Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Bingbopboop2
hesi pratice
| Question | Answer |
|---|---|
| The nurse asks a female client about the proverb "Glass Houses, " and she replies, "It will break the windows.". Which conclusion should be documented about this client's response? | impaired thinking |
| In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding? | left carotid artery bruit present; no bruit heard in the right carotid artery |
| To assess a client's pupillary reaction to accommodation, what action should the nurse take? | Observe pupil size when focusing on a near object and then a far object. |
| During an abdominal assessment, a client with a temperature of 103° F (39.4° C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement? | Nothing by mouth |
| When inspecting an adult woman's skin the nurse observes several areas of ecchymosis on her trunk and extremities. Which information in the client's history requires additional follow-up by the nurse? | Takes an oral anticoagulant |
| While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take? | Use a doppler ultrasonic stethoscope |
| The nurse is examining an older female client and suspects that she has a dysfunction in her hip region. Which procedure should the nurse perform to further assess for hip dysfunction? | abduct each hip while the client is supine |
| While auscultating a client's abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding? | Possible renal artery stenosis |
| An adult client exhibits an allergic reaction to an Insect bite. The nurse should observe the client's skin for which finding? | wheals |
| When assessing a client's rectal bleeding, which findings should the nurse document? | Color characteristics of each stool |
| An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks for a urine sample. the client returns with only a few drops of urine. Which action should the nurse implement? | Evaluate the client for bladder distention. |
| "Maybe I have lung cancer or something," and wants to get checked out since, "I can't seem to get rid of this body-wracking dry cough that has been hanging around for the last six weeks." What to document? | Describe having a "body-wracking dry cough" of 6 weeks duration. |
| A client is being evaluated for environmental allergies. While examining the client's nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis | Intranasal edema and swelling of turbinates. |
| While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information? | open ended questioning |
| When assessing the mid abdominal region of a client with an abdominal aortic aneurysm, which action should the nurse implement? | auscultate for bruit (IF NGN "turn off suction" for multiple answers) |
| The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle? | Sharp, severe pain |
| A adult client presents with complaints of gnawing epigastric pain. The pain is worse when is hungry and abates if he eats something. What problem do these symptoms suggest? | Peptic ulcer disease (PUD) |
| An older male client reports to the nurse that his feet are cold. Before covering the client's feet which assessment should the nurse complete? | assess volume of pedal pulses observe color of the feet and toes palpate dorsal surface of feet for warmth |
| The nurse should anticipate difficulty visualizing the point of max imal impulse (PMI) in which client? | A 54-year-old who is 5 feet (152.4 cm) tall and weighs 300 pounds |
| The nurse observes the presence of brittle, concave curves to the nails of a client on assessment. Which information should the nurse obtain from the client that may explain the appearance of the nails? | Iron deficiency anemia. |
| In obtaining a client's health history related to smoking cigarettes, the nurse plans to determine the client's smoking pack years. What information should the nurse obtain for this calculation? | Packs of cigarettes smoked per day. Number of years the client smoked |
| The nurse observes an older adult client walking aimlessly in the hallway and staring straight ahead with a blank expression. How should the nurse enter documentation of this finding in the client's electronic medical record (EMR)? | Wandering behavior with flat affect |
| rheumatroid arthritis | applicible swollen joints -small joints of the hand -fever and fatigue-morning stiffness-symmeterical involvement |
| When performing a neurological assessment on an alert client, the nurse observes that the client's pupils are both round, 3mm in size and responds briskly to life. Which notation should the nurse use when documenting the assessment | PERRL |
| While interviewing a newly admitted older female client, the nurse observes that the client ignores questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first? | Stand directly in front of the client and ask about any hearing loss. |
| The nurse is assessing a young adult female who is 5'5 and has a BMI score of 32. Based on this BMI, what should the nurse deduce about this client's general health? | Obese, serious threat to well-being |
| In assessing tactile fremitus in the client with suspected pneumo nia, the nurse should perform which action? | Place the palm of the hand on the chest wall to feel vibrations while the client speaks |
| While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. what does this indicate? | Cardiac enlargement |
| A client complains of stomach pain and localizes it in the middle section of the abdomen below the xiphoid process. Which abdominal location should the practical nurse document the client's pain? | epigastric region |
| The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. Which question should the nurse ask first? "Have you..." | Been sleeping well? |
| An adolescent female client comes to the clinic troubled by breast tenderness b 4 menstrual periods. On examination, the nurse notes generalized lumpiness of both breasts w/ no discrete masses and no nipple discharge. Which action should the nurse take? | Request a return visit after her menstrual period for a breast exam re-check |
| The nurse is examining a female who states she has no complaints has not had a physical examination 5+ years. The nurse palpates enlarged lymph nodes in the axilla. Which findings is most importantto report to the healthcare provider? | -nontender, firm lymph nodes |
| When family members express their concern about their father's recent memory loss, which assessment should the nurse suggest | determine if the client can recall what he ate for breakfast |
| Which assessment finding supports the client statement, "my feet swell all the time"? | 2+ pitting edema of the ankles bilaterally |
| The nurse examines a client's right great toe. The joint is red, edematous, and very painful with limited range of motion. The client's serum uric acid levels are elevated. Which action should the nurse tell the client to make? | Encourage fluid intake |
| the nurse assesses a client who comes to the clinic with neck stiffness and discomfort. Which finding of the cervical spine should the nurse inquire further about lifestyle habits | evaluation of the cranial nerve xi flexion |
| Client w/ itching and pain in the left ear started several days after beginning swimming lessons. The nurse observes discharge coming from the air with musty odor. How should the nurse expect the year to appear when performing in otoscopic examination | red, edematous ear canal with no visualization of the tympanic membrane |
| The nurse completes palpation of the thoracic region on an adolescent client. Which finding is considered normal for this adolescent client? | Nontender |
| The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While interviewing the client, which assessment technique should the nurse use when asking about the client's use of illegal drugs and alcohol? | Ask specifically about alcohol, marijuana, cocaine, heroin, and amounts. |
| To objectively confirm the presence of fever, before taking the client's temperature, which action should the nurse take? | Place the dorsum of the hand on the client's forehead. |
| The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding | Hematocrit. |
| While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perineal area and anus. Which findings indicates a normal appearance of the anus? | Increased pigmentation and coarse skin. |
| During assessment of a client's abdomen, the nurse observes that the client's umbilicus is depressed and below the surface of the abdomen. What action should the nurse take in response to the observation? | Document the normal finding |
| Which skill should the nurse have an older client demonstrate to evaluate performance of daily living activities? | Sorting a collection of socks |
| After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high pitched almost continuous gurgling in two quadrants. Which action should the nurse implement? | Auscultate the remaining two quadrants. |
| A male client who is admitted for an acute brain attack reports the onset of burning sensation in his hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client's paresthesia | evaluate clients muscle strength and hand grips |
| A client grimaces while preforming range of motion of the left knee during an annual health assessment. Which movements should the nurse utilize to assess the client's ability to normally perform range of motion on the right knee? | extension, flexion and hyperextension |
| While observing a client's face, which assessment finding requires immediate intervention by the nurse? | Oral mucosa is cyanotic. |
| While assessing the legs of client, nurse observes leathery-looking skin. The client reports aching tired legs that swell if she stands for long periods of time. To screen for venous insufficiency, the nurse should ask the client if she has experienced | Decreased pain when legs are elevated. |
| The nurse is assessing a client with gallstones for jaundice. Which action should the nurse perform to confirm this information? | Examine client's sclera for icterus. |
| performs two-point discrimination test by applying 2 needles lightly to fingertips and moving needle tips in ever-closing distances. client senses 2 points at distance of 3 mm on the fingers and 10 mm on palms. Which finding is accurate? | Normal sensory finding |
| While auscultating for bowel sounds in a 35-year-old male client the nurse notes a series of gurgles that lasts about 3 seconds and occur every five to 10 seconds in all quadrants. What does this finding indicate? | Normal bowl sounds |
| While completing an admission assessment, the nurse is unable to palpate the client's left dorsalis pedis (DP) pulse. Which inter vention is most important for the nurse to implement? | Use a Doppler to assess an audible DP pulse |
| Which is best approach for the nurse to use when interviewing a client about mental illness? | Begin with questions that are less sensitive in nature |
| The nurse completes palpitation of the abdomen on an older adult client. Which finding is considered normal for the client? | Peristaltic waves |
| The nurse has just completed palpation maneuvers for lymph nodes on an older adult female client. Which findings are considered normal for this elderly client? | Nodes are non-palpable |
| The nurse observes a red rash located in multiple body folds of an obese client. Went interviewing the client which information is most important for the nurse to obtain? | current medication use |
| When conducting a physical exam the nurse uses a tuning fork to assess for which condition | Hearing loss |
| 1. While interviewing an elderly client, the nurse observes that the client's hands tremble uncontrollably while reaching for a glass of water. How should the nurse document this finding? | intention tremor |
| During the admission assessment, a male client admitted with chest pain states he has no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take? | Ask the client how many pillows he sleeps on at night |
| A 20-year-old nulliparous female college student sees the nurse because she has missed her nurse requests a pregnancy test, which is negative. Based on this client's history, which assessment is most important for the nurse to obtain? | Body weight, hirsutism, thyroid enlargement |
| The nurse is assessing the perianalvare of a female client who states she has chronic constipation and has bright red blood on the toilet paper after having a bowel which finding the nurse report that is most consistent with ct complaints | Shiny blue skin sacks around the anal opening and a liner split |
| which finding should raise the greatest concern for a nurse who is performing an ear nose and throat ENT examination? | An ulceration under the tongue that has been present for the last three weeks |
| A male client reports the onset of a burning sensation in his hands and legs. How should the nurse document this finding in the electronic medical record? | Paresthesia reported |
| The school nurse is interviewing a 13-year-old girl who wants to go home from school because of "back pain". Which question should the nurse ask the adolescent first? | What were you doing when you first noticed this problem? |
| When family members expressed their concern about their father's recent memory loss, which assessment should the nurse suggest? | Determine if the client can recall what he ate for breakfast |
| while conducting a physical assessment the nurse shines a pen light into the client's right eye and moves the light source to check the clients left eye which finding indicates the need for further evaluation | The left iris is notched and the pupil size changes immediately |
| The nurse examines a client admitted with a deep, constant pain in the abdomen that radiates to the back. Which finding is most important for the nurse to report to the healthcare provider? | An audible abdominal bruit |
| The nurse examines a client's right great toe. The joint is red, edematous, and very painful with limited range of motion. The client's serum uric acid levels are elevated. Which action should the nurse tell the client to make? | Encourage fluid intake |
| the nurse observes that a client is experiencing melina. Which serum laboratory test should the nurse monitor in response to this finding | Hematocrit |
| During assessment for a young client's gynecological annual screening, the client reports amenorrhea. The nurse calculates the client's body mass index as 16. Which finding should the nurse document in the emar that indicates an expected rationale | trains for competition and runs 12 miles every day |
| The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpa tion, but reports pain when the pressure is released. Which action should the nurse implement? | Notify the health care provider of the rebound tenderness |
| The nurse is obtaining a health history for a client being admitted for new onset seizures. Which action should the nurse implement to accurately record the health history findings? | enter the information in the electronic medical record at the client's bedside |
| To assess for a carotid artery bruit, which action should the nurse take? | Place the bell of the stethoscope over the carotid artery |
| an adult male client tells the nurse that he smokes approximately 1 pack of cigarettes daily how can the nurse expect smoking is affect this client sleep? | He would have difficulty falling to sleep, and sleep very lightly with more frequent arousals |
| When assessing a client's skin, which finding should the nurse report to the healthcare provider? | Bluish discoloration of the nail beds |
| The nurse is evaluating a male client's hearing who reports hearing best in the left ear although words are muffled during conversation at a social gathering. Based on this finding, which assessment should the nurse implement? | Inspect the external ear canal |
| The nurse assess the client has nail clubbing. Which additional information is consistent with this | Oxygen saturation of 85% |
| While conducting a mental status examination of a newly admitted client, the nurse notes that his head is lowered and he stares at his hands with a blank look on his face. Based on these observations, which question should the nurse ask this client? | "How are you feeling today?" |
| To assess a female client for hirsutism, which action should the nurse take | Assess the appearance of the clients face |
| A client reports to the ED with pain and swelling of the right hand and wrist from a fall injury. During the admission assessment the client reports sharp intense pain on movement of the hand and wrist. which additional assessment should nurse perform? | Measure nailbed capillary refill time |
| Which assessment technique provides the nurse with the best data related to the client level of peripheral perfusion? | Image measuring cap refil |
| To assess for muscle atrophy in the legs, which action should the nurse take | Compare the appearance of the legs bilaterally |
| When assessing a client from the lower extremities, which finding requires the immediate intervention by the nurse? | right calf swelling and tenderness |
| A male client asks the nurse to look at a mole on his back. He tells the nurse the mole has changed from brown to black and enlarged in size but states he has trouble seeing it in the mirror. What is the priority nursing action? | Advise the client to see his healthcare provider for immediate evaluation |
| An older male client reports to the nurse that his feet are cold before covering the clients feet which assessment should the nurse complete? | -assess volume of the pedal pulses-observe color of the feet and toes-palpitate dorsal surface of the feet for warmth |
| While assessing a client, the nurse notes an audible expiratory wheeze and a respiratory rate of 30 breaths per minute. What action should the nurse implement? | Administer a respiratory aerosol treatment. |
| The nurse is assessing the visual acuity of a client who reports changes in vision. How many feet away from the ceiling chart should the client stand? (Enter a whole number) | 20 feet |
| The nurse is performing a pulmonary assessment for an adult who arrives at the clinic for an annual physical examination. Which assessment findings should the nurse identify as a normal finding? | The ribs articulate at a 45 degree angle with the sternum |
| Following a cerebral vascular accident CVA a male client prescriptions include neurologic assessment every eight hours and bed rest the assessment tool includes evaluation of the clients posture. What action should the nurse implement? | Document that posture could not be evaluated due to prescribed bed rest |
| The nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual's nutritional status? | Condition of the hair, nails, and skin |
| a client is admitted with a diagnosis of right lower lobe pneumonia. Which breath sound is the nurse most likely to auscultate over the right lower lobe? | Coarse crackles |
| While performing a mental status examination, which question should the nurse ask when attempting to evaluate a patient's judgement? | Do you write checks if you know your account is overdrawn? |
| the nurse is assessing elderly client in a community health clinic what assessment findings is an indicator for immediate medical follow-up? | A change in awareness of surroundings |
| The nurse observes that an adult clients abdomen is round and protuberant what additional findings require the most immediate follow-up assessment? | Contour appears asymmetric |
| when assessing a client who is obese the nurse is unable to locate the gallbladder when palpating below the liver margin at the interval border of the abdominal muscle. What is the most likely explanation for failure to locate | The gallbladder is normal |
| When inspecting a client's skin, which finding requires the most immediate follow-up by the nurse? | Generalized truncal rash |
| e-mail client returns to the clinic for a follow up visit after being treated for bladder infection while examining the client which finding indicates in expected response to the treatment? | Pain score of one out of 10 with urination |
| In assessing a client's heart sounds, the nurse heart S1 and S2 after placing the diaphragm of the stethoscope at the second intercostal space Which action should the nurse take next? | Move the diaphragm of the stethoscope to the left of the sternum |
| Nurse notes an enlarged, visible lymph node on the client's neck. What action should the nurse take next? | Ask the client about any localized tenderness at the site. |
| admitted for chest pain. With each question, the client answers in broken English that is mixed with French phrases and looks to his wife. his wife anxiously speaks up and contradicts each of the client's responses. What should the nurse do | Request an interpreter to communicate focused questions |
| the nurse notes the presence of kyphosis. The client tells the nurse that she has a history of osteoporosis. To obtain additional information related to this finding, the nurse should question the client about what additional information | Decreased height |
| In assessing an adult client, the nurse calculates the BMI (body mass index) as 14 kg/m2. What nursing problem should be in cluded in this client's plan of care? | Unbalanced nutrition, less than body needs. |
| complaining of breast tenderness before her menstrual periods. On examination, the nurse notes generalized lumpiness of both breasts with no discrete masses and no nipple discharge. Which action should the nurse take? | Request a return visit after her menstrual period for a breast exam re-check |
| The nurse auscultates the client's abdomen and hears gurgling sound every ten seconds. What action should the nurse take in response to this finding? | Document this normal bowel sound activity in the record. |
| A 75-year-old client with a recent history of a cerebrovascular accident (CVA) presents with right hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a brisk 4+ response. Whichis accurate | Hyperactive response consistent with an upper motor neuron disorder. |
| A male client arrives at the clinic for follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds | Press the stethoscope's diaphragm firmly on the skin over each lung field |
| Which assessment technique should the nurse use to confirm the presence of papilledema in a client with a rapidly decreasing level | Inspection |
| While obtaining a health history a make client tells the nurse that he sometimes experience shortness of breath the nurse determined that the ct respiration are regular and deep and his respiratory rate is 14 what is best nursing action | ask the client to describe the episode of dyspnea in more detail |
| An older adult client with a history of heart failure is brought to the clinic by a family member. Which findings confirm to the nurse that the client is experiencing an exacerbation of the HF? | jugular venous distention dyspnea peripheral edema |
| When performing a skin and all exam on an older female client, the nurse notes that she has longitudinal ridges on her fingernails. What does this finding indicate? | expected variation |
| During the admission assessment, the nurse observes that a client has a limping gait. What assessment should the nurse complete next | ask about pain while bearing weight |
| The nurse is assessing a female client who states that her hemorrhoids are inflamed and hurt constantly. Which intervention is best for the nurse implement to complete a focused assessment? | position client in left lateral position to inspect perianal area for fissures or sacs |
| The nurse observes an extension of the great toe and fanning of other toes when assessing the left foot planter reflex of an adult client. Which interpretation of this finding is accurate | pyramidal tract disease |
| While assessing a client, the nurse observes that the client has a frequent productive cough. What follow-up assessment should the nurse evaluate first? | sputum characteristics |
| The nurse is assessing a client who has a history of kidney stones and returns to the clinic with flank pain. Which intervention should the nurse implement first? | use a standard pain assessment questionnaire and scale |
| The nurse continues a neurologic assessment of the cranial nerve XI (spinal accessory) for a client as seen in the picture. Which instruction should the nurse give the client to complete this assessment? | shrug shoulders against resistance |
| When entering a client's room, the nurse observes that the client is in a tripod position. What action should the nurse take? | observe for signs of respiratory distress |
| Which method is best for the nurse to use in determining early development of ascites? | successive measurements of abdominal girth |
| The nurse assess a client with a sleep pattern disturbance. In developing a plan of care, what assessment data should the nurse obtain first? | usual bed time and time of awakening |
| The college health clinic nurse is preparing a seminar on testicular self-examination. Which instruction should be included in the content for this seminar | examine the testicles during bathing |
| A client reports to the healthcare provider's office for a routine post surgical evaluation six weeks after a hysterectomy. Which histo ry-taking approach should the nurse use to gather the needed information | collect information about the client's activities since surgery |
| When assessing a client's level of consciousness, the nurse de termines that the client is alert and ambulatory but confused. Which follow-up assessment should the nurse complete next? | complete a mental status exam |
| A client is seen in the emergent care clinic for right wrist pain with a pattern of ecchymosis observed on the wrist. Which motion should the nurse instruct the client to perform to assess the wrist mobility | Hyperextension and palmar flexion |
| The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of either venous or arterial insufficiency. Which assessment technique should differentiate the pathophysiology causing the ulcer | Observe the specific location and appearance of the ulceration |
| A client reports episode of syncope. Which assessment finding should the nurse anticipate | Decreased BP during orthostatic blood pressure measurement |
| The nurse is obtaining a health history for a client wishing to obtain a life insurance policy. When evaluating the abdomen, reports taking several antacids for heartburn that only occurs at night. Which finding should the nurse ask | Heartburn occurs when lying down at night |
| During an assessment for jugular vein distention of a client with right-sided heart failure, the nurse observes distention bilaterally usimh tangential lighting with the client in a semi-Fowler's position. Which action should the nurse take next? | Document the findings as observed |
| in reading a client's recorded, the nurse notes that the client is experiencing tinnitus. Which assessment provides the nurse with the information needed to evaluate of the condition | perform a hearing test |
| The nurse examines the client's abdomen. Which findings indi cates an abnormal response when palpitating the spleen? | firm mass palpated at bottom of the left rib cage |
| When assessing a client's consciousness, the nurse determines that the client does not open his eyes spontaneously. What should the nurse do next | ask the client to open his eyes |
| The nurse completes inspection of the abdomen on an adult client. Which finding is considered normal for this client | homogeneous color |
| Which assessment finding requires the most immediate follow up by the nurse? | cyanotic nailbeds |
| The nurse is performing a health interview with a patient who does not speak English well and has obtained an interpreter. Which action should the nurse implement? | maintain eye contact with client when questions are asked |
| prescription for ciprofloxacin 400 mg intra venously every 12 hours, which is to be infused over an hour. The IV bag contains ciprofloxacin 400 mg in dextrose 5% in water (D2W) 200 ml. How many mL/hr should the nurse program the infusion | 200 mL/hr |
| Before administering a laxative to a bedfast client, it is most important for the nurse to perform which assessment | determine the frequency and consistency of bowel movements |
| Which question by the nurse is likely to elicit the most information regarding a clients use of medications to treat a chronic cough? | What medications have you taken for your cough? |
| Heart sounds are loudest for S1 at the: | Apex of the heart |
| To assess a clients ability to think abstractly, which question is likely to provide the best information? | What does, "the early bird catches the worm" mean |
| The nurse observes that a client who is intoxicated has an ataxic gait. Which finding does the nurse expect to be positive upon further assessment? | Romberg sign |
| During a skin assessment, the school nurse observes several round, flat, pinpoint, red spots. How should the nurse document this finding? | Petechiae |
| A 16-year-old client with a history of chronic ear infections has dense white patches on the tympanic membranes. What should the nurse do next? | Record the findings in the client's record |
| During a health assessment, the nurse determines which technique to evaluate the ability to reside in an assisted living facility: | Instruct the client to demonstrate activities of daily living |
| Which assessments should the nurse conduct for a focused neurological assessment in the stroke unit? | Glasgow Coma Scale, Muscle Tone, Pupil Size, Level of Con sciousness |
| During range of motion, the nurse notes crepitation in the left knee. What is most likely related? | Degenerative disease |
| To confirm a report that a client is stuporous, which assessment should the nurse perform? | Determine the response to stimuli |
| For a client with gallstones, which action should the nurse perform to confirm jaundice? | Examine the client's sclera for icterus |
| The nurse documents Heberden's nodes during an assessment. Which finding should be documented? | Non-painful enlarged interphalangeal joints |
| During percussion, what indicates hepatomegaly? | A dull percussion tone outside the costal margins |
| Which history finding may explain erectile dysfunction in a male client? | History of type 2 diabetes mellitus |
| A client with audible wheezing, decreased tactile fremitus, and prolonged expirations has trouble breathing. What condition is likely | Asthma exacerbation |
| Which phrase supports the conclusion of orthopnea? | "I sleep on three pillows at night." |
| The nurse is assessing a client's abdomen and identifies a cen trally localized distension that is pulsating. This finding should direct the nurse to consider which pathology? | Aneurysm |
| Performing oral inspection of a client with dark pigmented skin, the nurse observes a patchy discoloration of the buccal mucosa. Which action should the nurse take? | Document this finding in the medical record |
| The left foot plantar reflex of an adult client, the nurse observes an extension of the great toe and fanning of other toes. Which interpretation of this finding is accurate? | Pyramidal tract disease |
| The nurse is doing a health assessment of a client who smoked 3 packs of cigarettes every day for the last 20 years before quitting 2 years ago. How should the nurse document the client's pack years? Enter the numerical value only. | 60 |
| brought to ED., by her boyfriend because she has not been feeling well all day and he believes she is getting worse. Which finding supports the nurse's suspicion that the client is experiencing appendicitis? | Peri-umbilical pain localizing to right lower quadrant |
| When assessing an older adult client, which finding is most indicative of dehydration? | Tenting noted in subclavicular area |
| The assessment on an older adult client calculates a balance score of 12 and a gait score of 8. Which do these results indicate? | Increased risk for falling |
| client with rectal bleeding. observes dried, dark red blood on the surface of a purpleshiny tissue mass that extrudes from the anal opening. When documenting in the client'sEMR, which findings should center physical assess ment? | Dried dark red blood on swollen external hemorrhoids |
Created by:
kyleenightin