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HESI Health Assessment Test bank Questions and Answeres (100% Correct Elaborations)

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The nurse is caring for a patient with chronic lower back pain. The nurse knows that the most reliable indicator of pain in this client is: The patient is reporting "6/10" pain. The patient is r... efusing to get out of bed. The patient is refusing to eat breakfast. The patient's heart rate is 90 beats per minute. A Which of the following actions should the nurse take to ensure an accurate blood pressure (BP) reading? Ensure the width of the BP cuff is equal to 80% of the arm circumference. Ensure the client's back is supported and feet are flat on the ground. Take two BP readings 20 seconds apart. Ensure that the patient's arm is above heart level. B The patient's arm should be supported at heart level. Separate BP readings may need to be taken, but not one right after the other. The length of the BP bladder should equal 80% of the arm circumferen The nurse obtains which piece of data during the general survey? Client is alert and calm. Client's heart rate is 80 beats per minute. Client's body mass index (BMI) is 30. Client's lung sounds are "clear" to auscultation. A A man is at the clinic for a complete physical exam. He states that he is "very anxious". What steps can the nurse take to make him more comfortable? Appear confident and unhurried during the exam. Measure vital signs at the end to allow the patient sufficient time to relax. Let him leave his clothes on during the examination. Obtain another nurse to examine the patient. A A father brings his 13 month-old child in for "fever" and he reports that the child has been "pulling on his left ear". Upon entering the exam room, the child is asleep in the father's arms. The nurse should perform which assessment first? Use the otoscope to look inside the ear. Use a penlight to check the eyes and nose. Auscultate the lungs, heart, and abdomen. Assess gross motor skills using the Denver II screening tool. C An 18 year-old presents to the emergency department with "headache." Which of these assessment findings alerts the nurse to recent opioid use? Pupillary constriction Hallucinations. Fever. Tachypnea. A- constricted pupils are a sign of recent opioid use, the rest are withdrawals While collecting the pulse on a 26 year-old client, the nurse notes that the heart rate seems to speed up and then slow down in accordance with respirations. The pulse is counted at 80 beats per minute. What should the nurse do next? Obtain orthostatic vital signs. Notify the physician. Document "sinus arrhythmia." Use a doppler to confirm the finding. C An elderly client with pneumonia is being treated in the intensive care unit (ICU). He is acutely agitated, restless, and disoriented. The nurse documents his level of consciousness as: Manic. Demented. Drowsy. Delirious. D The nurse is assessing a newborn infant. How should the nurse measure the heart rate (HR)? Palpate the radial pulse for 15 seconds and multiply by four. Palpate the brachial pulse for 30 seconds and multiply by two. Auscultate the apical site for 60 seconds. Apply a pulse oximeter to obtain both the HR and SpO2. C A 28 year-old is brought to the emergency department. He is disoriented and hallucinating, and vital signs are elevated. The nurse suspects that the patient is experiencing withdrawal symptoms from which substance? Alcohol. Cocaine. Cannabis. Opiates. A- hallucinations and delirium are commonly seen w alcohol withdrawal When evaluating the temperature of older adults, the nurse should remember which aspect about an older adult's body temperature? Fever is a reliable sign of infection in older adults. The older adult's body temperature varies widely because of the thinner subcutaneous layer. There are no differences in temperature between a young and old adult. Older adults body temperature runs lower than that of an adult. D Which error may result in a falsely low blood pressure (BP) reading? The patient has a full bladder. The arm is held above the level of the heart. The cuff size is too small for the client. The BP cuff is wrapped loosely around the arm. B- at heart level During a general survey of a post-operative patient, the nurse notes that the patient's eyes are closed but they temporarily open with loud verbal stimulus and a gentle shake to the shoulder. The nurse documents his level of consciousness as: Alert. Somnolent. Stuporous. Obtunded. D A 46-year-old male presents to the Emergency Department with syncope. He says his cardiologist recently placed him on a new medication for his blood pressure (BP). What should the nurse do first? Obtain orthostatic vital signs. Educate the patient on homeopathic methods to control his BP. Administer a fluid bolus. Advise the patient to stop taking this medication. A As a mandatory reporter, the nurse notifies the authorities with which of the following? Suspicion of child or elder abuse/neglect. Proof of substance abuse in minors. Any bruising on a child or older adult. Proof of intimate partner violence. A A 50 year-old patient is in the intensive care unit (ICU) with septic shock. The nurse receives an order to notify the provider if the patient's mean arterial pressure (MAP) is <60 mmHg. What does the nurse understand to be true? A MAP >60 is needed to maintain adequate tissue perfusion. MAP can only be obtained by using a noninvasive blood pressure (NIBP) monitor. MAP is the average of the systolic and diastolic pressures. A MAP of 40-60 mmHg indicates that the stroke volume is adequate. A An adult patient presents to the E.D. with "vaginal bleeding" and dizziness. Level of consciousness is decreased. The nurse prioritizes collecting which vital signs? Respiratory rate and temperature. Body mass index (BMI). Weight and oxygen saturation. Heart rate and blood pressure. D A 40 year-old patient with hypertension (HTN) presents to the internal medicine clinic for an initial visit. When obtaining the patient's blood pressure (BP), how should the nurse proceed? Cuff should be inflated to the exact point at which the palpated pulse disappeared. Cuff should be inflated to about 200 mmHg and then slowly deflated. Cuff should be inflated about 20-30 mmHg above the palpated systolic BP. Cuff should be inflated 30 mm Hg above the patient's pulse rate. C A patient presents to the clinic with "abdominal pain." The nurse asks all of the following questions during a full pain assessment, except: "When did this pain begin?" "What does your pain feel like?" "Point to where it hurts the most." "How is your pain tolerance?" D the nurse notes a patient's peripheral pulse is weak and barely palpable, the nurse document the pulse force? 0 3+ 1+ 2+ C The nurse nurse is assessing a woman presenting with "headache" and identifies suspicious injuries upon skin examination. Which question or statement should the nurse use to further assess the situation? "I need to report this abuse to the authorities." "I can see you are a victim of domestic violence. Please tell me about this." "Why would somebody want to hurt you?" Correct! "These types of injuries can sometimes be caused by other people. Is anyone hurting you or frightening you?" D Which statement is true regarding blood pressures (BP) obtained in the thigh? Thigh pressures are obtained in all clients with a history of mastectomy. Thigh BPs should be obtained in all clients to compare to the brachial BP. Systolic blood pressures in the thigh are higher compared to the arm. Thigh BPs are obtained with the client sitting. C The nurse is examining a patient undergoing withdrawal from opiates. The temperature is 102 degrees Fahrenheit. What other vital sign change does the nurse expect to find, in relation to the fever? Low oxygen saturation. Bradypnea. Elevated heart rate. Hypotension. C An adolescent male has been brought into the emergency department after a motorized scooter accident. How should the nurse begin the mental status examination? Assess the patient's level of consciousness. Assess the patient's judgment. Assess the patient's recent memory. Determine if the patient has suicidal thoughts. A A mother brings her 6 year-old child in for "irritability." How should the nurse conduct the mental status exam? The nurse can defer the mental status exam, as irritability is normal in a 6 year-old child. The nurse should begin the exam by having the patient fill out the GAD-7 and PHQ-9. The mini-mental state exam (MMSE) should be used to obtain a baseline for cognitive ability. Appearance, behavior, cognition, and thought processes can be assessed with special consideration for developmental milestones. D The RN is gathering the vital signs of an adult athlete and finds the following: temperature-36.9° C; pulse-48 beats per minute; respirations-12 breaths per minute; blood pressure-104/58 mm Hg. What should the nurse do next? Continue with the exam; these are normal vitals for a healthy, athletic adult. Document "bradypnea" in the client's chart. Notify the physician of the pulse and blood pressure. Recheck all vital signs to confirm the findings. A The nurse is assessing an 80 year-old client presenting for an annual check-up. As the nurse begins the mental status portion of the assessment, the nurse expects which finding? The patient will have no decrease in any of his abilities. Verbal responses may be slightly delayed. The patient may be disoriented to place. The patient may have mood swings and lapses in judgment. B The nurse is assessing an 88-year-old male patient. Which of the following assessment findings are expected in older adults? Additional fat deposits on the abdomen. Presence of lordosis and a narrow stance. Body changes including a longer trunk and shorter extremities. Increase in muscle mass from his younger years. A The nurse is conducting a mental status assessment on an adult female recovering from alcohol withdrawal. Which question by the nurse would best assess a person's judgment? "What is the similarity between a watch and a ruler?" "What are your plans once you leave the hospital?" "What brought you into the hospital 7 days ago?" "Do you ever see or hear things that aren't really there?" B A 5-year-old boy is brought to the emergency department by his mother. He points to his stomach and says, "Owie." Which pain assessment tool would be the best choice when assessing this child's pain? Wong-Baker FACES Pain Scale The nurse should use only objective data to assess for pain. Numeric rating scale Descriptor Scale A The school nurse is conducting a pain assessment on an adolescent presenting with "back pain that started last week." What should the nurse ask first? "How have you treated it?" "What were you doing when this pain started?" "Why do you think you are having this pain?" "Is it affecting your daily life?" B Which statement is true regarding head and chest circumference in infants and children? The newborn head circumference is usually about 2cm larger than the chest circumference. The nurse only needs to check a head circumference in premature infants. The head and chest circumference will even out at 3 months. Chest circumference should be greater than head circumference at birth. A A 40 year-old male with no significant past medical history presents to the clinic for his "annual check-up for work". How should the nurse conduct the mental status examination (MSE)? Defer the MSE, as the client has no concerns. Begin the MSE by assessing abstract reasoning and judgment. Start with a brief MSE by incorporating it into the interview. Integrate the Mini-Cog into the exam. C- Integrating the MSE into the health history is sufficient for most people. You will collect ample data to be able to assess mental health strengths and coping skills and to screen for any dysfunction. During new grad orientation, the nurse teaches about normal changes that can be expected in older adults. What should the nurse include in the teaching? Older adults have a slower respiratory rate. Older adults often have a wider pulse pressure. Older adults normally have joint pain. Older adults have a higher core body temperature. B A patient with a body mass index (BMI) of 24 falls under which category? Obese. Healthy weight for height. Extreme obesity. Overall rweight. B When assessing a 70-year-old patient with heart failure, the nurse notes he is consistently leaning forward with arms on the bedside table. What does the nurse understand to be true? The patient is eager and interested in participating in the exam. This position is often used when a patient is having respiratory difficulties. This is suspicious for pain; a focused abdominal exam should be prioritized. The client is in respiratory distress and should be assisted to a prone position. B The nurse is caring for an 8-year-old developmentally appropriate child who has several bruises of varying colors on the buttocks. What action should the nurse take next? Assume that the bruises were caused by spanking. Inform the child "You can tell me who did this to you and we will not allow them to see or hurt you again." Rely on the parents to provide information related to the cause of the bruising. When the child is alone, ask "How did you get these sore areas on your bottom?" D The nurse is preparing to perform brief head-to-toe assessments on assigned patients. Which technique is correct? The nurse uses the base of the fingers to assess pulsations. The nurse uses the ulnar surface of the hands to assess vibrations. The nurse uses the palmar surface of the hand to assess skin temperature. The nurse uses the dorsum of the hand to assess for crepitus. B While reviewing a patient's past medical history, the nurse notes that the patient has been diagnosed with orthostatic hypotension. What does the nurse understand to be true? Patients with documented orthostatic hypotension should be taught to get up slowly. Orthostatic hypotension is more often seen in young children. Anyone with orthostatic hypotension should have their blood pressure measured on their lower extremities. Patients with orthostatic hypotension experience a drop in heart rate of at least 20 bpm with position change. A The nurse understands which statement to be true regarding pulse pressure? Pulse pressure is an indicator of tissue perfusion. Normal pulse pressure is 10-30 mmHg. Pulse pressure is often narrower in the aging adult. Pulse pressure is reflective of stroke volume. D The nurse is assessing an elderly client presenting for an annual check-up. What question would be best for the nurse to use to assess cognitive function in this client? "Do you ever feel like people are watching you?" "What are your health goals?" "What have you eaten in the last 24 hours?" "Are you in any pain?" C A Chinese family presents to the clinic with flu-like symptoms. Upon examination of the 8 year-old child, the nurse notices linear bruising covering the chest and back . What should the nurse do first? Notify Child Protective Services. Perform a cultural assessment. Take photographs of the bruises. Document the finding as suspected abuse. B The nurse is assessing a client who recently suffered a stroke. Speech is impaired, although comprehension is intact. This finding reflects which type of aphasia? Global. Dysphonic. Wernicke's. Broca's. D During percussion of a patient's lungs, the nurse notes a clear, hollow sound. The nurse documents: Dullness. Flatness. Tympany. Resonance. D Resonance is a clear, hollow sound normally heard over adult's lungs. Dullness is a muffled thud and if heard over the lungs, it would indicate increased density associated with consolidation (pneumonia), fluid, or a mass. Tympany is a musical, drumlike sound heard over the abdomen Which of these situations could result in a falsely low blood pressure reading? Select all that apply. The cuff is loosely wrapped around the arm. The arm is held above the level of the heart. The person is sitting with his or her legs crossed.! The nurse does not inflate the cuff high enough. The blood pressure cuff is too small for the extremity. B D A patient with a history of alcoholism has been admitted to the ICU after surgery. The nurse closely monitors him for symptoms of alcohol withdrawal, including which of the following? Select all that apply. Elevated vital signs. Constricted pupils. Muscle aches. Nausea and vomiting. Headache. Auditory hallucinations. ADEF The correct method for measuring blood pressure includes deflating at what speed to identify the systolic pressure reading? 6-8 mmHg/second 15-20 mmHg/second 25-30 mmHg/second 2 to 3 mmHg/second D During an eye assessment of a black patient, the nurse would consider which of these an expected finding? Yellow nodules covering the cornea. Gray-blue tint to the sclera. Asymmetry of the palpebral fissures. Pale conjunctivae. B General survey reveals pallor in a client presenting with "fatigue." What should the nurse do to further assess for signs/symptoms of an iron deficiency? Ask the client if they experience dry eyes. Observe the sclera. Examine the bones and joints. Inspect the nails. D A 62 year-old female presents to the clinic with epistaxis lasting 6 hours. What is a priority question for the nurse to ask? "Do you smoke or drink alcohol?" "What have you eaten in the last 24 hours?" "Do you take any medications?" "Have you recently been on antibiotics?" C- Epistaxis (bleeding from nose) can result from trauma, forceful blowing or picking, and anticoagulant medications. A reversal agent may be needed if it is due to medication. An adult client presents with a "sore throat" that has "gotten so much worse over the past day". Upon examination, he is febrile, neck is swollen with decreased range of motion, and he is having a difficult time swallowing. These findings are most consistent with: Acute rhinitis. Oral malignancy. Viral sinusitis. Peritonsillar abscess. D During a complete HEENT and cranial nerve examination of a 65 year-old female, the nurse notices that the tonsils are halfway to the uvula, pink, and covered with crypts. What should the nurse do next? Gently touch the oropharynx with the tongue blade to test CNs IX and X. Assess for CN XII by having the client say "ahhhhh." Refer the patient to an allergy specialist. Obtain a throat culture upon suspicion of Group A Strep infection. B The assessment findings are normal, so a throat culture and referral are not needed. CN XII is assessed by having the client stick out their tongue. An elderly client presents to the clinic complaining that her mouth and eyes have become "very dry" within the past few weeks, enough so that her taste and vision have been affected. What question or statement should the nurse use next? "This dryness is normal with age. You will adapt to these changes.' "Have you started any new medications?" "Let's refer you to an ophthalmologist to check your vision." "You aren't drinking alcohol, are you?" B During an integumentary exam, the nurse notices a lesion that is suspicious of basal cell carcinoma. What data leads the nurse to this conclusion? A raised pink, scaly patch on a sun-exposed area. A nevus with color variation and irregular borders. A non healing pearly papule with a central red ulcer. A flat brown macule on the forearm. C An adolescent presents to the emergency department after getting into a fist fight at school. He has significant swelling around his eye. What other symptom leads the nurse to suspect retinal detachment? Loss of vision in one quadrant of the eye. Bilateral loss of central vision. Clear rhinorrhea and facial pain. Photosensitivity and a nonreactive pupil. A The school nurse is preparing to assess the visual acuity of an adolescent. How should the nurse proceed? Test extraocular movements and nystagmus with the penlight. Observe the ocular fundus with the ophthalmoscope. Assess for pupillary constriction and convergence. Utilize the Snellen chart positioned 20 feet from the patient. D An adult client with liver failure has deep pitting edema all over his body. Based on this finding, the nurse documents: Anasarca. Scleroderma. Jaundice. Erythema. A An emergency department nurse is examining a client newly admitted with pneumonia. The nurse depresses the client's nail beds and notes that color return takes 4 seconds. The nurse's immediate response is to: Document "Brisk capillary refill" in the client's chart. Assess for other signs of poor perfusion. Understand this to be an expected finding in clients with pneumonia. Ask another nurse to assess the cap refill. B Which assessment finding is most consistent with psoriasis? Pink/red plaques covered with silvery scales. Unilateral vesicles on the shoulder area. Fast growing pink, scaly patches on sun-exposed areas such as the face and hands. Red nonblanching intact skin on the sacrum and heels. A The nurse is examining a Black client who presents to the E.D. with nausea and vomiting. Upon examination, the client is tachycardic and tachypneic. Oxygen saturation is 98% on room air. Which assessment finding is most concerning in this patient? Yellow nodules underneath the eyelids. Thick, dark line along the gingival margin. Slight blue tint to the lips. Fruity breath odor. D A neonatal nurse is performing morning assessments. Which finding does the nurse prioritize reporting to the physician? Appearance of a blue tint to the face during feeding in a 4-hour old infant. Yellow sclera in a 2 day-old infant. Generalized red rash in a 4 day-old infant. Small white papules on the face in a 2 week-old infant. A The nurse is performing a head-to-toe assessment on a dark-skinned client presenting with "fatigue." To best assess for pallor, the nurse should check which of these areas? Conjunctivae. Sclera. Middle ear. Hair. A-Pallor will be best seen in lesser pigmented areas such as the oral mucosa and conjunctivae, which are normally pink in color. The nurse is examining a patient presenting with "severe headache." Which assessment finding leads the nurse to suspect increased intracranial pressure? Enlarged and tender occipital lymph nodes. Red, bulging tympanic membrane. Blurred margins of the optic disc. Pupils are 4mm and reactive. C A 12 year-old child presents to the clinic complaining of "ear pain". The mother accompanies the child. The nurse utilizes which technique? While inserting the otoscope, the nurse pulls the pinna up and back. The nurse examines the middle ear with the child in the prone position. The nurse percusses the mastoid process for dullness. The nurse pulls the pinna straight down and inspects the tympanic membrane with the penlight. A During a general survey of a 20 year-old patient presenting with "ear pain", the nurse observes ptosis and drooling from the left side of the mouth. The nurse suspects dysfunction of which cranial nerve (CN)? CN II. CN IV. CN VII. CN V. C The nurse is examining a 68 year-old male with a "hearing problem." The client says it started suddenly last week, is worse in the left ear, and it sounds like everyone is mumbling and whispering but it helps when they talk louder. Based on subjective data, what should the nurse do first? Assess his mood and ask how the hearing loss is affecting his life. Assume the client is developing presbycusis and refer for audiometric testing. Perform an otoscopic examination of the external and middle ear. Suspect a sensorineural loss and assess the functions of the inner ear. C During an examination of a 70 year-old client presenting with "rash", the nurse notices small grouped vesicles along the left side of the client's chest. The client says it started earlier in the week and it is "very painful." The nurse suspects: Kaposi Sarcoma. Herpes zoster. Candidiasis. Allergic drug reaction. B The nurse is assessing an adult Black client presenting to the emergency department with gastrointestinal bleeding. Interview reveals that the patient is on blood thinners. The nurse knows to observe for petechiae in which area? Genitalia. Oral mucosa. Scalp. Middle ear. B The nurse is caring for a client with a severe deficiency of thyroid hormone. Examination reveals decreased vital signs, weakness, and nonpitting edema on the face. The nurse documents: exophthalmos. anasarca. myxedema. scleroderma. C The nurse is assessing an elderly client with presbycusis. While gathering subjective data, it would be important for the nurse to: Ask how the hearing loss is impacting his daily life. Speak very loudly and slowly so the patient can hear the questions. Check for obstruction of the auditory canal as a possible cause. Assess for otitis media as a possible cause. A The nurse observes excess body hair on the upper lip and cheeks of a client with Cushing's syndrome. The nurse documents: "Hirsutism" "Anasarca" "Alopecia" "Milia" A A client presents with an acute strep throat infection. Upon examination of the lymph nodes, the nurse expects to palpate: Enlarged and tender submandibular nodes. Hard and immobile preauricular nodes. Atrophied and firm occipital nodes. No change in the lymph nodes. A During an assessment of a 4 month-old presenting with "vomiting and diarrhea", the nurse notes that the fontanels are markedly concave. Based on this assessment finding, what should the nurse do next? Palpate for pitting edema over the wrist area. Pinch skin on the abdomen and assess for recoil. Document this expected finding. Perform an ophthalmic exam to assess for papilledema. B An elderly client with chronic obstructive pulmonary disease (COPD) and lung cancer has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding as a result of these disorders? Cherry red color to the oral mucosa. Taut skin turgor. Nail base angle >180 degrees. Scleral icterus. C Which method should the nurse use to assess for accommodation? Assess peripheral vision of the client using the confrontation test. Have the client follow an object upward, downward, obliquely, and horizontally. Touch the cornea lightly with a cotton wisp. Observe for pupil constriction and convergence with near vision. D A college student is brought to the emergency department with a "severe headache". The nurse assesses for what other sign associated with meningitis? Decreased range of motion in the neck. Loss of smell. Bulging fontanels. Hypothermia. A- the acute onset of neck stiffness and pain along with headache and fever occurs with meningeal inflammation. A severe headache in an adult or child who has never had it before is a red flag. Head injury and cluster or migraine headaches are not associated with a fever or stiff neck. The nurse is caring for a client with an acute traumatic injury to their arm. Which assessment is the quickest and most reliable way to assess for the status of peripheral circulation? Press on the nail bed and count how long it takes for color to return. Check the angle of the fingernail base. Assess for unequal hair distribution on the forearms. Depress firmly over the wrist to check for pitting. Capillary refill is a quick and accurate assessment A The nurse is assessing the intravenous (IV) line site in a dark-skinned client. The nurse utilizes which technique to best assess for localized inflammation? Checking cap refill on the nailbeds. Assessing for increased vital signs. Utilize a Wood's lamp in a dimly lit room. Palpating the skin for temperature changes and swelling. D The nurse is examining a client with cataracts. What does the nurse expect to find during the examination? Blurred margins of the optic disk. Eye pain. Cloudy appearance to the lens. Gradual loss of peripheral vision. C A patient presents to urgent care with "excruciating" headache pain. The client reports the pain to be unilateral, occuring about twice a month, and the pain is accompanied by photophobia and nausea. These symptoms are most consistent with: Cluster headache. Sinus headache. Tension headache. Migraine headache. D- unilateral A mother brings her toddler in for a "runny nose" that "started suddenly this morning". The nurse notes a purulent, serosanguinous drainage coming from the right nare. The child's vital signs are within normal limits. What should the nurse do next? Refer to the provider for an antibiotic prescription. Inspect the right nare with the otoscope. Obtain a throat culture for possible strep infection. Tell the mother that this drainage is normal for a toddler. B-Children are prone to put an object up the nose, producing unilateral purulent drainage with a foul odor. Because some risk for aspiration exists, removal should be prompt. While examining the nares of an adult patient presenting with "cough and watery eyes" the nurse notices pale, swollen turbinates with clear nasal discharge. These findings are most consistent with which condition? Foreign object. Allergic rhinitis. Acute sinusitis. Epistaxis. B During an examination of a toddler presenting for a well check, the nurse performs an otoscopic examination to assess the tympanic membrane (TM). Which assessment finding is normal? TM is slightly retracted with a pearly gray color. TM appears amber-colored with absence of cerumen. TM appears light pink and slightly convex. TM is mobile and appears reddish-orange . A During a thyroid examination of a client presenting with "fatigue", the nurse observes no obvious enlargement. What should the nurse do next? Assume no abnormalities and document "no enlargement." Palpate the gland using a posterior approach. Auscultate the area for a bruit. Percuss the area for dullness. B A client presents to the clinic for a skin check. Which assessment finding is most suspicious for malignant melanoma? Tiny brown streaks on all of the nail beds. A 2 cm raised bright red papule on the chest. A 4 cm pink scaly patch on the forehead. An 8 mm asymmetrical nevus with purple coloration. D An elderly woman is brought to the hospital after her children found her confused and lying on the floor at home. Which examination finding is is most suggestive of dehydration in this client? Parched skin on the hands and legs. Sagging skin. Brittle, coarse hair. Dry mucous membranes. D The nurse is teaching a pregnant client about changes she may experience during her pregnancy, including: Hard and fixed cervical lymph nodes. Moderate vision loss. Inflammation of the gums. Tender, enlarged thyroid gland. C During a skin assessment, the nurse notes these lesions on a client's leg. The client says they are "itchy" and they appeared 2 days ago after a hike. What should the nurse document? picture looked like hives Papules. Urticaria. Vesicles. Macules. B An adult patient comes in with a 2-day history of nausea and vomiting. When assessing for dehydration, the most appropriate initial action by the nurse is to: Palpate the scalp for mobility. Check a urine sample. Assess for pitting edema over the tibia. Pinch skin on the forearm and assess for recoil. D A father brings his 10 month-old child to the clinic for a check-up. General survey reveals a yellow-orange tint to the child's face and hands. Sclera is white. What should the nurse do next? Reassure the father that this is an expected finding from eating too many Vitamin C-rich foods. Obtain a nutritional history. Document "acrocyanosis" in the client's chart. Notify the provider about your concern for jaundice. B The neonatal nurse notices that an infant's head looks enlarged compared to the previous shift. The nurse assesses for what other sign of hydrocephalus? Upward palpebral slant. Depressed fontanels. Downcast eyes. Lymph node enlargement. C The nurse is performing a physical examination on a child with strabismus and expects to assess: Ptosis. Asymmetrical corneal light reflex. Absence of a red reflex. Nystagmus B- Asymmetric corneal light reflex and an abnormal cover test are found with strabismus. Absence of red reflex is consistent with cataract. Poor peripheral vision describes glaucoma. Unequal palpebral fissures describes ptosis. The nurse is examining a patient with Hashimoto's disease. What sign or symptom is consistent with an underactive thyroid? Tremors. Diaphoresis. Tachycardia. Weight gain. D The nurse is examining a 92-year-old female during a check-up. The nurse concludes which findings to be normal age-associated changes? Select all that apply. Brown macules on the hands and arms. Vertical ridges on the nail beds. Tender vesicles on the left side of the face. Non blanching, red, intact skin over the coccyx bone. Bristly hairs on the chin and upper lip. Thin, loose skin with decreased turgor. 3mm pupils with a slightly sluggish pupillary light reflex. ABEFG The nurse is performing a full cranial nerve (CN) examination on an adult client. Which assessments will be performed? Select all that apply. To test CN I (olfactory nerve), the nurse looks inside the nose with the otoscope. To test CN XII (hypoglossal nerve), the nurse assesses the gag reflex. To test CN XI (spinal accessory nerve), the nurse assess neck strength. To test CN VIII (vestibulocochlear nerve), the nurse observes facial symmetry. To test CN V (trigeminal nerve), the nurse assesses jaw strength. To test CN II (optic nerve), the nurse assesses extraocular movements CE The nurse is examining a patient with Grave's disease. What findings are consistent with an overactive thyroid? Select All That Apply. Unintentional weight gain. Diaphoresis Exophthalmos. Swelling of the hands and face. Tremors. Decreased heart rate. BCE A nurse educator is leading a new graduate orientation class on pressure ulcers. Topics include pressure ulcer prevention and assessment. The nuse should include which of the following statements? Select all that apply. Common sites for pressure ulcers are the heels, sacrum, coccyx, and hips. Stage II pressure ulcers extend into the epidermis or dermis. Stage III pressure ulcers are deep, exposing muscle, bone, and tendon. Risk factors for pressure ulcers including impaired mobility, poor nutrition, and bowel and bladder incontinence. Stage I pressure ulcers appear as reddened areas that blanch with pressure. The best way to prevent pressure ulcers is to turn your immobile patients twice a day. ABD The nurse is assessing an adult male client presenting with "abdominal pain". Which finding is considered normal? Pulsatile, whooshing sounds heard during auscultation with the bell. Dark, tarry stools. Drumlike notes heard during percussion. Protuberant abdominal contour. C tympany? The nurse is caring for a client with cirrhosis. Which technique should the nurse use first to monitor for the early onset of ascites in this hospitalized client? Measure abdominal girth on a routine basis. Test for a fluid wave on the abdomen. Percuss for shifting dullness. Palpate deeply to assess for rebound tenderness A The nurse is assessing an adult client recovering from abdominal surgery. Which finding causes the nurse to suspect acute hypoxia in this client? barrel chest. clubbing of distal phalanx. sudden anxiety and restlessness. respiratory rate 20 breaths per minute. C An adult client on a ventilator becomes acutely restless and agitated. Which assessment finding alerts the nurse to a left pneumothorax? Increased tactile fremitus. Dullness to percussion. Unequal chest expansion. Presence of bronchial breath sounds. C-Unequal chest expansion, decreased or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest expansion, hyperresonant percussion tones, and decreased or absent breath sounds are found with the presence of pneumothorax. The neonatal nurse is completing a respiratory assessment on a sleeping newborn infant. Which finding is considered a normal variation? Presence of wheezing. Diminished breath sounds. Irregular respiratory pattern with brief periods of apnea. Nasal flaring. C The nurse is examining a client with a long history emphysema. The nurse is most likely to observe which of these? Respiratory rate 10-24 breaths/minute. Narrow costal angle. High-pitched breath sounds in the lower lobes. Enlarged anteroposterior diameter. D When assessing tactile fremitus, the nurse recalls that it is normal to feel the vibrations more intensely: Over the scapular bones. Laterally, where the skin is thinner. Over the major bronchi. Over areas of atelectasis. C A 20 year-old client presents to the clinic for "flu-like symptoms." Examination reveals a congested cough, elevated vital signs (temperature, pulse, and respirations), as well as increased fremitus and crackles in the left lower lobe. The nurse suspects: Emphysema. Asthma Exacerbation. Pneumothorax. Pneumonia. D Which statement is true regarding older adults and the respiratory system? Decreased ability to cough and a los of protective airway reflexes increases the older adult's risk for postoperative pulmonary complications. Older adults have a decreased anteroposterior diameter due to curvature of the thoracic spine. The older adult takes slower, deeper breaths compared to a middle-aged adult which increased their risk for acidosis. It may be normal to hear bronchial breath sounds throughout the lungs of an older adult due to anatomical changes within the thorax. A The nurse is examining a patient with heart failure. What data leads to the nurse to suspect a pleural effusion? Drum-like notes upon percussion. Bradypnea. Positive fluid wave test. Decreased chest expansion. D-Pleural effusions often cause decreased and/or asymmetric chest expansion and shortness of breath and tachypnea. The nurse is examining an adult client presenting with "chest pain." During auscultation of the posterior thorax, the nurse notices that when the patient whispers "1-2-3" it sounds clear and distinct to the examiner. The nurse suspects which condition? Normal, healthy lungs. Consolidation of lung tissue. Constricted airways. Lung collapse. B While examining an adult patient, the nurse notes a normal abdominal aortic pulsation. What data supports this finding? Waves of peristalsis in the upper quadrants. Easily palpable pulsation between the umbilicus and suprapubic area. Pulsatile, blowing sounds heard upon auscultation with the bell. Faint pulsation visible in the epigastric area. D The nurse is examining a hospitalized client and observes respirations that are shallow and irregular, at 10 breaths per minute. What is the most likely cause of this finding? Diabetic ketoacidosis. Pneumonia. Fever. Recent administration of opioids. D A client presents to the emergency department with asthma exacerbation. What does the nurse expect to find upon examination? Wheezing and accessory muscle use. Purulent mucus production. Tracheal shift. Presence of bronchophony. A Upon examination of a patient presenting with "abdominal pain," the nurse hears high-pitched, gurgling sounds in the right lower and upper quadrants. What should the nurse do next? Relisten to those quadrants and count the sounds to determine if they are hyperactive. Auscultate the other two quadrants. Assume bowel obstruction and notify the provider. Percuss all quadrants. B The nurse is preparing to examine the lungs of an adult client. Which statement is true regarding the normal anatomy of the thorax and lungs? Both lungs have an upper, middle, and lower lobe. Lower ribs articulate with the spine at about 45 degrees. The suprasternal notch is continuous with the 2nd rib. The left lung is shorter than the right lung. B-The sternal angle (angle of Louis), not the suprasternal notch, is continuous with the 2nd rib. The right lung is shorter than the left lung because of the underlying liver. Only the right lung has a middle lobe The nurse is performing a focused respiratory assessment of a client who is in respiratory distress two days after abdominal surgery. What is mostimportant for the nurse to assess? Percussion of anterior and posterior lung fields. Assessing both anterior and posterior chest expansion. Palpation for tactile fremitus. Auscultation of bilateral breath sounds. D An adult client presents to the emergency department with "difficulty breathing." General survey reveals anxiety, accessory muscle use, and dry cough. The nurses first action would be to: Administer 2 liters oxygen via nasal cannula. Assume asthma exacerbation and prepare a nebulizer treatment. Auscultate lung fields and obtain an oxygen saturation. Assist the client to a supine position for a full respiratory exam. C An adult client is being treated for lobar pneumonia. Which collection of signs/symptoms is most likely to be found in this patient? Hyperresonance to percussion and cyanosis. A congested cough and decreased voice sounds. Wheezing upon auscultation and decreased fremitus. Tachycardia and crackles upon auscultation. D- Lobar pneumonia (consolidation of alveolar and lung tissue) will cause increased HR, RR, and fever, increased fremitus, dullness to percussion, increased voice sounds, and crackles The nurse is examining a client with severe ascites and expects to assess: Rounded contour with loose abdominal skin. Hyperactive bowel sounds. Protuberant abdominal contour with everted umbilicus. Soft abdomen with sunken umbilicus. C The nurse is preparing to perform an abdominal exam. Which method will the nurse utilize during this exam? Utilize dim lighting to assist in relaxation. Inspect, palpate, percuss, then auscultate the quadrants. Inquire about painful areas and examine those areas last. Assist the patient to a Semi-Fowler's position with their arms above their head. C The nurse is examining an adult client 1 day after hernia surgery. Which assessment finding leads the nurse to suspect atelectasis in this client? Splinting of the abdomen during coughing. Slight pallor to the conjunctivae. Hyperresonance upon percussion. Decreased breath sounds in lung bases. D- Atelectasis is collapse of alveoli. Common assessment findings include hypoxia, decreased or absent breath sounds, and there may also be dullness to percussion The nurse is caring for a patient after thoracic surgery to remove a part of the lung. The nurse documents "subcutaneous emphysema" after assessing which of these? Booming sounds upon percussion. A palpable vibration with voice sounds. An audible grating sound with breathing. A coarse, crackling sensation palpable over the skin surface. D- Crepitus that is palpable over the skin surface is consistent with subcutaneous emphysema. After auscultating a client's lungs, the nurse documents "fine crackles in lower lobes." What assessment finding led the nurse to this conclusion? Continuous, High-pitched squeaking sounds heard upon expiration. Low-pitched, bubbling sounds that diminish with coughing. High-pitched, crowing sound heard over the trachea. Discontinuous, high-pitched, popping sounds heard at the end of inspiration. D- Fine crackles are discontinuous, high-pitched, popping sounds heard upon inspiration. These are the result of fluid-filled alveoli. The nurse is preparing to auscultate the lung sounds of an adult client. It is important for the nurse to implement which of the following techniques? Auscultate lung fields on the left then move to auscultate the right lung fields. Ask the client to breathe in and out quickly through the nose. Auscultate posteriorly from the apices at C7 down to the bases at T6. Clean the diaphragm endpiece of the stethoscope and hold it firmly on the chest wall. D The nurse is examining the abdomen of a 1 day-old infant. Which of the following is not an expected finding? Marked peristalsis. Abdominal movement with breathing. Sticky, greenish-black stool. Slight bulge along the midline visible during crying. A During the examination of a client presenting with "abdominal pain", the nurse identifies a positive Blumberg sign. What should the nurse do next? Tell the patient to refrain from eating or drinking at this time and notify the provider. Suspect ascites and test for a fluid wave. Educate the patient about the importance of following a low-fat diet. Percuss for organomegaly. A A patient with a history of diabetes and recurrent urinary tract infections presents to their primary care provider with "abdominal pain." After bringing the patient to the examination room, what should the nurse do first? Strain the urine for debris. Perform a full pain assessment. Assess for rebound tenderness. Percuss for costovertebral tenderness. B A mother brings her 4 year-old daughter in for a "cough" that came on suddenly during the night. Which piece of data leads the nurse to suspect croup? Equal anteroposterior and transverse diameters. Temperature 99.1 degrees Fahrenheit. Audible high-pitched inspiratory crowing sound. Bronchovesicular breath sounds. C The nurse is performing a head-to-toe assessment on a pregnant female, and knows to expect which finding upon examination of the thorax and lungs? Fine crackles in the lungs. Deeper respirations. Respiratory rate 30-40 breaths/min. Wheezing with exertion. B An adult is brought to the emergency department after being found on the floor at home. The patient's respirations are fast and deep with a rate of 40 respirations per minute. What is the most likely cause of this finding? Narcotic use. Atelectasis. Inflammation of the pleura. Metabolic acidosis. D- Hyperventilation is characterized by an increase in both rate and depth, and it can be caused by extreme exertion, anxiety, or alterations that cause metabolic acidosis including salicylate OD or DKA. When performing deep palpation in the right upper quadrant of a client with abdominal pain, the nurse asks the client to take a deep breath. The patient grimaces and suddenly stops inhaling. The nurse suspects: Appendicitis Hepatomegaly. Bowel obstruction Cholecystitis D- In a person with inflammation of the gallbladder, or cholecystitis, pain occurs as the descending liver pushes the inflamed gallbladder onto the examining hand during inspiration (Murphy test) The nurse is caring for a post-operative patient who has not urinated in 6 hours. How should the nurse first assess for urinary retention? Test for shifting dullness over the abdomen. Perform a straight cath. Percuss and palpate the suprapubic area. Auscultate for rushing sounds near the groin. C A patient presents to the clinic complaining of "epigastric pain for one week". History of Present Illness reveals that the pain is "gnawing" and "worse in the middle of the night." The nurse suspects: Diverticulitis. Peptic Ulcer Disease. Appendicitis. Cholecystitis. B The nurse is examining a client with shortness of breath. What should the nurse inspect when assessing for evidence of long-standing hypoxemia? Respiratory pattern. Fingernails. Skin color. Posture. B The nurse is reassessing an adolescent client who is scheduled for an appendectomy in 4 hours. Which assessment finding alerts the nurse to immediately notify the provider? Reports of abdominal pain 4/10. Small amount of emesis containing bile. Sudden onset of abdominal rigidity. Presence of hypoactive bowel sounds. C A mother brings her 3 month-old infant to the clinic for "cold symptoms." When performing the physical assessment, the nurse notes that the child has nasal flaring and subscostal retractions. The nurse's next action should be to: Reassure the mother that these are normal symptoms of a cold. Apply a pulse oximeter and contact the provider. Conduct the rest of the head-to-toe examination. Percuss the lungs fields. B While caring for a client after hip replacement surgery, the nurse notices that a patient has had a black, tarry stool. The nurse suspects: Decreased fat absorption. Use of iron supplements. Gastrointestinal bleeding. Localized rectal bleeding. B The nurse is performing an abdominal examination on an adult client. Which finding should be reported to the provider? Vascular sounds heard with the bell. Rounded abdominal contour. Concave, midline umbilicus. High-pitched bowel sounds heard every few seconds. A During a full pain assessment, a client points to the area between the costal margins. The nurse documents this location as: Umbilical. Hepatic. Suprapubic. Epigastric. D The nurse is caring for a client admitted for heart failure exacerbation. Which assessment finding alerts the nurse to the presence of pulmonary edema? Abdominal distention. Pink, frothy sputum. Chest pain. Taut skin. B The nurse is examining a client with "flu-like symptoms." While auscultating the breath sounds, the nurse hears a low-pitched, grating sound upon inspiration and expiration. The nurse suspects: Atelectasis. Asthma exacerbation. Collapsed lung. Inflammation of the pleura. D- pleuritis Upon auscultation of the posterior thorax in a client with emphysema, the nurse hears a continuous, high-pitched, squeaking sound upon expiration at the 7th-10th intercostal spaces (ICS) bilaterally. The nurse documents: "Stridor observed." "Fine rales auscultated in 7th-10th ICS, posterior bilateral." "Wheezing noted in bilateral lower lobes." "Rhonchi in bilateral lungs." High-pitched squeaking sounds C- High-pitched squeaking sounds are consistent with air being squeezed or compressed through narrowed passageways, from acute asthma or chronic emphysema The nurse is examining an adult patient. During auscultation of the posterior thorax, the nurse notes clear, soft, low pitched breath sounds. Inspiration is louder than expiration. What is the correct interpretation of this finding? These are vesicular breath sounds, which are normal in that location. These are bronchial breath sounds, which are abnormal in that location. These are bronchovesicular breath sounds, which are normal in that location. These are diminished breath sounds, which are consistent with emphysema. A All of these statements about the sternal angle are true, except: It is the articulation of the manubrium and body of the sternum. It marks the site of tracheal bifurcation into the right and left bronchi. It is continuous with the second rib. It should be 90 degrees. D A nurse educator is teaching new graduate nurses about pneumonia, including signs/symptoms, prevention, and treatment. What should the nurse educator include in the teaching? Flu vaccination will not help to reduce one's risk of developing pneumonia Cough and chest pain are common symptoms of pneumonia. Decreased fremitus and hyperresonance upon percussion will be present. Antibiotics are used to treat all types of pneumonia. B The nurse is preparing to examine an older adult client with abdominal pain. Which statement is true? Constipation and development of hard, lumpy stools are normal and physiologic changes in the gastrointestinal system. The older adults abdomen may normally have a distended, protuberant appearance due to increased fat deposits. Because musculature is thinner in the older adult, abdominal rigidity with acute abdominal conditions is less common in aging. Absent bowel sounds are common due to decreased appetite with aging. C-Constipation, hard stools. absent bowel sounds, and abdominal distention are not normal age-associated changes. The nurse suspects intraabdominal fluid collection in a patient presenting with heart failure exacerbation. Which of these procedures are appropriate for the nurse to use when assessing for ascites? Select all that apply. Assess for rebound tenderness on the left side of the abdomen. Ask the supine client to flex the right hip against resistance. Measure abdominal girth on a daily basis. Percuss for costovertebral angle tenderness. Percuss the abdomen for shifting dullness. Test for a fluid wave across the abdomen cef Which of the following conditions may result in the nurse auscultating hypoactive bowel sounds? Select All That Apply. Gastroenteritis Peritonitis Opioid use. Post-abdominal surgery Late bowel obstruction Laxative use cdef The nurse is preparing to auscultate the lungs of an adult during an annual check-up. Which techniques are correct? Select All That Apply. Auscultating anteriorly from the subclavicular area down to the 9th rib. Auscultating while the client is sitting up on the exam table. Skipping any areas with overlying chest hair. Auscultating in a side-to-side pattern, from the apices down to the bases. Instructing the patient to take deep breaths through the mouth. Pressing the bell firmly over the thorax. bde After assessing muscle strength in an older adult client who had an ischemic stroke six months prior, the nurse documents the following findings: Left leg 2/5Right leg 5/5Left arm 2/5Right arm 5/5What does the nurse expect to find when testing his reflexes on the left side? Hyperactive reflexes Normal reflexes Lack of reflexes Diminished reflexes A hyperactive on effected side A patient has been diagnosed with venous insufficiency in the right leg. Which of these findings would the nurse most likely observe in the affected leg? Brownish discoloration. Cyanosis of the nail beds. Absent pulses. Leg pain with walking. A During an assessment of a client presenting with "fatigue", the nurse notes that the patient's apical impulse is easily palpable over the 5th and 6th intercostal spaces at the anterior axillary line. This finding most likely indicates: Cardiac atrophy. Dehydration. Ventricular dilation. A normal functioning heart. C While assessing a newborn infant, the nurse notes fanning of the toes when the nurse strokes the lateral edge and across the ball of the foot. The nurse understands this to be: A positive Babinski, which is an expected finding. A sign of central nervous system damage. A positive Moro reflex, which is normal in a newborn. A negative plantar reflex, which is an abnormal finding. A The nurse suspects arterial insufficiency in an older adult client presenting with "left leg pain." Which assessment finding best supports this hypothesis? Dorsalis pedis pulses are 2+ and popliteal pulses are 1+ bilaterally. Ankle-brachial index of 1.20. Pallor in the right leg when it is elevated off the table. 3+ pitting edema in the right leg. C-S/S of PAD include elevational pallor, delayed venous filling >15 sec While performing a head-to-toe assessment on a hospitalized client, the nurse notes the capillary refill time on the fingers is 4 seconds. What should the nurse do next? Consider this a normal capillary refill time that requires no further assessment. Assess for additional signs of poor perfusion. Use the profile sign to detect early clubbing. Suspect that the patient has a deep vein thrombosis. B In the assessment of a 7 month-old, the mother reports that in the last week he has been sleeping all of the time, and is extremely fussy when he is awake. Which assessment finding alerts the nurse to potential neurological damage? Presence of the Moro reflex. Babinski sign. Absence of the palmar grasp. Absence of the rooting reflex. A During a health assessment, the client reports being treated for osteoarthritis. Which finding alerts the nurse to the presence of Bouchard's nodes? Proximal interphalangeal joint nodules. Proximal intertarsal joint swelling of big toe. Frozen, non-movable phalangeal joints. Nontender enlargement of the distal interphalangeal joints. A While performing a head-to-toe assessment on a client with diabetes, the nurse is unable to palpate the client's pedal pulses. What should the nurse do next? Palpate pulse points with legs dependent. Use a doppler to check blood flow. Notify the healthcare provider. Apply a heating pad to both feet to stimulate blood flow. B The nurse is testing the deep tendon reflexes (DTRs) of an adult client who is in the clinic for an annual physical examination. When striking the achilles tendon, the nurse is unable to elicit a reflex. The nurse's next response should be to: Ask the patient to lock their fingers and pull. Refer the patient to a specialist for further testing. Document these reflexes as 0 on a scale of 0 to 4+. A Which collection of signs/symptoms is most consistent with acute coronary syndrome (ACS)? Radiating chest discomfort that fully subsides with rest. Epigastric pain exacerbated by food. Heavy, aching chest pain with dizziness and pallor. Palpitations and sharp chest pain with deep breaths. C-unstable agina The nurse is assessing a newborn baby that was born breech. What should the nurse do to assess for congenital hip dysplasia? With knees flexed, adduct and abduct the legs and assess for clicking or pain. Assess for weakness with the stepping reflex. Assess leg strength bilaterally against resistance. Elicit the tonic neck reflex and assess for asymmetry A A young adult presents to the clinic complaining of "dizziness." The client describes it as "the room is spinning." Based on the subjective data, what does the nurse expect to assess during the neurological examination? Abnormal word recall test. Absence of a pain sensation. Hemiparesis. Positive Romberg test. D The nurse is completing a neurological examination on an elderly client. Which finding is expected? Smaller pupils with absent light reflex. Hyperactive deep tendon reflexes. Asymmetric tracking of the eyes. Slower, more deliberate gait, with a wider stance. D A post-mastectomy patients presents to the clinic complaining that her right arm is "aching and stiff." The nurse suspects lymphedema with which assessment finding? Tricolor change in response to cold temperatures. Hard, lumpy swelling of the right arm. Severe pitting edema in both upper extremities. Atrophy and pallor of the right arm. B During an examination of an adult with rheumatoid arthritis, the nurse hears a whooshing sound with the stethoscope's bell over the left carotid artery. What does the nurse understand to be true? Auscultation of the carotids should reveal complete and total silence. This client may be at an increased risk of ischemic stroke. This is an expected finding in older adults. Carotid pressure should be estimated next in the examination. B The nurse is performing a neurological assessment on a 7 year-old. What would the nurse include in the cranial nerve portion of the examination? "I'm going to use my finger to tap on your arm." "Close your eyes and tell me if I am tapping your arm or leg." "I'm going to make some silly faces and I want you to copy me." "Hop up and down on one foot." C When assessing cerebellar function on an adult client, the nurse should ask the client to: "Stare straight ahead while I shine this penlight in your eye'." "Resist my attempt to move your left arm." "Close your eyes and tell me what number I draw on your hand." "Alternate touching your nose and my finger." D During the monofilament test on an adult client presenting with "foot pain", the patient is able to feel 4 out of 10 tested points. Given this information, what would the nurse suspect? Peripheral neuropathy. Cerebellar dysfunction. Expected finding for age. Frontal lobe lesion. A An older adult client with diabetes states that he recently began to have pain in his left calf when going for his evening walk. This pain is relieved by resting in a chair for a few minutes. The nurse interprets that this patient is most likely experiencing: Claudication caused by blockage of an artery supplying the left calf. Musculoskeletal symptoms related to age and decreased activity tolerance. Neuropathy related to his diabetes. Ischemia related to a venous obstruction. A An adult client is recovering from a myocardial infarction and complaining of "sharp chest pain." Upon examination, the nurse hears a high-pitched, scratchy sound during S1 and S2 at the apex. The nurse suspects: Ventricular atrophy resulting from muscle damage. Increased cardiac output. Systolic and diastolic regurgitation. Inflammation of the pericardial membranes. D During a neurological assessment of a client who has had a stroke, the nurse simultaneously places two pin points on the client's skin. The patient is able to feel only one point at 16mm on the right index finger and 85mm on the upper arms. The nurse understands this to be: A normal response in the middle-aged adult. An abnormal response as a result of a sensory cortex lesion. Suspicious of a cerebellar lesion; the RN should assess their gait. Consistent with occitibal lobe damage. B The nurse is examining an adolescent client. Using the diaphragm, the nurse hears an intermittent extra early diastolic sound at the second interspace, left sternal border. The nurse knows this is a: Split S2. Tricuspid murmur. Carotid bruit. Physiologic S3. A The nurse is examining a school-aged child. Using the bell of the stethoscope, the nurse hears a midsystolic, soft, blowing, whooshing sound at the left middle sternal border. The nurse understand this to be mostconsistent with a: S3 gallop. Systolic murmur S4 gallop. Diastolic murmur B-Systolic murmurs occur with between S1 and S2. The nurse is performing a complete examination on an older adult client. Which of the following is a normal age-associated change? Pain with hip adduction and abduction. Decline in blood pressure due to decreased cardiac output. Resting heart rate decreases over time. Stiffening of arterial walls resulting in a wider pulse pressure. D A patient with peripheral arterial disease and associated paresthesia is most likely to report which of the following during the health history: "Wearing my compression socks at work helps a lot." "It feels much better when I walk or elevate my legs." "I often have a pins and needles feeling in my foot." "My legs are so swollen and heavy at the end of the day." C During assessment with the Glasgow Coma Scale, the nurse depresses the client's sternum and notices extension of the upper extremities and plantar flexion of the feet. The nurse documents this finding as: Withdraws from painful stimulus. Motor response 3/5. Decerebrate posturing. Decorticate posturing. C The home health nurse is performing a cardiovascular assessment. While auscultating the apical pulse and palpating the radial pulse at the same time, the nurse records the apical pulse as 60 bpm and the radial pulse as 68 bpm. What should the nurse do next? Use a doppler device to confirm flow at the apical site. Recheck the pulse rates at the apical and radial sites. Document the pulse deficit as 8 bpm. Document the pulse deficit as -8 bpm. B- It is not possible for the apical to be slower than the radial pulse. The nurse should recheck. During a routine head-to-toe examination of an adult, the nurse is unable to palpate the ulnar pulses. Cap refill is 2 seconds. What should the nurse do next? Refer the individual for further evaluation. Continue with the examination. Obtain a doppler to confirm ulnar flow. Perform a modified allen test to check patency. B The nurse is gathering a health history. Which of the following is a risk factor for peripheral vascular disease? Consumption of 1 alcoholic drink per day. Occupation requires a lot of walking. High level of high-density lipoprotein (HDL) cholesterol. Body mass index of 36 kg/m2 D During the health history of an older adult client, the client's significant other states "he is always confused and never listens to me!" During the neurological examination, the nurse should: Assess his mental status and ability to follow directions before testing cerebellar function and sensation. Proceed with the complete neurological exam, knowing that mental status does not affect his ability to participate. Defer the exam due to his altered level of consciousness. Limit him to a brief screening exam due to the patient's altered mental status. A The nurse is examining an adult client presenting with "headache". Which assessment finding indicates limited cervical spine range of motion (ROM)? Left lateral bending 45 degrees. Right rotation 75 degrees. Forward flexion 20 degrees. Extension 60 degrees. C Which of the following is an expected musculoskeletal change during the last trimester of pregnancy? Decreasing estrogen causes the ligaments in the body to shorten which cause joint pain and inflammation. Relaxation of the pelvic muscles may cause a kyphotic stance. The lower back curves inward, which puts strain on the low back muscles. Excess fluid puts pressure on the upper extremity nerves which may cause ascending weakness. C While assessing a 3 month-old infant, the nurse offers his finger to the baby's palm and the baby tightly grasps. What does the nurse know about this response? Persistence of this Moro reflex can indicate neurological damage. This is consistent with occipital lobe damage. This response is expected at this age. This reflex should have disappeared shortly after birth. C The nurse is performing a functional assessment on an elderly male with limited range of motion (ROM) in the knee. Which assessment finding is consistent with this data? Quadriceps strength is 4/5 bilaterally. The patient has a deliberate gait with a wider stance. Absence of bulge sign. Client displays a limping gait. D The nurse suspects a patient has different true leg lengths. To confirm this suspicion, what should the nurse do next? Measure each leg from the anterior iliac spine to the medial malleolus. Perform the Bulge or Ballottement tests. Ask the patient to walk across the room. Measure bilaterally from the umbilicus to the medial malleolus. A bilateral edema in the legs. Based on these findings, what should the nurse do next? Assume chronic venous insufficiency and notify the provider. Observe the neck veins for distention. Suspect coronary artery disease as the cause for these symptoms. Obtain ankle-brachial index (ABI) bilaterally. B A pregnant female in her third trimester is in the clinic for "leg pain and swelling." How should the nurse assess for deep vein thrombophlebitis (DVT)? Observe for atrophy of the lower leg muscles. Assess for elevational pallor bilaterally. Assess for increased pain with dorsiflexion of the foot. Check ankle-brachial index (ABI) on the affected leg. C The nurse is preparing to assess a client with chronic venous insufficiency. Upon examination of the affected leg, the nurse should expect which findings? Select all that apply. Coldness to palpation. Ankle-brachial index less than 0.90 Edema. Absent pedal pulses. Irregularly shaped, weeping ulcer. "Aching" leg pain is relieved with elevation. CEF Which of the following signs is most likely to be seen with severe peripheral arterial disease? Dependent rubor. Multiple varicose veins. 4+ pitting edema. Ankle-brachial index of 0.98. A-Dependent rubor is consistent with severe PAD. Chronic hypoxia produces loss of vasomotor tone and pooling of blood in the veins. During an examination of an adult male presenting with "lower back pain", how should the nurse assess for herniated intervertebral disc? Observe for an outward curvature of the thoracic spine. Ask the patient to flex the left and right hip against resistance. Assess for hyperreflexia in the upper extermities. Assess for pain while the nurse raises each leg off the table. D- Lateral tilting and sciatic pain with passive straight leg raising (Lasegue test) are findings that occur with a herniated nucleus pulposus. The nurse is performing a neurological recheck on an adult client who sustained a head injury. Which of the following signs/symptoms alerts the nurse to increasing intracranial pressure? Select all that apply. Glasgow Coma Scale score of "0". Nonreactive pupil. Intact plantar reflex. Systolic hypertension. Stereognosis. Drowsiness. BDF To assess for rotator cuff injury, what should the nurse do? Check for a positive bulge sign. Evaluate muscle tone bilaterally. Assess arm span with a tape measure. Assess the patient's ability to abduct the arm. D The nurse auscultates a loud murmur just after S2 over the pulmonic valve area. A slight thrill is palpated over the area. The nurse documents: Grade 6/6 systolic murmur present at left midclavicular line. Grade 5/6 systolic murmur present at left upper sternal border. Grade 4/6 diastolic murmur present at 2nd left intercostal space. Grade 5/6 diastolic murmur present at 4th left intercostal space. C What should the nurse include in the examination of a newborn infant born 2 hours earlier? Auscultate for soft, systolic murmurs, which strongly suggest cardiac pathology. Assess for overall cyanosis, which may signal congenital heart disease. Obtain the heart rate, which should fall within 80-160 beats per minute. Obtain the apical heart rate at the 6th intercostal space left sternal border. B- Overall cyanosis, not acryocyanosis, signals congenital heart disease. During the health history interview, an adult client with hyperlipidemia reveals that he sometimes feels "pressure" in his chest during strenuous activity, but it subsides after resting for about 5-10 minutes. The nurse suspects: Normal age-related chest pain. Peripheral arterial disease. Coronary artery disease. Transient ischemic attack. C When assessing a 68 year-old patient presenting with "left leg pain", the nurse notes that the left femoral pulse is weak. What should the nurse do next? Document the finding as normal in older adults. Auscultate the site to identify partial occlusion. Ask the client to stand and palpate again. Palpate for enlarged lymph nodes in the area. B The nurse is assessing a client with suspected peripheral arterial disease (PAD). Which assessment finding supports this hypothesis? The circumference of the left leg is 1cm larger than the right leg. The blood pressure at the ankle is significantly lower than in the arm. 3+ pedal pulses. The client has dependent edema. B An elderly patient has just been admitted to the intensive care unit (ICU) with acute decompensated heart failure. Based on this diagnosis, what does the nurse expect to assess in this client? Select All That Apply. Unilateral edema in the legs. Flat neck veins. S3 gallop. Cool, clammy skin. SpO2 96-99 on Room Air%. Bradypnea. Crackles upon auscultation of lung fields. CDFG- Manifestations of ADHF are a result of fluid volume overload and decreased cardiac output. The pt will be hypoxic and dyspneic due to pulmonary edema (crackles in lungs), and therefore the patient will be tachpyneic. blood pressure will be low and a pulse deficit will be present due to low stroke volume. The skin will be cool and clammy The nurse is examining a client with systolic dysfunction. Using the bell, the nurse hears an extra early diastolic sound at the apex of the heart. The nurse interprets this sound as: Split S1. S3 gallop. Split S2. S4 gallop. B B. Denial The spouse is exhibiting the first stage of denial (B) of Kubler-Ross's grief model by ignoring that the client's death is imminent (A, C, and D) are stages of grief that are not being displayed by the client's spouse during this observation. The registered nurse (RN) notifies the spouse of a client who was admitted to hospice with shallow respirations, of a change in the client's condition. Over the past hour, the client's respiratory pattern has changed to a Cheyne Stokes pattern. After receiving this information, the client's spouse begins vacuuming around the bed. Which stage of grief is the spouse displaying during the visit? A. Acceptance B. Denial C. Bargaining D. Depression A. Cold applications produce a topical anesthetic effect to reduce pain as well as constrict blood vessels to minimize bruising (A). Local ice over an injured area will not lower the core temperature (B). The cold pack causes vasoconstriction which reduces circulation, not (C), to traumatized tissue and limits further edema around the injury (D), but not by reabsorption of edematous fluid. The registered nurse (RN) places an ice pack on a middle school student who comes to the school clinic complaining of a sprained ankle. Which therapeutic response should the RN anticipate? A. Reduced pain and minimized bruising. B. Lowering of body core temperature. C. Increased circulation around injury. D. Reabsorption of edema at injury. A. Diminished hair on legs C. Skin cool to touch. Diminished hair on the legs (A) and skin that is cool to the touch (C) are symptoms of decreased arterial blood flow. (B, D, and E) are not indicators for impaired circulation. The registered nurse (RN) palpates a weak pedal pulse on the client'rs right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation (Select all that apply.) A. Diminished hair on legs. B. Bruising on extremities. C. Skin cool to touch. D. Capillary refill less than 3 seconds. E. Darkened skin on extremities. C. Lethargy Changes in the level of consciousness occur in the early stages of shock which decreases the perfusion to the brain which is manifested as lethargy (C). The respiratory rate increases, not (D). (A and B) are late signs of hypovolemic shock due to cardiac compensatory measures. Twenty four hours after a client returns from surgical gastric bypass, the registered nurse (RN) observes large amounts of blood in the nasogastric tube (NGT) cannister. Which assessment finding should the RN report as early signs of hypovolemic shock? A. Faint pedal pulses B. Decrease in blood pressure. C. Lethargy. D. Slow breathing. D. Rise slowly when getting out of bed or chair. The client's new medication is an angiotensin-converting enzyme (ACE) inhibitor, which has the side effect of orthostatic hypotension. Instructing the client to rise from a chair or bed slowly (D) is indicated to avoid dizziness and falling. (A, B, and C) are not indicated when taking an ACE inhibitor. The registered nurse (RN) is caring for a client who has taken atenolol for 2 years. The healthcare provider recently changed the medication to enalapril to manage the client's blood pressure. Which instruction should the RN provide the client regarding the new medication? A. Take the medication at bedtime. B. Report presence of increased bruising. C. Check pulse before taking medication. D. Rise slowly when getting out of bed or chair. A. Prepare the client for a chest x-ray at the bedside. A chest x-ray (A) should be performed immediately after the procedure to ensure lung expansion has been maintained after removal of the chest tube. (B) provides additional data after removal of the CT. (C) may assist the client to breathe easily, but the priority after chest tube removal is to ensure that the procedure was successful. The entire system, including the chest tube is discarded and not taken apart (D). The registered nurse (RN) is assisting the healthcare provider (HCP) with the removal of a chest tube. Which intervention has the highest priority and should be anticipated by the RN after removal of the chest tube? A. Prepare the client for chest x-ray at the bedside. B. Review arterial blood gases after removal. C. Elevate the head of the bed to 45 degrees. D. Assist with disassembling the drainage system. D. A fracture that bends or splinters part of the bone. An incomplete fracture (D) occurs through part of the thickness of bone. A linear (A) and a spiral fracture (B) describe the direction of the fracture line. An open fracture (C) is a compound fracture that breaks through the skin. A male client is admitted after falling from his bed. The healthcare provider (HCP) tells the family that he has an incomplete fracture of the humerus. The family asks the nurse what this means. Which type of fracture should the RN explain from these findings? A. Straight fracture line that is also a simple, closed fracture. B. Nondisplaced fracture line that wraps around the bone. C. A complete fracture that also punctures the skin. D. A fracture that bends or splinters part of the bone. A. Hematemesis B. Gastric pain on an empty stomach D. Intolerance of spicy foods (A, B and D) correct. Manifestations of PUD include hematemesis (A), gastric pain (B), and spicy food intolerance. (C) is consistent with cholecystitis (D). (E) is not consistent with PUD. The registered nurse (RN) is caring for a client with peptic ulcer disease (PUD). What assessment should the RN identify that is consistent with PUD? (Select all that apply) A. Hematemesis B. Gastric pain on an empty stomach C. Colic-like pain with fatty food ingestion D. Intolerance of spicy foods E. Diarrhea and stearrhea D. A client who has chronic constipation (D) often strains to pass constipated stool which increases intestinal pressure that weakens the intestinal walls and causes out-pouching sacs, called diverticula which commonly occur in the signmoid. Regular use of laxatives (A) can result in the bowel's dependency on the laxative to stimulate intestinal motility, but constipation due to lack of fiver in diet, not (C), is a predisposing factor for formation of diverticula. Growths that protrude into the colon lumen are polyps (B), which are often pre-cancerous lesions. A client is newly diagnosed with diverticulosis. The registered nurse (RN) is assessing the client's basic knowledge about the disease process. Which statement by the client conveys the client's understanding of the etiology of diverticula? A. Over use of laxatives for bowel regularity result in loss of peristaltic tone. B. Inflammation of the colon mucosa that cause growths that protrude into the lumen. C. Diverticulosis is the result of high fiber diet and sedentary life style. D. Chronic constipation causes weakening of colon wall which result in out-pouching sacs. C. In some Asian cultures, it is not appropriate to look a person of authority in the eyes, so the client is being respectful bu looking down while speaking with the nurse (C). (A, B, and D) does not reflect behaviors common to Asian culture. The registered nurse (RN) is caring for an Asian client who refuses to make eye contact during conversations. How should the RN assess this client's response? A. The client cannot understand the nurse. B. The client is uncomfortable with the nurse. C. The client is treating the nurse with respect. D. The client is purposefully disrespecting the nurse. A. A decrease in urine output is a sign of dehydration. When the urine output returns to a normal range, 40 ml/hour (A), the client's kidneys are perfusing adequately and indicates the client's status is stabilizing. A blood pressure of 76/42 (B) and tented skin (D) are consistent with dehydration and possible hypovolemia, however the client's urine output is improving. Specific gravity of 1.001 is indicative of the kidney's ability to concentrate urine adequately. The registered nurse (RN) is caring for a client who developed oliguria and was diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding indicates to the RN that the client is stabilizing? A. Urine output of 40 ml/hour B. Apical pulse 100 and blood pressure 76/42. C. Urine specific gravity of 1.001. D. Tented skin on the dorsal surface of the hands. B Orthostatic hypotension (B) can be a sign of fluid volume deficit in an older adult client who has experienced severe diarrhea. (A and C) are signs of excess fluid volume. Cheyne Stocks respirations (D) is an abnormal breathing pattern often seen in a client who is near death. An older client is admitted to the hospital with severe diarrhea. The registered nurse (RN) is completing an assessment and notes the client has dry mucous membranes and poor skin turgor. Which assessment data should the RN gather to determine if the client has fluid volume deficit? A Combination therapy is necessary to decrease the development of resistant strains of TB (A) and ensure treatment effectiveness. (B, C, and D) are not the rationales for multiple drug protocol for TB. The registered nurse (RN) is caring for a client with tuberculosis (TB) who is taking a combination drug regimen. The client complains about taking "so many pills." What information should the RN provide to the client about the prescribed treatment? A. The development of resistant strains of TB are decreased with a combination of drugs. B. Compliance to the medication regimen is challenging but should be maintained. C. Side effects are minimized with the use of a single medication but is less effective. D. The treatment time is decreased from 6 months to 3 months with this standard regimen. A The two hour postprandial level should be less than 140 mg/dl for a young adult client (B). (A, C and D) are elevated and not normal at 2 hours after ingesting the glucose solution. The registered nurse (RN) is caring for a young adult who is having an oral glucose tolerance test (OGTT). which laboratory result should the RN assess as a normal value for the two hour postprandial result? A. 140 mg/dl B. 160 mg/dl C. 180 mg/dl D. 200 mg/dl C Vital signs should be checked every 10 to 20 minutes (C) to assess for bleeding after biopsy of the liver, which is highly vascular. The client should be positioned on the right side, not the left (A), with a pillow or sandbag under the costal margin and supporting the biopsy site. Voiding immediately after the procedure (B) is not the highest priority intervention after a liver biopsy. The client should be maintained on bedrest (D) for several hours to decrease the risk of bleeding from the biopsy site. After a liver biopsy is performed at the bedside, the registered nurse (RN) is assigned the care of the client. Which nursing intervention is most important for the RN to implement? A. Position the client on the left side with pillow placed under the costal margin. B. Assist the client with voiding immediately after the procedure. C. Evaluate teh vital signs q10 to 20 minutes for every 2 hours after the procedure. D. Ambulate client 3 times in first hour with pillow held at abdomen. B Closed angle glaucoma C Chronic hypertension (B and C) are correct. OTC decongestants can increase intraocular pressure and should be avoided in clients with closed angle glaucoma (B). Decongestants can increase the heart rate and blood pressure which impact the client's management of chronic hypertension (C). Although the healthcare provider should be informed of all medications taken, (A, D, and E) are not directly affected by a decongestant. While reviewing the client's electronic medical record (EMR), the registered nurse (RN) assesses a client who is at risk for possible interaction with an over-the-counter (OTC) decongestant. Which client health history should the RN report to the healthcare provider concerning the OTC medication? (Select all that apply) A. Type I diabetes mellitus (DM) B. Closed angle glaucoma C. Chronic hypertension D. Rheumatoid arthritis E. Crohn's disease B RLQ rebound abdominal tenderness (B) may be related to acute appendicitis and should be reported to the healthcare provider. (A, C and D) are expected findings associated with gastroenteritis that are not urgent findings or life threatening. The registered nurse (RN) is evaluating a client who presents with symptoms of gastroenteritis. Which assessment finding should the RN report to the healthcare provider? A. Dry mucous membranes and lips. B. Rebound abdominal tenderness over right lower quadrant. C. Dizziness when client ambulates from a sitting position. D. Poor skin turgor over client's risk. A. All alcohol (A) and any foods that contain tyramine should be avoided while taking an MAO inhibitor, which interact to cause a hypertensive crisis. (B and C) should be discussed, but are not as important as (A). Although assessing blood pressure and pulse may be indicated, it is not necessary prior to taking each dose (D). The registered nurse (RN) reviews the new prescription, phelezine, a monoamine oxidase inhibitor (MAOI), for a client on the psychiatric unit with depression. Which information is most important for the RN to assess? A. Consumption of any alcohol or tyramine-rich foods. B. Complaints of nausea or vomiting. C. Therapeutic serum drug levels. D. Blood pressure and pulse prior to taking each dose. B When completing an assessment, the RN should maintain eye cotnact with the client (B) to gather additional information from the client's nonverbal cues. (A, C, and D) do not use both verbal and nonverbal communication techniques to gather data during an assessment. Which actions should the registered nurse (RN) implement to complete an assessment for a client using an interpreter? A. Ask close-ended questions with assistance of the interpreter. B. Maintain eye contact with the client while listening to the translation. C. Instruct interpreter to answer questions from the interpreter's point of view. D. Protect the client's privacy by asking a limited number of questions. A A chronic seasonal cough related to bronchitis is likely accompanied with phlegm production and wheezing (A). Although smoking can contribute to chronic cough, the typical seasonal cough is an inflammatory reaction to seasonal changes (B). Hemoptysis (C) or a "new" cough or changes in a persistent chronic cough is likely related to lung cancer (C). Night sweats (D) is a trend in fever that is often seen with tuberculosis. The registered nurse (RN) is interviewing a female client who states she has a persistent cough during the winter caused by bronchitis. Which additional finding should the RN assess for bronchitis? A. Phlegm production and wheezing. B. Smoking history C. Hemoptysis D. Night sweats A, B, C, E (A, B, C, and E) are correct. To ensure compliance, language (A), education (B), lifestyle (C), and financial resources (E) should be considered when preparing the client's discharge instructions about continued treatment of TB. (D) does not directly impact compliance with long term treatment of TB. The registered nurse (RN) is teaching a client who is being discharged after treatment of tuberculosis (TB). Which cultural issues should the RN assess when preparing the client for discharge? (Select all that apply.) a. native language b. education level c. type of lifestyle d. previous medical history e. financial resources A Checking the pH of the aspirate (A) is the best method to validate that the NGT is not displaced and should reveal an acidic pH of 1.5 to 3.5 due to presence of gastric acid. (B, C and D) are not reliable methods to ensure NGT placement in the stomach. The registered nurse (RN) is caring for a client with a newly placed nasogastric tube (NGT). Once the placement of the NG tube is verified by x-ray, which technique should the RN use as a reliable method to ensure the NGT is not displaced? a. check the pH of aspirated stomach contents obtained from the NGT b. auscultate over the epigastrium while injecting air into the NGT c. disconnect and place the end of NGT in water to see if bubbles appear d. listen for hyperactive bowel sounds in all four quadrants in the abdomen A, C, E (A, C, and E) are correct, and these interventions aid the client in maneuvering through the stages of grieving and establishing a foundation to continue life. Assisting the client in finding the support group and sharing stories of other clients can be miscontrued as a violation of HIPPA rights of other clients (B). Each client deals with grief differently, so offering a time line for grieving (D) is not an expected outcome for this client and offers false reassurance. A client is admitted for dehydration, weight loss, and a flat affect. After reviewing the client's history, the registered nurse (RN) discovers that the client's spouse died 2 weeks ago. Which nursing interventions should the RN implement to help the client begin the process of dealing with loss? a. Establish trust by creating a safe atmosphere for sharing. b. Share personal stories about how other clients dealt with grief. c. Help the client identify ways to adapt lifestyle to accommodate loss. d. Assure the client that their grief will last a short period of time. e. Explore ways to assist the client to make new emotional investments. D A characteristic finding of DI is excretion of large quantities of urine (5 to 20L/day), and most clients compensate for fluid loss by drinking large amounts of water (polydipsia) (D). (A) is indicative of an infection, not DI. (B) can be characteristic of hypovolemia, but not an initial finding of DI. Muscle rigidity (C) can be a serious manifestation of a closed head injury that requires immediate action, but is not related to DI. The registered nurse (RN) is caring for a client who has a closed head injury from a motor vehicle collision. Which finding should the RN assess the client for the risk of diabetes insipidus (DI)? a. high fever b. low blood pressure c. muscle rigidity d. polydipsia D Pursed lip breathing helps eliminate CO2 (D) by increasing positive pressure within the alveoli which makes it easier to expel air from lungs. (A, B and C) do not explain the reason for using pursed lip breathing. The registered nurse (RN) is teaching a client who is newly diagnosed with emphysema to perform pursed lip breathing. What is the primary reason for teaching the client this method of breathing? a. Decreases respiratory rate b. Increases O2 saturation throughout the body c. Conserves energy while ambulating d. Promotes CO2 elimination D The RN should ask the client if he has a history of ulcerative colitis (D), which is characterized by these presenting symptoms. Irritable bowel (A) often includes irregular bowel movements with constipation. Diverticulitis (B) is related to constipation, bowel irregularity and cramping. Crohn's disease (C) can cause constipation or diarrhea, abscess formation, and abdominal cramping, but tenesmus is rare. The registered nurse (RN) is assessing a male client who arrives at the clinic with severe abdominal cramping, pain, tenesmus, and dehydration. The RN discovers that the client has had 14 to 20 loose stools with rectal bleeding. Which condition should the RN ask the client about his medical history? a. Irritable bowel syndrome b. diverticulitis c. Crohn's disease d. ulcerative colitis C, D (C and D) are correct. Beta 2 receptor agonist agents provide immediate return of airflow and resolve wheezing (C) and improve oxygenation (D). (A and B) are side effects. (E) is not an expected response. The registered nurse (RN) is making early morning rounds on a group of clients when a client begins exhibiting symptoms of an acute asthma attack. The RN administers a PRN prescription for a Beta 2 receptor agonist agent. Which client response should the RN expect? a. tachycardia b. increased blood pressure c. rapid resolution of wheezing d. improved pulse oximetry values e. reduce fever airway inflammation A, C, E Communication techniques for clients with cognitive impairments should be simple (A), without environmental distractions (C), and direct (E). (B) increases anxiety in a client, so it is important to give the client time to answer a question before moving to the next one. (D) is the family's view of the client's mental status and does not give the RN an objective view of the client's cognitive impairment. A registered nurse (RN) is performing a mini-mental state examination (MMSE) for a client who is being admitted to an assisted living community. Which communication techniques should the RN implement to decrease anxiety in the client? (Select all that apply.) A. Use simple sentences during the examination. B. Move to another question if the client seems confused. C. Reduce environmental detractors during the examination. D. Allow family to answer for the client to decrease frustration. E. Ask questions one at a time to decrease confusion. A All alcohol (A) and any foods that contain tyramine should be avoided while taking an MAO inhibitor, which interact to cause a hypertensive crisis. (B and C) should be discussed, but are not as important as (A). Although assessing blood pressure and pulse may be indicated, it is not necessary prior to taking each dose (D). The registered nurse (RN) reviews the new prescription, phenelzine, a monoamine oxidase inhibitor (MAOI), for a client on the psychiatric unit with depression. Which information is most important for the RN to assess? A. Consumption of any alcohol or tyramine-rich foods. B. Complaints of nausea or vomiting. C. Therapeutic serum drug levels. D. Blood pressure and pulse prior to taking each dose. A Sarcoidosis, an autoimmune inflammatory disease affecting multiple organs, has shown presence in relatives due to multiple genes that together to increase the susceptibility of developing the disease, which most commonly occurs in African American women and women of Northern European heritage (A). (B, C, and D) have a lower percentage of women affected by sarcoidosis than African American women. A female client is recently diagnosed with Sarciodosis. The client tells the registered nurse (RN) that she does not understand why she has this. When teaching about the occurrence of sarcoidosis, the RN should include that sarcoidosis most commonly occurs with which ethnic group of women? A. African American women B. Caucasian women C. Asian women D. Hispanic women A Headache, nausea, blurred vision and insomnia are symptoms of excessive use of ipratropium, so withholding the medication (A) until the healthcare provider is notified should be initiated to maintain client safety. If the symptoms continue and are not addressed immediately, then (B, C, and D) may place the client in imminent danger. A client who uses ipratropium reports having nausea, blurred vision, headaches, and insomnia after using the inhaler. Which action should the registered nurse (RN) implement first? A. Withhold medication and report symptoms and vital signs to healthcare provider. B. Give PRN medication for nausea and vomiting and evaluate client in 30 minutes. C. Reassure client that the ipratropium given will alleviate the symptoms. D. Delay administration of ipratropium until next maintenance medication is scheduled. B Troponin (B) is the most sensitive and specific test for myocardial damage. Troponin elevation is more specific than CK-MB (A). (C) can be elevated when there is skeletal muscle damage. (D) can be elevated nonspecifically and create false positives, so is not a reliable choice. A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for evaluation for Acute Coronary Syndrome (ACS). Which cardiac biomarker should the registered nurse (RN) anticipate to be elevated if the client experienced myocardial damage? A. Creatine Kinase (CK-MB) B. Serum troponin C. Myoglobin D. Ischemia modified albumin D A client with a large bone fracture is at risk for intramedullary fat leaking into the blood stream and becoming embolic. Dyspnea is an indication of fat embolism to the lungs and should be reported to the healthcare provider immediately. (A, B, and C) are expected findings after a fall and do not require immediate notification of a healthcare provider. The registered nurse (RN) is caring for an older client who recently experienced a fractured pelvis from a fall. Which assessment finding is most important for the RN to report to the healthcare provider? A. Lower back pain B. Headache of 7 on scale of 1 to 10 C. Blood pressure of 140/98 D. Dypsnea A Maintaining hemodynamic stability in a client with esophageal varices can precipitate a life-threatening crisis if esophageal varies leak or rupture and can result in hemorrhage. The priority is assessing and monitoring infusions of IV fluids and any replacement blood products (A). The healthcare provider should be present during (B and D) in the event the client's esophageal varies rupture and bleed profusely. Bedrest (C) is not a priority at this time. While caring for a client who has esophageal varices, which nursing intervention is most important for the registered nurse (RN) to implement? A. Monitor infusing IV fluids and any replacement blood products B. Prepare for esophagogastroduodenoscopy (EGD) C. Maintain a client on strict bedrest D. Insert a nasogastric tube (NGT) for intermittent suction D Stiffness in joints is an early sign of contractures and muscle atrophy (D) related to inactivity and immobility. Decreased pedal pulses (A), upper extremity (B) and a loss of appetite (C) are not directly related to immobility. The registered nurse (RN) is caring for an older client who has been bedridden for two weeks. Which assessment findings indicate to the RN that the client is developing a complication related to immobility? A. Decreased pedal pulses B. Edema in upper extremities C. Loss of appetite for food D. Stiffness in right ankle joint B The first priority of a successful physical assessment is establishing rapport with the client. Having the client sign the admission forms, taking his vital signs, and obtaining equipment are also important but aren't the nurse's first priority in most cases. An 82-year-old client is admitted with pneumonia. Which of the following actions should be the nurse's first priority as she performs this client's admission assessment? A. Having the client sign the admission forms B. Establishing rapport with the client C. Obtaining the necessary equipment D. Taking the client's vital signs A Reflection is a technique that involves repeating something the client has just said. It can help the nurse obtain more specific information. Facilitation involves using phrases that encourage the client to continue with his story. Confirmation helps clear misconceptions. Summarization restates the information that the client has given. An 86-year-old client is admitted with a diagnosis of syncope. He tells the nurse, "When I get up in the morning, I feel dizzy." The nurse replies, "You feel dizzy when you get out of bed in the morning?" What communication strategy is this nurse using? A. Reflection B. Facilitation C. Confirmation D. Summarization D After assembling the necessary equipment, the nurse should perform the first part of the assessment-forming an initial impression of the client by observing his appearance. Vital signs should follow this initial observation. Assessment for skin lesions and anthropometric measurements should occur later in the assessment process. An occupational health nurse is performing a physical assessment on a prospective company employee. Which assessment should she perform first? A. Vital signs B. Presence of skin lesions C. Anthropometric measurements D. Appearance B When determining a pulse deficit, the nurse should palpate the radial pulse while auscultating the apical pulse. The apical pulse rate minus the radial pulse rate equals the pulse deficit. Pulse deficit isn't identified using the carotid or brachial pulses. A 52-year-old client is admitted with unstable angina. The nurse assigned to the client notes an irregular rhythm when assessing his pulse. To further assess the irregular pulse, the nurse knows she must determine the client's pulse deficit. Which pulses help identify pulse deficit? A. Carotid and apical B. Apical and radial C. Radial and brachial D. Carotid and radial C When percussing over dense tissue, such as muscle, the nurse should expect to hear flatness. Tympany is heard over an area of air collection, dullness isn't heard over organs, and resonance is a low-pitched sound heard over normal lung tissue. A 65-year-old client who underwent a right-sided thoracotomy 2 days ago complains of nausea. The nurse performs an abdominal assessment. Which sound should she hear when percussing over dense tissue? A. Tympany B. Dullness C. Flatness D. Dullness A. The nurse should neither underinflate nor overinfalte the cuff. The ideal method is to palpate the radial pulse while inflating the cuff. When the radial pulse disappears, the nurse should inflate the cuff an additional 30 mm Hg and then close the valve. The other methods of obtaining blood pressure are incorrect. A nurse is assessing the blood pressure of a client with diabetic ketoacidosis. How high should she inflate the blood pressure cuff before releasing the valve and listening for blood pressure? A. Inflate the cuff until the radial pulse disappears, and then inflate it an additional 30 mm Hg. B. Inflate the cuff to 200 mm Hg; if you hear the sound immediately, inflate to 220 mm Hg. C. Inflate the cuff until the needle on the manometer stops bouncing. D. Inflate the cuff until the client reports feeling a tingling sensation in his hand. A Anthropometric arm measurements help assess nutritional status. Less than 90% of the standard indicates caloric deprivation. This result doesn't indicate a normal measurement and doesn't show caloric excess. Protein malnutrition is determined by albumin levels. A 73-year old female client with Alzheimer's disease is admitted to the hospital with dehydration. Her daughter, who has been caring for the client at home, verbalizes frustration that the client refuses to eat or drink. The nurse performs anthropometric arm measurements on the client, and the result is 85% if the standard. What does this result suggest? A. Caloric deprivation B. Normalcy C. Protein malnutrition D. Caloric excess D Clients with iron deficiency anemia typically have spoon-shaped nails. Dark, yellowish nails occur with liver disease. White, transverse bands are associated with hypoalbuminemia. White patches on the nails may be associated with a fungal infection. A 76-year-old client is diagnosed with iron deficiency anemia. Which finding should the nurse expect when assessing this client's nails? A. Dark, yellowish color B. Transverse bands of white C. White patches D. Spoon shape A A contract with a psychiatric client should include the nurse's expectations and responsibilities as well as the client's. A description of the client's therapies, the length of hospitalization, and insurance and financial information wouldn't be included in a contract. A 23-year-old client is admitted to an inpatient psychiatric unit with severe depression. To develop rapport with the client, the nurse initiates a contract. What should the contract include? A. Expectations and responsibilities for you and the client B. A description of the therapies the client will undergo C. A prediction of the length of hospitalization D. The client's insurance and financial information B When a client identifies a history of substance abuse, the nurse should assess the risk of withdrawal, which includes determining the substance being used. Determining how the substance was obtained and asking if the client's employer knows about her behavior aren't relevant. Telling the client she really shouldn't use an additive substance is judgmental and inappropriate. During an assessment, an 18-year-old female states that she uses an addictive substance. Which response by the nurse is most appropriate? A. "How do you obtain these substances?" B. "What substance do you use?" C. "Does your employer know about this?" D. "You really shouldn't do that." A The Snellen chart measures visual acuity and provides readings such as 20/50. A person with 20/50 vision can view from 20 feet that which a person with normal vision can view from 50 feet. The other explanations are incorrect. A nurse is assessing a child's visual acuity using the Snellen chart. The result is 20/50 in both eyes. Which explanation should the nurse give to the child's parent? A. "What normal eyes see at a distance of 50 feet, your child's eyes see at a distance of 20 feet." B. "What normal eyes see at a distance of 20 feet, your child's eyes see at a distance of 50 feet." C. "To see what normal eyes sees at a distance of 20 feet, your child's eyes need a 50% magnification increase." D. "Your child's eyes see 20% of what children with normal vision see at 50 feet." D A continuous flow of speech from which the client jumps abruptly from topic to topic is called flight of ideas. Neologism is the distortion or invention of words. Echolalia is the client's repetition of the interviewer's words. Confabulation is the fabrication of events to fill in for memory loss. During an interview, a client has episodes in which she jumps abruptly from topic to topic. Which identifies this type of speech? A. Neologisms B. Echolalia C. Confabulation D. Flight of ideas B Pervasive maladaptive patterns of behavior suggest a personality disorder. Schizophrenia is characterized by an impaired perception of reality. An anxiety disorder is characterized by anxiety and avoidant behavior. Obsessive-compulsive disorder involves recurrent obsessions and compulsions. After making violent threats against her husband, a client who has just gone through a painful divorce is brought to the inpatient psychiatric unit by the police. Her threats of violence toward her ex-husband are most consistent with which diagnosis? A. Schizophrenia B. Personality disorder C. Anxiety disorder D. Obsessive-compulsive disorder A To evaluate skin turgor, the nurse should gently squeeze the skin on the forearm or sternum. The skin quickly returns to its original shape, the client's skin turgor is normal. If it returns to its original shape slowly after 30 seconds or maintains a tented position, the skin has poor turgor, which is a sign of dehydration. Palpating or transilluminating the skin doesn't detect dehydration. Pressing on the nail beds help evaluate circulation. A client is admitted with excessive vomiting after eating at a buffet. To assess the client's skin turgor for signs of dehydration. The nurse should: A. Squeeze the skin on his forearm or sternum B. Palpate the skin on the dorsum of his hand C. Press on the nail beds to cause blanching D. Transilluminate the skin over the forearm C Papules are small, raised, circumscribed, solid lesions. Macules are flat lesions. Pustules are small, inflamed, blister-like lesions. Plaques are broad, raised areas on the skin. A nurse notes a number of small, firm, round, raised lesions on the client's body. She should chart these findings as: A. Macules B. Pustules C. Papules D. Plaques B Telangiectases are small, dilated vessels that form a web-like pattern. They're commonly seen on the face, especially in clients with a history of alcohol abuse. Purpura is a red or purple discoloration of the skin. Angiomas are benign tumors near the surface of the skin. Petechiae are pinpoint hemorrhages in the skin or mucous membranes. A 49-year-old client with a history of alcohol abuse is admitted with bleeding esophageal varices. The nurse assessing him notes several small, weblike, vascular lesions on his cheeks. The nurse should chart these findings as: A. Purpura B. Telangiectases C. Angiomas D. Petechiae C Typically, melanomas are black or purple nodules that are irregularly shaped. Pale patches on the skin, skin flaking, and flat areas of discoloration aren't signs of melanoma. A 65-year-old client comes to the plastic surgeon's office for a follow-up appointment after having a basal cell lesion removed from his face. When teaching the client how to inspect his skin for signs of melanoma, the nurse should tell the client to look for: A. pale patches on the skin B. skin flaking that won't go away C. black or purple irregularly shaped nodules D. flat areas of discoloration D Conjunctivitis causes redness of the eye as well as itching and increased tearing. A child would be unlikely to develop a cataract or glaucoma. Ptosis refers to a drooping eyelid. A 9-year old child tells his school nurse that his eye itches and tears much more than usual. When the nurse examines his eye, his sclera is reddened. Which eye abnormality do these signs and symptoms most suggest? A. Cataracts B. Ptosis C. Glaucoma D. Conjunctivitis B Shining a light in the right eye should cause right eye constriction (direct) and left eye constriction (consensual). The other papillary responses aren't normal and may indicate a neurologic problem. A nurse is inspecting a 10-year-old child's pupils as part of a routine eye examination. When the nurse shines indirect light into the child's right eye, the normal response would be: A. both eyes dilate B. both eyes constrict C. the right eye constricts, and the left eye dilates D. no response D The focus of a mental health assessment should be to gather information from the client so the nurse can develop a care plan. Goals for care and client outcomes shouldn't be determined until after the assessment is complete. The mental health assessment primarily focuses on the client's mental health, not medical problems. A nurse is performing a mental health assessment of a client seeking help to control her overwhelming anxiety. During the mental health assessment, what should be the nurse's focus? A. To state goals for care of the client B. To determine outcomes for the patient C. To distinguish medical problems from mental health problems D. To gather information from the client C The normal eardrum (tympanic membrane) is gray. A pink, white, or red tympanic membrane may indicate infection and effusion. An 11-year-old child reports to the school nurse with an earache and sore throat. The nurse inspects the tympanic membrane using an otoscope. Which color suggests a normal eardrum? A. Pink B. White C. Gray D. red C To perform an otoscopic examination on a client age 3 or older, the nurse should pull the auricle up and back to straighten the ear canal. Pulling the auricle in other manners described may cause injury to the child's eardrum. A nurse is performing an otoscopic examination on a 3-year-old child who has an earache and a fever. In which direction should the nurse pull the child's auricle to straighten the ear canal? A. Down and forward B. Up and forward C. Up and back D. Down and back C The submental lymph node is located directly under the chin. The preauricular lymph node is located in front of the ear. The submandibular nodes are under the mandible, and the supraclavicular nodes are above the clavicle. A mother states her daughter has been complaining for 3 days of a sore throat, which has increased in severity. The nurse palpates the girl's neck and identifies a swollen lymph node directly under the chin. Which lymph node is this? A. Preauricular B. Submandibular C. Submental D. Supraclavicular D With pneumothorax, the nurse may observe intercostal retractions; with right-sided pneumothorax, deviation to the left may also be present. Funnel chest is a chest deformity. Barrel chest occurs with chronic obstructive lung disease. A 19-year-old college student is brought to the emergency department with dyspnea and asymmetrical breathing patterns after falling down a flight of steps at a party. His admission chest X-ray shows right-sided pneumothorax. During inspection, what other characteristic of pneumothorax might the nurse observe? A. Funnel chest B. Barrel chest C. Intercostal retractions D. Tracheal deviation C For a client with pneumothorax, the pleural space on the affected side is increased, which produces a hyperresonant sound on percussion. Tympanic sounds occur over air and may be heard with a large pneumothorax. Dullness is heard over a solid area, such as in pneumonia, and flatness occurs with consolidation. After a fall from a scaffold, a 32-year-old construction worker complains of shortness of breath and has labored breathing. His admission chest X-ray reveals a small, right-sided pneumothorax. What sound should the nurse expect when percussing over the right lung? A. Tympany B. Dullness C. Hyperresonance D. Flatness A A nurse is performing an admission assessment of a 63-year-old client with pneumonia. While auscultating his lungs, the nurse asks him to repeatedly say "ninety-nine." For what sound is the nurse checking? A. Bronchophony B. Egophony C. Pectoriloquy D. Crepitus C With pneumothorax, air movement is diminished or absent in the affect lung, so breath sounds are diminished in that area. Crackles are related to collapsed or fluid-filled alveoli. Rhonchi result from fluid in large airways. Wheezes are caused by blocked airflow. A client develops a pneumothorax after an attempted central line insertion. What breath sounds should the nurse expect to hear over the affected lung? A. Crackles B. Rhonchi C. Diminished sounds D. Wheezes B The pulses on tops of the feet are the dorsalis pedis pulses. The popliteal pulse is located behind the knee. The posterior tibial pulse is found posterior to the medial malleolus. The anterior tibial pulse is located anterior to the ankle. A 63-year-old client is hospitalized in the coronary care unit after experiencing an anterior myocardial infarction (MI). As the nurse performs the initial assessment, she palpates the pulses on the top of the client's feet. What are these pulses? A. Popliteal pulses B. Dorsalis pedis pulses C. Posterior tibial pulses D. Anterior tibial pulses D The pain typically associated with an MI is characterized by tightness and pressure. The other types of pain described could be associated with an MI but are less common. A 57-year-old, obese client comes to the emergency department complaining of chest pain that developed while he was climbing the stairs. The nurse asks the client to describe his chest pain. Which type of chest pain is most commonly associated with MI? A. Sore and aching B. Dull and stabbing C. Sharp and burning D. Tightness and pressure D The first heart sound, S1, which produces the "lub" sound, is associated with closure of the mitral and tricuspid valves. The second heart sound, S2, or the "dub" sound, is a result of closure of the aortic and pulmonic valves. A 19-year-old client is admitted to the coronary care unit after experiencing a syncopal episode while playing basketball. When auscultating his heart sounds, the nurse hears a "lub-dub" sound. What mechanical event in the heart is associated with the "lub" sound? A. Closure of the mitral and aortic valves B. Closure of the tricuspid and aortic valves C. Closure of the aortic and pulmonic valves D. Closure of the mitral and tricuspid valves A The apical impulse, also usually the point of maximum impulse, can be found at the fifth intercostal space medial to the left midclavicular line. The other areas are incorrect. A nurse is inspecting a 58-year-old client's chest wall to locate the apical pulse. Where should the nurse look? A. At the fifth intercostal space medial to the left midclavicular line. B. Over the base of the heart C. Over the aortic area D. At the third intercostal space to the left of the sternum B After menopause, glandular tissues atrophy and are replaced with fatty deposits. The breasts become flabbier and smaller, and the nipples flatten and become less erectile. Breast enlargement is most common during puberty and pregnancy. Asymmetrical areolae and inverted nipples may indicate a more serious breast condition. A nurse is assessing a 53-year-old client who's beginning to undergo menopause. Which finding is a normal change associated with menopause? A. Breast enlargement B. Flattened nipples C. Asymmetrical areolae D. Inverted nipples C An irregularly shaped lump in the breast suggests malignancy. A malignant mass bay also be firm, tender, and not easily mobile. During the examination of a 36-year-old client's right breast, the nurse palpates a lump. Which characteristic most suggests that the lump may be malignant? A. Softness B. Mobility C. Irregular shape D. Nontender D Because certain changes take place in the breasts during the menstrual cycle, menstruating women should perform a BSE 7 to 10 days after the beginning of her cycle. The other choices aren't optimal times. A 28-year-old client asks, "When should I perform breast self examination (BSE)?" The best response from the nurse would be: A. "On the first day of your menstrual cycle each month." B. "On the last day of your menstrual cycle each month." C. "On the first day of every month." D. "7 to 10 days after your menstrual cycle begins each month." C The preferred method for palpating a client's breast is to use three middle finger pads and to gently rotate them around the breast, moving in concentric circles. Using the whole palm, one index finger, or the pad of the thumb doesn't allow the client to adequately feel the breast tissue and identify abnormalities. When palpating a client's breast, the nurse should use: A. The whole palm of the palpating hand B. One index finger C. Three middle finger pads D. The pad of the thumb C Burning abdominal pain is most commonly associated with peptic ulcer disease. Cholecystitis and pancreatitis cause stabbing abdominal pain. Appendicitis causes severe abdominal cramping. A 47-year-old client complains of burning abdominal pain after eating at a Mexican restaurant. Burning abdominal pain is most commonly associated with: A. Cholecystitis B. Appendicitits C. Peptic ulcer disease D. Pancreatitis D When measuring abdominal girth, the nurse should measure the abdomen at its fullest point. Measuring at the other points may not accurately evaluate an increase in abdominal size. A physician orders daily measurement of abdominal girth for a 35-year-old client with upper-GI bleeding. At which point on the abdomen should the nurse take her measurement? A. Just below the rib cage B. Just above the pelvis C. Across the umbilicus D. At the fullest point D Because abdominal rigidity may indicate peritoneal inflammation, the nurse should avoid palpation because it may lead to pain or organ rupture. Performing deep palpation on a client who has ascites, is constipated, or is ticklish may be difficult, but it isn't contraindicated. A 27-year-old client comes to the emergency room complaining of abdominal pain. Deep palpation of the abdomen shouldn't be performed if the client: A. Has ascites B. Reports constipation C. Is ticklish D. Has abdominal rigidity C Water should be used to lubricate the speculum before an internal vaginal examination. Other lubricants are discouraged because they can alter the results of a Pananicolaou test. A nurse is assisting a physician with a routine pelvic examination. What lubricant should the nurse use on the speculum? A. Water-soluble jelly B. Petroleum jelly C. Warm water D. Mineral oil B Although menses duration may vary, the duration in a nomrla menstrual cycle is 2 to 8 days. A nurse is teaching a group of fifth-grade girls about menstruation. She tells them that menses occurs every 21 to 38 days and that the duration is normally: A. 2 to 4 days B. 2 to 8 days C. 3 to 5 days D. 4 to 7 days C Pain during percussion over the costovertebral angle suggests kidney inflammation. Clients with ureteral stones, ovarian cysts, or bladder cancer more commonly complain of abdominal pain. A client with a urinary tract infection reports pain when the nurse percusses her back at the costovertebral angle. This finding suggests: A. A ureteral stone B. an ovarian cyst C. kidney inflammation D. bladder cancer C To assess for scoliosis, the nurse should inspect the spine for abnormalities while the client is bending forward at the waist. This position can make spinal deformities more apparent. The other actions don't assist with the diagnosis of scoliosis. A school nurse is performing an annual screening on a 12-year-old student. To assess for scoliosis, the nurse should: A. Palpate for crepitus B. Measure the length of the spine from neck to waist. C. Ask the client to bend forward at the waist D. Palpate the spinous processes C A normal testicle is oval and rubbery. An irregularly shaped or nodular testicle may indicate malignancy. A round testicle isn't normally found. A 28-year-old client tells a nurse that he discovered a lump in his scrotum. Before palpating his testicles, the nurse should know that a normal testicle is: A. irregularly shaped B. Round C. Rubbery D. Nodular A The purpose of palpating a client's inguinal area during assessment is to check for herniation. The nurse wouldn't find a pulse, testicle, or prostate gland in this area. A 46-year-old construction worker comes to the clinic for his annual physical examination. During the assessment, the nurse palpates the inguinal area for what reason? A. To check for herniation B. To locate a pulse C. To check for a nondescended testicle D. To assess the prostate gland C A normal prostate gland is about the size of a walnut. The other choices are incorrect. A 62-year-old client complains of urinary hesitancy. During the assessment, the nurse palpates his prostrate gland. The nurse should know that a normal prostate gland is about the size of a: A. marble B. grape C. walnut D. peach B With internal rotation of the hip, inward turning and pointing of the foot to a pigeon-toed position occurs. A misshapen pelvis and unequal leg length doesn't indicate rotation. Outward pointing of the toes is related to external rotation of the hip. After slipping in her bathroom, an 80-year-old client is brought to the emergency department with a deformed right hip and hip pain that she rates as an 8 on a scale of 1 to 10. The nurse examining her notices gross internal rotation of the right hip. Which of the following signs alerts the nurse to this assessment? A. A misshapen pelvis B. Inward pointing of the foot C. Outward pointing of the foot D. Unequal leg lengths B Pain or numbness in the hand or fingers that occurs when the client's wrist is flexed is called Phalen's sign. This finding is indicative of carpal tunnel syndrome. A fractured wrist would cause pain with any movement. Stroke and paralysis aren't indicated by pain with wrist flexion. A 34-year-old client complains of pain and tingling in her right wrist. During the assessment, the client reports pain when the nurse flexes the wrist for 30 seconds. The nurse knows that this finding indicates: A. a fractured wrist B. carpal tunnel syndrome C. a stroke D. paralysis D A client with hematuria may have brown or bright-red urine. With hypervolemia, urine would be pale in appearance. Benign prostatic hyperplasia and urinary tract infection usually don't affect urine color. A 58-year-old client comes to the clinic for his annual physical examination. The nurse notices that the client's urine specimen has a brown appearance. What does this finding suggest? A. Hypervolemia B. Benign prostatic hyperplasia C. Urinary tract infection D. Hematuria A, C, D, E, F To perform a swift assessment of a musculoskeletal injury, the nurse should remember the 5 P's: pain, paresthesia, paralysis, pallor and pulses. The nurse wouldn't assess pliability with a suspected fracture. A nurse is assessing the leg of a client who has come to the emergency department with a suspected fractured femur. To perform a quick and accurate assessment, the nurse should evaluate the affected leg for which of the following signs and symptoms? Select all that apply. A. Pain B. Pliability C. Paresthesia D. Paralysis E. Pallor F. Pulses A Although Babinkski's reflex is a normal finding in infants and children younger than age 2, it's always an abnormal finding in adults. It wouldn't be classified as hyperactive or diminished. A 30-year-old client is brought to the emergency department with head injuries from a motorcycle accident. During the neurological assessment, the client displays Babinski's reflex. The nurse knows that this finding is: A. an abnormal response B. a normal response C. a hyperactive response D. a diminished response D The ability to identify a common object by touching and manipulating is called stereognosis. If the client has impaired stereognosis, the nurse should next test graphesthesia. Apraxia is the inability to perform coordinated movments. Aphasia is a language deficit. During a routine physical examination, a 68-year-old client can't identify a pencil or a cotton ball when manipulating the object with his hands, keeping his eyes closed. The nurse knows that this abnormal finding indicates: A. Apraxia B. Aphasia C. Graphesthesia D. Impaired stereognosis C CN VII (the facial nerve) has sensory and motor components. The nurse should assess the sensory component by testing the client's taste perception and test the motor component by observing the function of the facial muscles. The acoustic nerve (CN VIII) is responsible for hearing and equilibrium. The trigeminal nerve (CN V) allows for differentiation of sensations on the face. The glossopharyngeal nerve (CN IX) is responsible for swallowing. A nurse is assessing the cranial nerves of a 62-year-old client who had a stroke. How should the nurse assess the function of cranial nerve (CN) VII? A. Test the client's hearing and ask him if he ever experiences dizziness or vertigo B. Test the client's ability to feel light touch on his face as well as his ability to differentiate between sharp and dull sensations on his face C. Test the client's ability to identify tastes, and observe his face for symmetry at rest and wile making facial expressions, such as smiling or frowning D. Test the client's gag reflex and ability to swallow B Muscle tone, which represents muscular resistance to passive stretching, is assessed by performing passive ROM exercises. DTRs reflect neurologic function. Romberg's test evaluates balance. Constructitonal ability testing assesses the client's ability to perform simple tasks and use various objects. A client's muscle tone is assessed by performing: A. deep tendon reflex (DTR) testing B. Passive range-of-motion (ROM) exercises C. Romberg's test D. constructional ability testing B A client with chronic venous insufficiency is likely to have ulceration around the ankle. Arterial insufficiency is more likely to cause ulceration around the toes. A skin infection or allergy would be characterized by multiple areas of skin disruption, not an ulceration. An 84-year-old client complains of leg pain. A nurse assesses his legs and discovers an ulcerated area close to the ankle on his left leg. The nurse knows that this finding indicates: A. arterial insufficiency B. chronic venous insufficiency C. skin infection D. skin allergy BMI = weight in pounds/(height in inches x height in inches) x 703 180/(70 x 70) x 703 = 25.82 or 25.8 A nurse records a client's weight as 180 lb and his height as 70". What's this client's body mass index (BMI)? Round your answer to one decimal place. SOAP modified format Subjective Objective Assessment Plan What color ink should be used when documenting on paper Permanent black ink What is the correct order for vital signs T, P, RR, BP, extremity, pt position, SPO2 What should be at the top of every page of documentation Patient initials and date and time of entry What should be at the end of every documentation entry Interviewers signature How do you correct a mistake in documentation 1) Draw a single line through the incorrect documentation 2) Write error above the entry 3) Initial and date the crossed out entry Documentation tips 1) Avoid complete sentences 2) Do not use A, an, the 3) Do not put opinion in notes 4) Avoid use of normal or within normal limits Normal oral temp range 96.4 - 99.1 F Febrile With fever Afebrile Without fever Hyperthermia symptoms 1) Cessation of shivering 2) Bradycardia 3) Decrease in respiratory minute volume Most common and easy method of assessing temperature Oral What methods of assessing temperature reflects core temperature 1) Oral 2) Rectal 3) Tympanic 4) Temporal Artery What is the least accurate method of assessing temperature axillary Which patients are contraindicated for rectal temperature readings Patients with increased HR Preferred method of taking infants and small children's temperatures Rectal Pulse deficit - Difference between apical peripheral pulse Pulse amplitude scale 0 = no pulse 1 = diminished, weak 2 = normal and expected 3 = full or strong 4 = bounding Which pulses are assessed during a routine physical assessment? 1) Apical 2) Radial 3) Dorsalis pedis 4) Posterior tibialis Normal heart rate in resting adult 60 to 100 bpm Well trained athletes heart rate Heart rate less than 60 bpm When is it normal for someone to have a rapid heart rate over 100 bpm Someone with anxiety and right after exercise Eupnea Normal RR, rhythm and depth Normal SPO2 value 95-100% What level is poor oxygenation below 90% Systolic BP Maximum pressure on the artery during ventricular contraction Diastolic BP Resting pressure during ventricular filling Pulse pressure Difference between systolic and diastolic Stroke volume Amount of blood ejected with each beat How does age affect BP BP increases with age What BP is pre hypertensive? Sustained BP over 120/80 What extremities should you avoid taking a BP in Extremities with IV lines, invasive lines, history of mastectomy/lymph node issues Orthostatic hypertension - Decreased BP with change in position - Drop in SBP of 25 mmHg or DBP of 10 mmHG - Symptoms 1) Dizziness 2) Weakness 3) Blurred vision 4) Syncope 5) Changes in BP/HR - Causes 1) Hypovolemia 2) Impaired vasoconstriction 3) Medications Precautions in someone with orthostatic hypertension - change positions slowly - falls risk - assist back to bed if symptomatic What is the main objective of the health history - To gather accurate information to provide immediate care - Establish rapport with the client What does establishing a positive patient relationship depend on 1) courtesy 2) comfort 3) connection 4) confirmation 5) confidentiality What questions should you begin with for a health history interview Open ended questions Approaching Sensitive Issues - Use language that is understandable. - Do not apologize for broaching the issue. - Ensure privacy. - Be direct and firm. - Do not preach. - Do not push too hard. CAGE questionnaire Cutting down Annoyance Guilty feeling Eye-openers - Helps diagnose alcoholism TACE questionnaire T - how many drinks does it TAKE to make you feel right A - Have people ANNOYED you by criticizing your drinking C - Have you felt you out to cut down on your drinking E - Have you had an EYE -OPENER first thing in the morning CRAFFT questionnaire - Screening tool for alcohol and substance abuse in adolescents Car Relax Alone Forget Friends Trouble What is the goal of a screening tool? To find out if the problem exists Three questions to detect partner violence - Have you ever been hit, kicked, punched, or otherwise hurt by someone within the past year? - Do you feel safe in your current relationship? - Is there a partner from a previous relationship who is making you feel unsafe now? HITS questionnaire The wording of the question is "In the last year how often did your partner: 1) Hurt you physically?" 2) Insult or talk down to you?" 3) Threaten you with physical harm?" 4) Scream or curse at you?" FICA Faith Importance and Influence Community Address/action in care Format of interview CC HPI PMH PSH FH SH ROS Is pain subjective or objective Subjective PMH 1) Allergies 2) Childhood and adult illnesses 3) Immunizations 4) Diagnostic and lab results Symptom analysis tool OLDCARTS Complete history Most often recorded the first time you see the patient Inventory history - Related to but does not replace the complete history - Touches on major points without complete detail - Entire history will be completed in more than one session Problem (or focused) history Taken when a problem is acute so that only the need of the moment is given full attention Interim history - Designed to chronicle events that have occurred since your last meeting with the patient - Substance determined by nature of problem and need of the moment - Should always be complemented by the patient's previous medical record Transduction of pain Action potential moves to the spinal cord Transmission of pain Pain impulse moves from spinal cord to the brain Modulation of pain Neurons from the brain stem release neurotransmitters that block the pain impulse Steps in pain 1) Noxious stimuli and transduction 2) Transmission 3) Perception of pain 4) Modulation Neuropathic pain - Pain within nervous system - Abnormal processing of pain from nerve fibers - Often chronic Visceral pain - Originates from larger internal organs - Often described as crampy - Physical pain based on site of organ Somatic pain Originates from MS system Referred pain Pain is felt from a different site other than where it originates Gallbladder referred pain The shoulder Kidney referred pain The lower back Acute pain - Less than 6 mos Chronic pain - pain lasting longer than 6 months - Hard to treat Elderly and pain - No evidence exists to suggest that older individuals perceive pain to a lesser degree or that sensitivity is diminished Infants and pain - Do not have adequate number of inhibitory neurotransmitters, so thought to be more sensitive to pain (premies > full-term) What is most reliable indicator of pain Subjective report Pain rating scale - scale 0 to 10 - Pain rating scales can indicate a baseline intensity, track changes, and give some degree of evaluation to a treatment modality - Reflect pain intensity - Older adults may prefer the descriptor scale that asks patients to indicate their pain by using selected pain term words Verbal descriptor scales have the patient use words to describe pain Visual analog scales have the patient mark the intensity of the pain on a horizontal line from "no pain" to "worst pain" Should pain be discounted when objective, physical evidence is not found NO Epidermis - Protection - Avascular - Contains Keratin - Top layer of the skin Dermis - Connective tissue collagen, elasticity - Sensory nerve fibers - Vascular - Nourish the epidermis - Middle layer Hypodermis - Connects dermis to organs - Connective tissue and fat - Acts as insulation and shock protection - Bottom layer Lanugo - fine downy hair of newborn infant Vernix caseosa thick, cheesy substance on newborn infant Sebum holding water in the skin producing milia Children developmental considerations of skin - Epidermis thickens, darkens, and becomes lubricated - Hair growth accelerates Adolescents - Secretions from apocrine sweat glands increase - Subcutaneous fat deposits increase - Secondary sex characteristics Linea nigra Increased pigmentation midline of abdomen that occurs in pregnant women Chloasma Discoloration changes on face representing the "mask of pregnancy" Striae gravidarum Stretch marks, which can develop over the abdomen, breast, and thighs after pregnancy Elasticity in the aging adult Loses elasticity; skin folds and sags Sweat and sebaceous glands in the aging adult Decrease in number and function, leaving skin dry Senile purpura in the aging adult Discoloration due to increasing capillary fragility Skin breakdown due to multiple factors in the aging adult Cell replacement is slower and wound healing is delayed Hair matrix in the aging adult Functioning melanocytes decrease, leading to gray fine hair Annular or circular lesions Round Confluent lesions Cant tell where one ends and the other begins Discrete lesions -distinct, individual lesions that remain seperate (eg acrochordon= skin tags, or acne) Gyrate lesions Worm like lesions Grouped lesions Discrete lesions grouped together Linear lesions Lesions in a straight line Target lesions Round lesions with a light outer ring and dark inner ring Zosteriform lesions Band like, unilateral lesion group Polycyclic lesions are lesions that are circular but united Examples: psoriasis Macule flat skin lesion with only a color change Patch skin lesion Larger macule Papule - A small, raised, solid pimple or swelling, often forming part of a rash on the skin and typically inflamed but not producing pus. - Smaller than 1 cm Plaque - A plaque is a solid, raised, flat-topped lesion greater than 1 cm. in diameter. It is analogous to the geological formation, the plateau. Nodule A nodule is a raised solid lesion more than 1 cm. and may be in the epidermis, dermis, or subcutaneous tissue. Tumor A tumor is a solid mass of the skin or subcutaneous tissue; it is larger than a nodule. Wheal - Transient, circumscribed, elevated papules or plaques, often with erythematous borders and pale centers. Urticaria Urticaria (hives) is a vascular reaction of the skin marked by the transient appearance of smooth, slightly elevated papules or plaques (wheals) that are erythematous and that are often attended by severe pruritus. Individual lesions resolve without scarring in several hours. Vesicle A small, superficial, circumscribed elevation of the skin, less than 0.5 cm, that contains serous fluid. Bulla A raised, circumscribed lesion greater than 0.5 cm that contains serous fluid. Cyst A cyst is a benign, round, dome-shaped encapsulated lesion that contains fluid or semi-fluid material. It may be firm or fluctuant and often distends the overlying skin. Pustule A small (< 1 cm in diameter), circumscribed superficial elevation of the skin that is filled with purulent material. Can also be described as a vesicle filled with pus. Crusts Varying colors of liquid debris (serum or pus) that has dried on the surface of the skin. Scale skin lesions Visible fragments of the stratum corneum as it is shed from the skin. Fissure Sharply-defined, linear or wedge-shaped tears in the epidermis with abrupt walls. Erosion Loss of superficial layers of upper epidermis by wearing away as from friction or pressure. Ulcer A localized defect in the skin of irregular size and shape where epidermis and some dermis have been lost. Stage 1 ulcer Skin is intact but has evolved- so this is still a secondary lesion- lighter skin will blanch at this point. (NEEDs intervention STAT) Stage 2 Pressure ulcer loss of epidermis/dermis-could look like a shallow abrasion Stage 3 pressure ulcer goes all the way into sub q tissue Stage 4 pressure ulcer involves all skin layers and goes into muscle, bone, tendon Excoriation Skin abrasions, usually superficial, due to scratching of the skin. Scar A mark on the skin that is left after a cut or other wound has healed. Atrophic Scar Pitted or sunken scars Lichenification Diffuse thickening of the epidermis, with resulting accentuation of skin lines. Keloid - A tough heaped-up scar that rises quite abruptly above the rest of the skin. - Commonly found in African Americans, Asians, and Hispanics Vascular Lesions - Occur with systemic disorders - Proliferation of blood vessels Hemangiomas - Port-wine stain (nevus flammeus) - Strawberry mark (immature hemangioma) - Cavernous hemangioma (mature) Telangiectases - Spider or star angioma - Venous lake Purpuric lesions - Petechiae - Purpura Lesions caused by trauma or abuse - Pattern injury - Hematoma - Contusion (bruise) Aging adult skin inspection - Pale (deceased melanin), thin skin, less elasticity - Senile Lentigines often called "Liver Spots" - Keratoses rough, crusty, elevated, often on dorsal surface of hand or on face. Petechiae tiny hemorrhages, bleeding from superficial capillaries, do not blanch, also look for in buccal cavity Signs of arterial insufficiency - Decreased hair on extremities - Coolness of skin on extremities - Shiny, thin skin Edema rating scale - 1+ = mild edema, slight indentation - 2+= moderate pitting, indentation goes away rapidly - 3+= deep pitting, remains a short time, area "looks" swollen - 4+= very deep pitting, indentation lasts a long time, area "looks" very swollen Anasarca heart failure, organ failure Nevi acronym ABCDE ABCDE A - Asymmetry B - Border irregularity C - Color nonuniform D - Diameter greater than 6 mm E - Evolving size and shape Basal Cell Carcinoma - most common form of skin cancer - Basal layer of epidermis - Deeply pigmented, central red ulcer, pearly edges-may look like an open pore (face, ears and neck, scalp shoulders are common sites) - Warning signs 1) Open sore 2) Bleeding 3) Wont heal 4) Older age 5) Toxin exposure 6) Repeated trauma Squamous cell - Less common - Grows rapidly - Central ulcer with surrounding erythema - Scaly patch - Elevated - Can be mobile (scalp (bald),ears, lips and hands) Melanoma - mixed pigmentation, characteristics of dysplastic nevi - ½ arise from pre-existing nevi other ½ do not. (trunk, back, palms, soles, nails in dark-skinned individuals) - Melanocytes cells are there at birth. - Etiology- hormonal factors, uv, hereditary - Warning signs 1) Fair skin 2) Light eyes 3) Immune suppression 4) Atypical nevi Hirsutism - Women with male hair distribution - Can indicate endocrine problem Soft Spots - Allow for brain growth during first year of life - Posterior fontanel closes by 1 to 2 mos - Anterior fontanel closes between 9 mos and 2 years Lymphoid tissue growth at birth - Well developed at birth - Grows to adult size when the child is 6 years old Acromegaly Head enlargement Pagets Disease - Acorn shaped head - Headaches - Deafness - Optic problems - Coarse facial features - Over growth of bony structures on face senile tremors - Head nodding/yes and no - Benign - Occur with age Hydrocephalus Excess CSF in the skull Cushings's disease - Adrenal disorder - Excessive secretion of steroids - Moon Face - Red Cheeks Downs Syndrome - Large epicanthal folds - Thin lips - Wide Spread eyes - Large tongue Temporal Artery Assessment - Done in HEENT assessment - Should feel elastic and smooth, 1+weakness Temporal arteritis - Inflammation of the temporal artery from some impaired immune response. - May cause problems with vision/severe HA. - Occurs ususally in adults over 50 y/o. Assessing Neck Alignment - Midline - Ask patient to swallow - Movement of thyroid cartilage /gland - Palpate with thumbs bilaterally Assessment of Thyroid gland - Posterior approach - Anterior approach - Auscultate thyroid for bruit, if enlarged Conjunctiva transparent protective covering of exposed part of eye Cornea covers and protects iris and pupil Lacrimal gland In upper outer corner over eye, secretes tears Movement of the extraocular muscles stimulated by three cranial nerves 1) Cranial nerve VI: abducens nerve, innervates lateral rectus muscle, which abducts eye 2) Cranial nerve IV: trochlear nerve, innervates superior oblique muscle 3) Cranial nerve III: oculomotor nerve, innervates all the rest: the superior, inferior, and medial rectus and the inferior oblique muscles Sclera - Tough, protective, white covering - Continuous anteriorly with smooth, transparent cornea, which covers iris and pupil Cornea Physiology - Part of refracting media of eye, bending incoming light rays so that they will be focused on inner retina - Very sensitive to touch; contact with a wisp of cotton stimulates a blink in both eyes, called corneal reflex - Trigeminal nerve, cranial nerve V and facial nerve, cranial nerve VII Iris - Functions as a diaphragm, varying opening at its center, the pupil - Controls amount of light admitted into retina Pupil - Round and regular; size determined by balance between parasympathetic and sympathetic chains of autonomic nervous system - Stimulation of parasympathetic branch, through cranial nerve III, causes constriction of pupil - Stimulation of sympathetic branch dilates pupil and elevates eyelid - Pupil size also reacts to amount of ambient light and to accommodation, or focusing an object on retina Lens - Biconvex disc located just posterior to pupil - Transparent, it serves as a refracting medium, keeping a viewed object in focus on retina Retina - The visual receptive layer of eye where light waves change into nerve impulses - Retinal structures viewed through ophthalmoscope are optic disc, retinal vessels, general background, and macula Optic disc Where optic nerve connects to the eyeball Pupillary light reflex - Normal constriction of pupils when bright light shines on retina - When one eye exposed to bright light, a direct light reflex occurs, constriction of that pupil; and a consensual light reflex, simultaneous constriction of other pupil Fixation - A reflex direction of eye toward an object attracting person's attention - Image fixed in center of visual field, the fovea centralis - These ocular movements are impaired by drugs, alcohol, fatigue, and inattention Accommodation - Adaptation of eye for near vision - Although lens cannot be observed directly, the following components of accommodation can be observed: - Convergence (motion toward) of the axes of the eyeballs - Pupillary constriction Pupils in Aging Adults - Pupil size decreases - Lens loses elasticity becoming hard and glasslike - Visual age begins to diminish by age 50 - Worsens more so after age 70 Presbyopia Lens loses elasticity, becoming hard and glasslike, which decreases ability to change shape to accommodate for near vision Most common causes of decreased visual functioning in older adults 1) Cataract Formation 2) Glaucoma 3) Macular degeneration 4) Loss of central vision Cataract - Clouding of the lens - Can effect one or both eyes - Occurs with age Glaucoma - Damage to optic nerve fiber - Progressive Macular degernation - Incurable - Treatable - breakdown of cells in macula of retina Strabismus Lazy eye Diplopia Double Vision External Ear - Auricle or Pinna - Consists of movable cartilage and skin - Auditory Canal - A cul-de-sac 2.5 to 3 cm long in adults that terminates at eardrum, or tympanic membrane - Lined with glands that secrete cerumen, a yellow waxy material that lubricates and protects ear - Forms sticky barrier to keep foreign bodies from entering and reaching sensitive tympanic membrane Tympanic Membrane - AKA the eardrum - Separates external and middle ear - Translucent membrane with a pearly gray color - Oval and slightly concave, pulled in at its center by one of middle ear ossicles, the malleus Middle Ear - Tiny air-filled cavity inside temporal bone - Contains tiny ear bones, or auditory ossicles: the malleus, incus, and stapes Eustachian tube - Opening that connects middle ear with nasopharynx and allows passage of air - Normally closed, but opens with swallowing or yawning Three functions of the middle ear - Conducts sound vibrations from outer ear to central hearing apparatus in inner ear - Protects inner ear by reducing amplitude of loud sounds - Eustachian tube allows equalization of air pressure on each side of TM so that it does not rupture Inner Ear - Contains the bony labyrinth, which holds sensory organs for equilibrium and hearing - Although the inner ear is not accessible to direct examination, its functions can be assessed Conductive hearing loss - Involves a mechanical dysfunction of external or middle ear - Partial loss because person is able to hear if sound amplitude is increased enough to reach normal nerve elements in inner ear - May be caused by impacted cerumen, foreign bodies, a perforated TM, pus or serum in middle ear, and otosclerosis, which is a decrease in mobility of ossicles Sensorineural (or perceptive) hearing loss - Signifies pathology of inner ear, cranial nerve VIII, or auditory areas of cerebral cortex - Increase in amplitude may not enable person to understand words -May be caused by presbycusis, which is a gradual nerve degeneration that occurs with aging, and by ototoxic drugs, which affect hair cells in cochlea Presbycusis A gradual nerve degeneration that occurs with aging, and by ototoxic drugs, which affect hair cells in cochlea During history, notice clues from normal conversation indicating possible hearing loss - Lip reading or watching your face and lips rather than your eyes - Frowning or straining forward to hear - Posturing of head to catch sounds with better ear - Misunderstands questions; frequently asks you to repeat - Irritable or shows startle reflex when you raise your voice - Person's speech sounds garbled, vowel sounds distorted - Inappropriately loud voice - Flat, monotonous tone of voice Tinnitus Questions - Ever felt ringing, crackling, or buzzing in your ears? When did this occur? - Does it seem louder at night? - Are you taking any medications? Vertigo Questions - Ever felt vertigo, that the room is spinning around or feel that you are spinning? - Ever felt dizzy, like you are not quite steady, or falling or losing your balance? Giddy, lightheaded? Two pairs of sinuses are accessible to examine during HEENT assessment - Frontal sinuses in frontal bone above and medial to orbits - Maxillary sinuses in maxilla (cheekbone) along side walls of nasal cavity Other two sets are smaller and deeper and cannot be examined during a HEENT assessment - Ethmoid sinuses between the orbits - Sphenoid sinuses deep within skull in the sphenoid bone Sinuses present at birth - Only maxillary and ethmoid sinuses are present at birth. - Maxillary sinuses reach full size after all permanent teeth have erupted. - Ethmoid sinuses grow rapidly between 6 and 8 years of age and after puberty. - Frontal sinuses are absent at birth, fairly well developed between ages 7 and 8, and reach full size after puberty. - Sphenoid sinuses are minute at birth and develop after puberty. Tonsils - Behind folds, each is a mass of lymphoid tissue Nasal cavity Inspection and Palpation - View each nasal cavity with person's head erect and then with head tilted back. - Inspect nasal mucosa, noting its normal red color and smooth moist surface. - Note any swelling, discharge, bleeding, or foreign body. Nasal septum Inspection and Palpation - Observe nasal septum for deviation; deviated septum is common and is not significant unless air flow is obstructed. - If present in hospitalized patient, document deviated septum in event that person needs nasal suctioning or a nasogastric tube - Note any perforation or bleeding in septum. Palpation of Sinus Areas - Using thumbs, press frontal sinuses by pressing up and under the eyebrows and over maxillary sinuses below cheekbones. - Transillumination You may use this technique when you suspect sinus inflammation, although it is of limited usefulness. A diffuse red glow is a normal response; comes from light shining through air in the healthy sinus. Inspection of Teeth and Gums Condition of teeth is an index of person's general health. Tonsil Grade 1+ Visible 2+ Halfway between tonsillar pillars and uvula 3+ Touching uvula 4+ Touching each other Tonsils in healthy people, and children You may normally see 1+ or 2+ tonsils in healthy people, especially in children, because lymphoid tissue is proportionately enlarged until puberty Cooper's ligaments - Suspensory ligaments - Fibrous bands extending vertically from surface to attach on chest wall muscles - Support breast tissue - Become contracted in cancer of breast - Create a dimple in overlying skin 5 segments of the breast - Divided into 5 segments - 4 Quadrants 1) Upper Inner Quadrant 2) Lower Inner Quadrant 3) Upper Outer Quadrant 4) Lower Outer Quadrant - Axillary tail of Spence Breast Lymphatic Drainage - Breast has extensive lymphatic drainage - More than 75%, drains into ipsilateral axillary nodes Four Groups of Axillary Nodes 1) Central axillary nodes: high up in middle of axilla, over ribs and serratus anterior muscle; receive lymph from other three groups of nodes 2) Pectoral (anterior): along lateral edge of pectoralis major muscle, just inside anterior axillary fold 3) Subscapular (posterior): along lateral edge of scapula, deep in posterior axillary fold 4) Lateral: along the humerus, inside upper arm Gynecomastia - During adolescence, it is common for breast tissue to temporarily enlarge - Condition is usually unilateral and temporary - Reassurance is necessary for adolescent male, whose attention is riveted on his body image - Gynecomastia may reappear in aging male and may be due to testosterone deficiency Adolescents Breast Growth - Beginning of breast development precedes menarche by about 2 years - Menarche occurs in breast development stage 3 or 4, usually just after peak of adolescent growth spurt around age 12 - Breasts of nonpregnant woman change with ebb and flow of hormones during monthly menstrual cycle - Nodularity increases from midcycle up to menstruation - During the 3 to 4 days before menstruation, breasts feel full, tight, heavy, and occasionally sore; breast volume is smallest on days 4 to 7 of menstrual cycle Pregnant Women - Breast changes start during the second month of pregnancy and are an early sign for most women - Colostrum may be expressed after fourth month Colostrum - This thick yellow fluid is precursor for milk, containing same amount of protein and lactose, but practically no fat - Breasts produce colostrum for first few days after delivery - It is rich with antibodies that protect newborn against infection, so breastfeeding is important Milk Production Lactation, milk production, begins 1 to 3 days post partum Risk Factors for Breast Cancer - Age - Gender - Personal and Family History - Benign Breast Disease - Genetic mutations of BRAC1 and BRAC2 - Increased tissue density - Early Menarche & Late Menopause - Nullparity - HRT after menopause - Late age when giving birth - Radiation exposure - DES exposure in utero - Alcohol use - Diet Age to begin mammograms 45 (get them annually until 55) Breast Self Exam Timing 7 to 10 days after LMP date Pregnant and postmenopausal women should choose specific date Technique Multiple positions Look in mirror, while moving arms Entire breast tissue examined Use pads of fingers Folder towel under shoulder Peau d'orange - When breast has a spotty, orange texture to it - Sign of breast cancer Palpation of Breast - If woman reports a problem, begin with unaffected side first - Gently palpate with 3/4 pads of fingers - Do not lift fingers from breast - Gently compress nipple between index finger and thumb - 1 or 2 hands Breast Cancer Mass Symptoms - Usually unilateral mass - Irregular shape - Poorly delineated from surrounding tissues - Limited mobility, fixed to surrounding tissues - Usually nontender - Hard consistency - Edema (peau d'orange) - Skin erythemic, dimpling, retraction, ulceration - Axillary lymphadenopathy - Nipple discharge: bloody, clear Endometrial Cancer Risk Factors - Age: over 40 - Early menarche/ late menopause - Infertility (pg is protective) - Personal history of ovarian or breast cancer - Family hx of endometrial or breast cancer - Obesity/ high fat diet - Taking tamoxifen Endometrial Cancer Symptoms - Abnormal uterine bleeding/ spotting - Post-menopause - Pelvic mass - Weight loss without trying Cervical Cancer Risk Factors - Human papilloma virus (HPV) - Never or rarely screened for cervical cancer - Early age of 1st intercourse - Multiple lifetime partners/ partners with multiple partners - Smoking - Low SES - FH - DES exposure - Long-term use OCPs - More than 3 term pregnancies - Diet low in fruits/veggies Cervical Cancer Signs and Symptoms - Abnormal vaginal bleeding/ discharge - Lesion on cervix - Post-coital bleeding - Dyspareunia - Pelvic pain Gardasil and Cervarix vaccines Cervical Cancer Prevention HPV - Human Papillomavirus - Common STI - Most people never even know they have HPV because virus usually does not cause any symptoms and body is able to fight it off - However, sometimes virus lingers in a woman's cervix and can cause changes that may eventually lead to cervical cancer - Remind women that obtaining vaccine does not mean they can forget about routine pelvic examinations and Pap tests Ovarian Cancer Risk Factors - Age: after menopause - Early menarche/ late menopause - Infertility drugs - Personal history/ - BRCA1 BRCA2 - Family history of ovarian or breast cancer - Obesity Ovarian Cancer Signs and Symptoms - No symptoms with early stage - Palpation of ovarian mass - Abdominal swelling, bloating, pain - Weight loss/ feeling full quickly - Urinary frequency/ urgency - Pelvic pressure/ pain - Abdominal distention/ ascites Uterine cervix: at end of the canal, projects into the vagina - In nulliparous female, the cervix appears as a smooth doughnut-shaped area with a small circular hole, or os - After childbirth, os is slightly enlarged and irregular Chadwick's sign - Abluish discoloration of the cervix, vagina, and labia resulting from increased blood flow. - It can be observed as early as 6 to 8 weeks after conception, and its presence is an early sign of pregnancy. Priapism A condition in which a penis remains erect for hours in the absence of stimulation or after stimulation has ended. Phimosis Inability to retract foreskin Paraphimosis Inability to place foreskin back into the normal position after retraction hypospadias In boys with hypospadias, the urethra opens in the bottom of the penis rather than the tip. epispadias In boys with epispadias, the urethra opens in top of the penis rather than the tip. discharge of the penis - Urethritis - white/ clear - Gonorrhea or chlamydia- yellow Balantitis A swelling of the foreskin, or head of the penis. Meatal stenosis Pinpoint opening of the urinary meatus Herpes Simplex Virus - HSV-2 - Clear, painful vesicles/ erythematous - Recurrences Condyloma acuminatum - HPV/ Genital warts - Single or multiple - Soft, painless, flesh-color, cauliflower Syphilis chancre - Small papule, starts white turns red - Becomes round, oval ulcer - Nontender, indurated base Scrotum Inspection and Palpation - Asymmetrical - Left lower than right - Transilluminate if a mass is felt Cremasteric reflex - Elicited by lightly stroking or poking the superior and medial (inner) part of the thigh—regardless of the direction of stroke. - The testes with elevate with contraction of muscle Hydrocele - A sac filled with fluid that forms around a testicle. - Painless swelling - Cystic - Transilluminate Scrotal hernia - Swelling; reduced when supine - Nontender, soft mass Sebaceous cyst May be a cause of benign lump in the scrotal skin Cryptochidism - Failure of one or both testes descend - Usu painless but can cause infection if not treated Orchitis - Inflammation (mumps) - Pain heaviness fever - Scrotum enlarged, red Testicular torsion - Twisting of spermatic cord - Painful - Thick cord, swollen tender testis - Emergency Epididymitis - Without sudden pain - Scrotum enlarged, red, swollen, tender Spermatic cord varicocele - Abnormal dilation of veins in cord - c/o pain, heaviness - Palpable tortuous veins - "bag of worms" Spermatocele - Sperm-filled cystic mass on epididymis - Small, movable, nontender - Transilluminate Exam of Anus and Rectum - Inspect perianal area - Skin - Lesions/ scars - Inflammation - Hemorrhoids - Excoriations - Fistula - Perform valsalva maneuver Palpation-Digital rectal exam (DRE) - Insert and rotate finger 360° - Smooth, soft - Nontender - Even tone with tightening - Hemorrhoids - Tenderness - Mass - Lack or/ uneven tone Penile Cancer Risk Factors - Human papilloma virus (HPV) infection - Type 16, 18, 31 - Found in 50% of penile cancer cases - Lack of circumcision as a child - Smegma and phimosis - > age 55 - Smoking - Hx. AIDS Penile Cancer symptoms - Abnormal growths (glans/ foreskin) - Skin color of penis changes color - Red, moist, ulcer - Usually painless Testicular Cancer Risk Factors - Young men 20-30s - Cryptochidism - FH (brother) - Hx of testicular cancer - HIV - Race - Teach monthly self-exams (TSE) - When to begin/ timing Testicular Cancer Symptoms - No early symptoms - Enlarged testicle, lump (painless), swelling, heaviness, achyness in abd or scrotum - Back pain a sign of metastasis Prostate Cancer Risk Factors - Older than 50 - Race - Nationality - FH- esp 1st degree relative, esp brother - Diet high in red meat/ fat dairy Prostate Cancer Symptoms - Early: asymptomatic - Urinary frequency, urgency, nocturia, weak stream, burning on urination, hematuria, lower back pain, impotence Screening for Prostate Cancer - Digital Rectal Exam - Prostate-Specific Antigen (PSA) - Glycoprotein produced by all types of prostate tissue- health and non-healthy tissue - PSA level monitoring (4-10) - Screening- age >50 or earlier for increased risk - Biopsy is definitive dx Costal Angle in patients with COPD - Greater than 90 degrees - Larger angle if patient has COPD or some chronic lung issue No sound in an area of lung tissue Could mean consolidation Where does most mucus build up happen in the lungs The Right Middle Lobe Which lung has greatest risk of aspiration? - Can aspirate food, liquid, own secretions - More often to happen in the right lung because the bronchi is more vertical for the right lung than the left lung - If diminished sound in right but not left, assume possible aspiration AP/T diameter - Normal is 1:2 - AP should be less than T or lateral diameter - If AP becomes larger than T it could mean long standing lung problems Variations in the Aging Patient - Calcified costal cartilages - Decreased mobility - Muscle strength decreased - Alveoli become less elastic (oxygen exchange decreases) - Mucus membranes become drier - Changes in anatomy lead to decreased vital capacity (amount of air you can breathe in), and increased residual volume (air left in your lungs, cant expire air out completely) - Skeletal muscle changes that signal increased work of breathing Kyphosis Back curved out Lordosis Back Curved in Pectus Excavatum - Caved in Ribs - Congenital Paectus Carinatum Extended Rib Cage Stridor - When obstruction is in larynx, bronchi, trachea (large airways) - Inflammation or an object - Can hear when walking into the room Wheezing - When obstruction is in smaller airway - Sound on Expiration - Normal heard in asthmatics Kussmaul - Fast and deep breathing - When in metabolic acidosis - Happens in DKA Cheyne-Stokes - Not good at all - If brain damage or patient over dose - Not compatible with long term of life - Changing rates and depths with periods of apnea Biot/ ataxic - Irregular episodes of tachypnea and apnea - Not compatible with long term of life Respiratory Distress - Patient has trouble breathing - Sitting up - Lip pursing - Nasal flaring - Kids will grunt to help with pressures - Rapid rise and fall - Shallow breaths - Use more muscles to breathe rather than just the diaphragm Crepitus - Crunchy - Air is trapped in subcutaneous tissue - After abdominal surgery or c section - Feel crunchy on skin Pleural friction rub - Classic sound and feel - Leather rubbing on leather - Feel vibration - Inflammation of plerual sac What type of conditions would cause decreased or asymmetric thoracic expansion? COPD, Pneumothorax Tactile Fremitus - Palpable vibration - Sound is generated through larynx (patient makes noise) - Lung tissue is more dense and conducts sound/vibration better - Feel for vibration in lungs - Vibrations transmit well through solids (not air though) - If consolidation - it would transmit really well Tactile Fremitus Technique - Systematic palpation - Client recites "99" - Naturally feel it better over the scapular Decreased or diminished fremitus - Emphysema - Obstruction (Barrier) - Massive edema - Pleural thickening Increased fremitus - Coarse or rough sensations - Consolidations Percussion in lungs - Should be resonate - Dull over bony structures or consolidations - Hyperresonance over hyperinflation Vesicular Sounds Heard over tissue Bronchial Sounds Heard over breathing airways, not tissue Bronchiovesicular sounds Where airway meets tissue Crackles - Clear with cough - Have to do with mucous - Ask them to cough - Adolectysis - where alveoli are collapsed - Sign of fluid in lungs Rhonchi - Low pitched wheeze - Sounds like a snore - Usually due to excessive mucus in airways - Usually clear after coughing - Can be caused by airway narrowing Lobar Pneumonia - Sound dense - Have no sound - Coarse crackles Bronchitis - Wheezing - Coarse crackles because of mucous Heart failure - Build up of fluid - Crackles that wont clear with a cough because of fluid in lungs - Wet crackly sounds Lung Cancer Risk Factors - Tobacco use - Marijuana - Family History - Chemical exposure - Environmental exposure - Race/Gender (Higher in black men) - Risk increasing for women - Recurring lung inflammation - Moderate alcohol intake Lung Cancer Warning Signs - Change in resp. pattern - Persistent cough - Sputum streaked with blood, purulent, rust colored - Hemoptysis (Coughing up blood) - Chest & shoulder pain (Referred pain) - Recurring pleural effusions (Fluid build up between membrane and lung tissue) Epigastric - Top middle region of abdomen - Epigastric hernia - Stomach ulcer - Pancreatitis - Gallstones - Heart Burn Umbilical - Middle, middle region of abdomen - Pancreatitis - Early appendicitis - Stomach ulcer - IBD - Small bowel umbilical hernia Hypogastric - Bottom middle region of the abdomen - UTI - Appendicitis - Diverticular Disease - IBD - Pelvic pain Left Hypochondriac - Top left region of abdomen - Gallstones - Stomach Ulcer - Pancreatitis Right Hypochondriac - Top right region of abdomen - Duodenal ulcer - Stomach Ulcer - Bilary colic - Pancreatitis Left lumbar region of abdomen - Left middle region of abdomen - Kidney stones - UTI - Constipation - Lumbar hernia Right lumbar region of abdomen - Right middle region of abdomen - Kidney stones - Diverticular disease - Constipation - IBD Left Inguinal region of abdomen - Left lower region of abdomen - Appendicitis - Pelvic pain - Constipation - Groin Pain - Inguinal Hernia Right inguinal region of abdomen - Right lower region of abdomen - Diverticular disease - Pelvic pain - Groin Pain - Inguinal hernia Abdomen Physical Exam - Empty bladder! - Inspect - Auscultate - Palpate - Percuss - Assess tender areas last Cullen sign - Pancreatitis - Round red circle on abdomen Diastis Recti - Abdominal Separation - Common prenatal and postpartum proble Pulsations of the Abdomen - Normally you may see pulsations from aorta beneath skin in epigastric area, particularly in thin persons with good muscle wall relaxation Peristalsis could indicate what? - An obstruction - Peristalsis before obstruction - Nothing after obstruction Borborygmus - Hyperactive bowel sounds - The sound of hyper peristalsis (stomach growling ) Hypoactive - Decreased BS- few and far between - Absent- silent x 5 minutes of continual listening Kidney percussion/palpation area Costovertebral angle How to assess for Ascitic fluid - Fluid Wave Ulnar surface of your hand at midline "Strike" the flank - Shifting Dullness Where does fluid go? - Percussion Dullness in areas of fluid - Tympany over empty abdomen Blumberg Sign - Peritoneal inflammation, possible appendicitis - Rebound tenderness Murphy's Sign - Place fingers under the liver border and pt holds their breath - Should not elicit pain - Gallbladder inflammation Iliopsoas muscle test - Client raises right leg- examiner pushes down on right thigh - Does client c/o pain in RLQ? McBurney's Point - Pain with appendicitis Bowel Obstruction S/S - Vomiting - Absence of stool or gas - Dehydration - Fever - Pressure from excess fluid and gas (distention) - Hypovolemic shock Hypovelmic shock - Low BP - High pulse - Cool skin Risk Factors for Colon Cancer - Age older than 50 years (push for 45 years) - Family history - Personal history - Colon cancer - Polyps - Inflammatory bowel disease - Ovarian or endometrial cancer - African Americans - Diet low in fiber high in red meat - Obesity - Smoking - Lack of exercise - Heavy alcohol use - Diabetes Type 2 Relaxation or incompetence of the lower esophageal sphincter causes: GERD Borborygmi sounds are: High-pitched tinkling sounds Atrioventricular Valves - Rt. Atrium/Ventricle (Tricuspid valve) - Lt. Atrium/Ventricle (Mitral valve) Semilunar Valves - Rt. Ventricle/ PA (Pulmonic valve) - Lt. Ventricle/ Aorta (Aortic valve) Try pulling my arm - Tricuspid valve - Pulmonary valve - Mitral valve - Aortic valve Diastole - "filling stage" - Blood moves from atria to ventricles (third heart sound). = S3 - AV valves open - passive filling into ventricles - ventricles dilate, & rest - Causes complete emptying of atria (fourth heart sound). = S4 Systole - "emptying stage" - ventricular pressure rises - AV valves close!! - semilunar valves open - blood is ejected from heart into Pulmonary artery or Aorta - Ventricles contract - s1 sound s3 - ken - tuc - KY - Sometimes called the ventricular gallop - Occurs after s2 - Can be heard in young adults and children, and will usually disappear when sitting up, does not vary with respirations - In adults it can mean heart failure, volume overload, valve problems, high cardiac output states (hyperthyroidism, anemia, pregnancy) - Heard best at apex of heart s4 - Heard best at base of heart - TEN - nes- see - Sometimes called atrial gallop - Older adults (elderly) after exercise would be a normal variation - In adults it can mean CAD, cardiomyopathy, aortic stenosis, HTN Jugular vein distention - Reflects right side of the heart, no valve b/w svc and right atrium. Thrill turbulant blood flow, correlates with murmur, cardiac enlargement (occupies a greater space) A palpable rushing vibration over the base of the heart is called a: Thrill; Rationale: A thrill is a fine, palpable, rushing vibration; a palpable murmur. Heave A heave is a prolonged, stronger than normal contraction of the heart. This is most ofter felt of the right ventricle and is indicative of right ventricular hypertrophy, or enlargement of the right ventricle. Venous Insufficiency - Constant pain - Skin warm - Brown discolored/Erythema/ cyanosis - Engorgement of veins - Pulses palpable (weak - bounding) - Tenderness - Edema - Pitting/ nonpitting - Homan sign + - Varicose veins Atrial insufficiency - Claudication - Pain with activity - Weak or absent pulses - Bruits - Pallor/ cyanosis/cool - Thin skin/atrophy, shiny skin - Loss of hair - Nails thick - Ulcer - Allen test Allen Test - Constrict blood in arm - Release ulnar artery first to see if blood flow returns- avoid radial cannulation Homan Sign Calf pain with passive dorsiflexion of the foot Three P's of occlusion - Pain - Pallor - Pulsnessness Increased RR - Fever - Asthma - Dehydration - COPD - Hyperventilation - Lung conditions - Infections - Newborns - Acidosis - Overdoses - Heart Conditions Decreased RR - Brain conditions - Use of narcotics - Sleep apnea - Metabolic - Alcohol B. Denial The spouse is exhibiting the first stage of denial (B) of Kubler-Ross's grief model by ignoring that the client's death is imminent (A, C, and D) are stages of grief that are not being displayed by the client's spouse during this observation. The registered nurse (RN) notifies the spouse of a client who was admitted to hospice with shallow respirations, of a change in the client's condition. Over the past hour, the client's respiratory pattern has changed to a Cheyne Stokes pattern. After receiving this information, the client's spouse begins vacuuming around the bed. Which stage of grief is the spouse displaying during the visit? A. Acceptance B. Denial C. Bargaining D. Depression A. Cold applications produce a topical anesthetic effect to reduce pain as well as constrict blood vessels to minimize bruising (A). Local ice over an injured area will not lower the core temperature (B). The cold pack causes vasoconstriction which reduces circulation, not (C), to traumatized tissue and limits further edema around the injury (D), but not by reabsorption of edematous fluid. The registered nurse (RN) places an ice pack on a middle school student who comes to the school clinic complaining of a sprained ankle. Which therapeutic response should the RN anticipate? A. Reduced pain and minimized bruising. B. Lowering of body core temperature. C. Increased circulation around injury. D. Reabsorption of edema at injury. A. Diminished hair on legs C. Skin cool to touch. Diminished hair on the legs (A) and skin that is cool to the touch (C) are symptoms of decreased arterial blood flow. (B, D, and E) are not indicators for impaired circulation. The registered nurse (RN) palpates a weak pedal pulse on the client'rs right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation (Select all that apply.) A. Diminished hair on legs. B. Bruising on extremities. C. Skin cool to touch. D. Capillary refill less than 3 seconds. E. Darkened skin on extremities. C. Lethargy Changes in the level of consciousness occur in the early stages of shock which decreases the perfusion to the brain which is manifested as lethargy (C). The respiratory rate increases, not (D). (A and B) are late signs of hypovolemic shock due to cardiac compensatory measures. Twenty four hours after a client returns from surgical gastric bypass, the registered nurse (RN) observes large amounts of blood in the nasogastric tube (NGT) cannister. Which assessment finding should the RN report as early signs of hypovolemic shock? A. Faint pedal pulses B. Decrease in blood pressure. C. Lethargy. D. Slow breathing. D. Rise slowly when getting out of bed or chair. The client's new medication is an angiotensin-converting enzyme (ACE) inhibitor, which has the side effect of orthostatic hypotension. Instructing the client to rise from a chair or bed slowly (D) is indicated to avoid dizziness and falling. (A, B, and C) are not indicated when taking an ACE inhibitor. The registered nurse (RN) is caring for a client who has taken atenolol for 2 years. The healthcare provider recently changed the medication to enalapril to manage the client's blood pressure. Which instruction should the RN provide the client regarding the new medication? A. Take the medication at bedtime. B. Report presence of increased bruising. C. Check pulse before taking medication. D. Rise slowly when getting out of bed or chair. A. Prepare the client for a chest x-ray at the bedside. A chest x-ray (A) should be performed immediately after the procedure to ensure lung expansion has been maintained after removal of the chest tube. (B) provides additional data after removal of the CT. (C) may assist the client to breathe easily, but the priority after chest tube removal is to ensure that the procedure was successful. The entire system, including the chest tube is discarded and not taken apart (D). The registered nurse (RN) is assisting the healthcare provider (HCP) with the removal of a chest tube. Which intervention has the highest priority and should be anticipated by the RN after removal of the chest tube? A. Prepare the client for chest x-ray at the bedside. B. Review arterial blood gases after removal. C. Elevate the head of the bed to 45 degrees. D. Assist with disassembling the drainage system. D. A fracture that bends or splinters part of the bone. An incomplete fracture (D) occurs through part of the thickness of bone. A linear (A) and a spiral fracture (B) describe the direction of the fracture line. An open fracture (C) is a compound fracture that breaks through the skin. A male client is admitted after falling from his bed. The healthcare provider (HCP) tells the family that he has an incomplete fracture of the humerus. The family asks the nurse what this means. Which type of fracture should the RN explain from these findings? A. Straight fracture line that is also a simple, closed fracture. B. Nondisplaced fracture line that wraps around the bone. C. A complete fracture that also punctures the skin. D. A fracture that bends or splinters part of the bone. A. Hematemesis B. Gastric pain on an empty stomach D. Intolerance of spicy foods (A, B and D) correct. Manifestations of PUD include hematemesis (A), gastric pain (B), and spicy food intolerance. (C) is consistent with cholecystitis (D). (E) is not consistent with PUD. The registered nurse (RN) is caring for a client with peptic ulcer disease (PUD). What assessment should the RN identify that is consistent with PUD? (Select all that apply) A. Hematemesis B. Gastric pain on an empty stomach C. Colic-like pain with fatty food ingestion D. Intolerance of spicy foods E. Diarrhea and stearrhea D. A client who has chronic constipation (D) often strains to pass constipated stool which increases intestinal pressure that weakens the intestinal walls and causes out-pouching sacs, called diverticula which commonly occur in the signmoid. Regular use of laxatives (A) can result in the bowel's dependency on the laxative to stimulate intestinal motility, but constipation due to lack of fiver in diet, not (C), is a predisposing factor for formation of diverticula. Growths that protrude into the colon lumen are polyps (B), which are often pre-cancerous lesions. A client is newly diagnosed with diverticulosis. The registered nurse (RN) is assessing the client's basic knowledge about the disease process. Which statement by the client conveys the client's understanding of the etiology of diverticula? A. Over use of laxatives for bowel regularity result in loss of peristaltic tone. B. Inflammation of the colon mucosa that cause growths that protrude into the lumen. C. Diverticulosis is the result of high fiber diet and sedentary life style. D. Chronic constipation causes weakening of colon wall which result in out-pouching sacs. C. In some Asian cultures, it is not appropriate to look a person of authority in the eyes, so the client is being respectful bu looking down while speaking with the nurse (C). (A, B, and D) does not reflect behaviors common to Asian culture. The registered nurse (RN) is caring for an Asian client who refuses to make eye contact during conversations. How should the RN assess this client's response? A. The client cannot understand the nurse. B. The client is uncomfortable with the nurse. C. The client is treating the nurse with respect. D. The client is purposefully disrespecting the nurse. A. A decrease in urine output is a sign of dehydration. When the urine output returns to a normal range, 40 ml/hour (A), the client's kidneys are perfusing adequately and indicates the client's status is stabilizing. A blood pressure of 76/42 (B) and tented skin (D) are consistent with dehydration and possible hypovolemia, however the client's urine output is improving. Specific gravity of 1.001 is indicative of the kidney's ability to concentrate urine adequately. The registered nurse (RN) is caring for a client who developed oliguria and was diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding indicates to the RN that the client is stabilizing? A. Urine output of 40 ml/hour B. Apical pulse 100 and blood pressure 76/42. C. Urine specific gravity of 1.001. D. Tented skin on the dorsal surface of the hands. B Orthostatic hypotension (B) can be a sign of fluid volume deficit in an older adult client who has experienced severe diarrhea. (A and C) are signs of excess fluid volume. Cheyne Stocks respirations (D) is an abnormal breathing pattern often seen in a client who is near death. An older client is admitted to the hospital with severe diarrhea. The registered nurse (RN) is completing an assessment and notes the client has dry mucous membranes and poor skin turgor. Which assessment data should the RN gather to determine if the client has fluid volume deficit? A Combination therapy is necessary to decrease the development of resistant strains of TB (A) and ensure treatment effectiveness. (B, C, and D) are not the rationales for multiple drug protocol for TB. The registered nurse (RN) is caring for a client with tuberculosis (TB) who is taking a combination drug regimen. The client complains about taking "so many pills." What information should the RN provide to the client about the prescribed treatment? A. The development of resistant strains of TB are decreased with a combination of drugs. B. Compliance to the medication regimen is challenging but should be maintained. C. Side effects are minimized with the use of a single medication but is less effective. D. The treatment time is decreased from 6 months to 3 months with this standard regimen. A The two hour postprandial level should be less than 140 mg/dl for a young adult client (B). (A, C and D) are elevated and not normal at 2 hours after ingesting the glucose solution. The registered nurse (RN) is caring for a young adult who is having an oral glucose tolerance test (OGTT). which laboratory result should the RN assess as a normal value for the two hour postprandial result? A. 140 mg/dl B. 160 mg/dl C. 180 mg/dl D. 200 mg/dl C Vital signs should be checked every 10 to 20 minutes (C) to assess for bleeding after biopsy of the liver, which is highly vascular. The client should be positioned on the right side, not the left (A), with a pillow or sandbag under the costal margin and supporting the biopsy site. Voiding immediately after the procedure (B) is not the highest priority intervention after a liver biopsy. The client should be maintained on bedrest (D) for several hours to decrease the risk of bleeding from the biopsy site. After a liver biopsy is performed at the bedside, the registered nurse (RN) is assigned the care of the client. Which nursing intervention is most important for the RN to implement? A. Position the client on the left side with pillow placed under the costal margin. B. Assist the client with voiding immediately after the procedure. C. Evaluate teh vital signs q10 to 20 minutes for every 2 hours after the procedure. D. Ambulate client 3 times in first hour with pillow held at abdomen. B Closed angle glaucoma C Chronic hypertension (B and C) are correct. OTC decongestants can increase intraocular pressure and should be avoided in clients with closed angle glaucoma (B). Decongestants can increase the heart rate and blood pressure which impact the client's management of chronic hypertension (C). Although the healthcare provider should be informed of all medications taken, (A, D, and E) are not directly affected by a decongestant. While reviewing the client's electronic medical record (EMR), the registered nurse (RN) assesses a client who is at risk for possible interaction with an over-the-counter (OTC) decongestant. Which client health history should the RN report to the healthcare provider concerning the OTC medication? (Select all that apply) A. Type I diabetes mellitus (DM) B. Closed angle glaucoma C. Chronic hypertension D. Rheumatoid arthritis E. Crohn's disease B RLQ rebound abdominal tenderness (B) may be related to acute appendicitis and should be reported to the healthcare provider. (A, C and D) are expected findings associated with gastroenteritis that are not urgent findings or life threatening. The registered nurse (RN) is evaluating a client who presents with symptoms of gastroenteritis. Which assessment finding should the RN report to the healthcare provider? A. Dry mucous membranes and lips. B. Rebound abdominal tenderness over right lower quadrant. C. Dizziness when client ambulates from a sitting position. D. Poor skin turgor over client's risk. A. All alcohol (A) and any foods that contain tyramine should be avoided while taking an MAO inhibitor, which interact to cause a hypertensive crisis. (B and C) should be discussed, but are not as important as (A). Although assessing blood pressure and pulse may be indicated, it is not necessary prior to taking each dose (D). The registered nurse (RN) reviews the new prescription, phelezine, a monoamine oxidase inhibitor (MAOI), for a client on the psychiatric unit with depression. Which information is most important for the RN to assess? A. Consumption of any alcohol or tyramine-rich foods. B. Complaints of nausea or vomiting. C. Therapeutic serum drug levels. D. Blood pressure and pulse prior to taking each dose. B When completing an assessment, the RN should maintain eye cotnact with the client (B) to gather additional information from the client's nonverbal cues. (A, C, and D) do not use both verbal and nonverbal communication techniques to gather data during an assessment. Which actions should the registered nurse (RN) implement to complete an assessment for a client using an interpreter? A. Ask close-ended questions with assistance of the interpreter. B. Maintain eye contact with the client while listening to the translation. C. Instruct interpreter to answer questions from the interpreter's point of view. D. Protect the client's privacy by asking a limited number of questions. A A chronic seasonal cough related to bronchitis is likely accompanied with phlegm production and wheezing (A). Although smoking can contribute to chronic cough, the typical seasonal cough is an inflammatory reaction to seasonal changes (B). Hemoptysis (C) or a "new" cough or changes in a persistent chronic cough is likely related to lung cancer (C). Night sweats (D) is a trend in fever that is often seen with tuberculosis. The registered nurse (RN) is interviewing a female client who states she has a persistent cough during the winter caused by bronchitis. Which additional finding should the RN assess for bronchitis? A. Phlegm production and wheezing. B. Smoking history C. Hemoptysis D. Night sweats A, B, C, E (A, B, C, and E) are correct. To ensure compliance, language (A), education (B), lifestyle (C), and financial resources (E) should be considered when preparing the client's discharge instructions about continued treatment of TB. (D) does not directly impact compliance with long term treatment of TB. The registered nurse (RN) is teaching a client who is being discharged after treatment of tuberculosis (TB). Which cultural issues should the RN assess when preparing the client for discharge? (Select all that apply.) a. native language b. education level c. type of lifestyle d. previous medical history e. financial resources A Checking the pH of the aspirate (A) is the best method to validate that the NGT is not displaced and should reveal an acidic pH of 1.5 to 3.5 due to presence of gastric acid. (B, C and D) are not reliable methods to ensure NGT placement in the stomach. The registered nurse (RN) is caring for a client with a newly placed nasogastric tube (NGT). Once the placement of the NG tube is verified by x-ray, which technique should the RN use as a reliable method to ensure the NGT is not displaced? a. check the pH of aspirated stomach contents obtained from the NGT b. auscultate over the epigastrium while injecting air into the NGT c. disconnect and place the end of NGT in water to see if bubbles appear d. listen for hyperactive bowel sounds in all four quadrants in the abdomen A, C, E (A, C, and E) are correct, and these interventions aid the client in maneuvering through the stages of grieving and establishing a foundation to continue life. Assisting the client in finding the support group and sharing stories of other clients can be miscontrued as a violation of HIPPA rights of other clients (B). Each client deals with grief differently, so offering a time line for grieving (D) is not an expected outcome for this client and offers false reassurance. A client is admitted for dehydration, weight loss, and a flat affect. After reviewing the client's history, the registered nurse (RN) discovers that the client's spouse died 2 weeks ago. Which nursing interventions should the RN implement to help the client begin the process of dealing with loss? a. Establish trust by creating a safe atmosphere for sharing. b. Share personal stories about how other clients dealt with grief. c. Help the client identify ways to adapt lifestyle to accommodate loss. d. Assure the client that their grief will last a short period of time. e. Explore ways to assist the client to make new emotional investments. D A characteristic finding of DI is excretion of large quantities of urine (5 to 20L/day), and most clients compensate for fluid loss by drinking large amounts of water (polydipsia) (D). (A) is indicative of an infection, not DI. (B) can be characteristic of hypovolemia, but not an initial finding of DI. Muscle rigidity (C) can be a serious manifestation of a closed head injury that requires immediate action, but is not related to DI. The registered nurse (RN) is caring for a client who has a closed head injury from a motor vehicle collision. Which finding should the RN assess the client for the risk of diabetes insipidus (DI)? a. high fever b. low blood pressure c. muscle rigidity d. polydipsia D Pursed lip breathing helps eliminate CO2 (D) by increasing positive pressure within the alveoli which makes it easier to expel air from lungs. (A, B and C) do not explain the reason for using pursed lip breathing. The registered nurse (RN) is teaching a client who is newly diagnosed with emphysema to perform pursed lip breathing. What is the primary reason for teaching the client this method of breathing? a. Decreases respiratory rate b. Increases O2 saturation throughout the body c. Conserves energy while ambulating d. Promotes CO2 elimination D The RN should ask the client if he has a history of ulcerative colitis (D), which is characterized by these presenting symptoms. Irritable bowel (A) often includes irregular bowel movements with constipation. Diverticulitis (B) is related to constipation, bowel irregularity and cramping. Crohn's disease (C) can cause constipation or diarrhea, abscess formation, and abdominal cramping, but tenesmus is rare. The registered nurse (RN) is assessing a male client who arrives at the clinic with severe abdominal cramping, pain, tenesmus, and dehydration. The RN discovers that the client has had 14 to 20 loose stools with rectal bleeding. Which condition should the RN ask the client about his medical history? a. Irritable bowel syndrome b. diverticulitis c. Crohn's disease d. ulcerative colitis C, D (C and D) are correct. Beta 2 receptor agonist agents provide immediate return of airflow and resolve wheezing (C) and improve oxygenation (D). (A and B) are side effects. (E) is not an expected response. The registered nurse (RN) is making early morning rounds on a group of clients when a client begins exhibiting symptoms of an acute asthma attack. The RN administers a PRN prescription for a Beta 2 receptor agonist agent. Which client response should the RN expect? a. tachycardia b. increased blood pressure c. rapid resolution of wheezing d. improved pulse oximetry values e. reduce fever airway inflammation A, C, E Communication techniques for clients with cognitive impairments should be simple (A), without environmental distractions (C), and direct (E). (B) increases anxiety in a client, so it is important to give the client time to answer a question before moving to the next one. (D) is the family's view of the client's mental status and does not give the RN an objective view of the client's cognitive impairment. A registered nurse (RN) is performing a mini-mental state examination (MMSE) for a client who is being admitted to an assisted living community. Which communication techniques should the RN implement to decrease anxiety in the client? (Select all that apply.) A. Use simple sentences during the examination. B. Move to another question if the client seems confused. C. Reduce environmental detractors during the examination. D. Allow family to answer for the client to decrease frustration. E. Ask questions one at a time to decrease confusion. A All alcohol (A) and any foods that contain tyramine should be avoided while taking an MAO inhibitor, which interact to cause a hypertensive crisis. (B and C) should be discussed, but are not as important as (A). Although assessing blood pressure and pulse may be indicated, it is not necessary prior to taking each dose (D). The registered nurse (RN) reviews the new prescription, phenelzine, a monoamine oxidase inhibitor (MAOI), for a client on the psychiatric unit with depression. Which information is most important for the RN to assess? A. Consumption of any alcohol or tyramine-rich foods. B. Complaints of nausea or vomiting. C. Therapeutic serum drug levels. D. Blood pressure and pulse prior to taking each dose. A Sarcoidosis, an autoimmune inflammatory disease affecting multiple organs, has shown presence in relatives due to multiple genes that together to increase the susceptibility of developing the disease, which most commonly occurs in African American women and women of Northern European heritage (A). (B, C, and D) have a lower percentage of women affected by sarcoidosis than African American women. A female client is recently diagnosed with Sarciodosis. The client tells the registered nurse (RN) that she does not understand why she has this. When teaching about the occurrence of sarcoidosis, the RN should include that sarcoidosis most commonly occurs with which ethnic group of women? A. African American women B. Caucasian women C. Asian women D. Hispanic women A Headache, nausea, blurred vision and insomnia are symptoms of excessive use of ipratropium, so withholding the medication (A) until the healthcare provider is notified should be initiated to maintain client safety. If the symptoms continue and are not addressed immediately, then (B, C, and D) may place the client in imminent danger. A client who uses ipratropium reports having nausea, blurred vision, headaches, and insomnia after using the inhaler. Which action should the registered nurse (RN) implement first? A. Withhold medication and report symptoms and vital signs to healthcare provider. B. Give PRN medication for nausea and vomiting and evaluate client in 30 minutes. C. Reassure client that the ipratropium given will alleviate the symptoms. D. Delay administration of ipratropium until next maintenance medication is scheduled. B Troponin (B) is the most sensitive and specific test for myocardial damage. Troponin elevation is more specific than CK-MB (A). (C) can be elevated when there is skeletal muscle damage. (D) can be elevated nonspecifically and create false positives, so is not a reliable choice. A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for evaluation for Acute Coronary Syndrome (ACS). Which cardiac biomarker should the registered nurse (RN) anticipate to be elevated if the client experienced myocardial damage? A. Creatine Kinase (CK-MB) B. Serum troponin C. Myoglobin D. Ischemia modified albumin D A client with a large bone fracture is at risk for intramedullary fat leaking into the blood stream and becoming embolic. Dyspnea is an indication of fat embolism to the lungs and should be reported to the healthcare provider immediately. (A, B, and C) are expected findings after a fall and do not require immediate notification of a healthcare provider. The registered nurse (RN) is caring for an older client who recently experienced a fractured pelvis from a fall. Which assessment finding is most important for the RN to report to the healthcare provider? A. Lower back pain B. Headache of 7 on scale of 1 to 10 C. Blood pressure of 140/98 D. Dypsnea A Maintaining hemodynamic stability in a client with esophageal varices can precipitate a life-threatening crisis if esophageal varies leak or rupture and can result in hemorrhage. The priority is assessing and monitoring infusions of IV fluids and any replacement blood products (A). The healthcare provider should be present during (B and D) in the event the client's esophageal varies rupture and bleed profusely. Bedrest (C) is not a priority at this time. While caring for a client who has esophageal varices, which nursing intervention is most important for the registered nurse (RN) to implement? A. Monitor infusing IV fluids and any replacement blood products B. Prepare for esophagogastroduodenoscopy (EGD) C. Maintain a client on strict bedrest D. Insert a nasogastric tube (NGT) for intermittent suction D Stiffness in joints is an early sign of contractures and muscle atrophy (D) related to inactivity and immobility. Decreased pedal pulses (A), upper extremity (B) and a loss of appetite (C) are not directly related to immobility. The registered nurse (RN) is caring for an older client who has been bedridden for two weeks. Which assessment findings indicate to the RN that the client is developing a complication related to immobility? A. Decreased pedal pulses B. Edema in upper extremities C. Loss of appetite for food D. Stiffness in right ankle joint B The first priority of a successful physical assessment is establishing rapport with the client. Having the client sign the admission forms, taking his vital signs, and obtaining equipment are also impo