-years should be documented for this client? (Enter numeric value only.)
- Following a cerebrovascular accident (CVA), a client's prescriptions include neurologic assessments every 8 hours, and bedrest. The agency assessment tool includes evaluation of the client's posture. Which action should the nurse implement?A)Assist the client to stand at the bedside long enough to observe posture.B)Observe the client's ability to sit upright or unassisted while in the bed.C)Document that posture could not be evaluated due to prescribed bedrest.D)Ask the client to describe normal posture while walking and standing.
Exam Review
- The nurse assesses a client with a sleep pattern disturbance. While developing a plan of care (POC), which assessment data should the nurse obtain first?A)Amount and type of caffeinated drinks before bedtime.B)Usual bed time and time of awakenings.C)History of seasonal allergies and nasal congestion.D)Urinary frequency and episodes of nocturia.
- An older adult client with a history of heart failure (HF) comes to the clinic troubled by awakening during the night in a cold sweat, accompanied by difficulty breathing, and a racing heart beat. Which assessment should the nurse complete first?A)Assess the elasticity of the client's skin.B)Auscultate the client's breath sounds.C)Ask about any environmental allergiesD)Measure the client's core temperature.
- A male client reports the onset of a burning sensation in his hands and legs. How should the nurse document this finding in the electronic medical record (EMR)?A)Paresthesia reported.B)Circulation impaired.C)Inflammation present.D)Reports feeling "on fire."
- While the nurse is taking a health history, the client announces, "I don't have time for this. This is a waste of time. I need treatment." Which response is best for the nurse to provide?A)"I am sorry you feel that way. Perhaps you'd like to return when you have more time."B)"You sound angry. Would you like to tell me about it?"C)Move closer and place a hand on the client's shoulder to demonstrate concern.D)Ignore the angry outburst and continue with the history questions.