Final Exam: NR 304/ NR304 (2023/ 2024) Health Assessment II Exam| Questions and Verified Answers| Already Graded A
QUESTION
The nurse is assessing the
... [Show More] neurological status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patient's toes fan out, and the big toe shows dorsiflexion. The nurse interprets this result as:
A. Negative Babinski sign, which is normal for adults.
B. Positive Babinski sign, which is abnormal for adults.
C. Clonus, which is a hyperactive response.
D. Achilles reflex, which is an expected response.
Answer:
B. Positive Babinski sign, which is abnormal for adults.
QUESTION
While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following response: abduction and flexion of the arms and legs; fanning of the fingers, and curling of the index finger and thumb in a C position, followed by the infant bringing in the arms and legs to the body. What does the nurse know about this response?
A. This response could indicate brachial nerve palsy.
B. This reaction is an expected startle response at this age.
C. This reaction is an abnormal reflex and finding at this age.
D. This response is normal as long as the movements are bilaterally symmetric.
Answer:
C. This reaction is an abnormal reflex and finding at this age.
QUESTION
A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make?
A. "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level."
B. "I will call the provider to get a prescription for discontinuing the IV heparin today."
C. "Both heparin and warfarin work together to dissolve the clots."
D. "The IV heparin increases the effects of the warfarin and decreases the length of your hospital stay."
Answer:
A. "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level."
QUESTION
A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions?
A. Elevating the feet
B. Massaging her legs
C. Flexing her ankles
D. Ambulating soon after surgery
Answer:
B. Massaging her legs
QUESTION
A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis?
A. Myringotomy
B. Laparoscopic appendectomy
C. Hip arthroplasty
D. Cataract extraction
Answer:
C. Hip arthroplasty
QUESTION
A nurse is caring for who reports an area of redness, warmth, tenderness, and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding?
A. Obtain a venous duplex ultrasound
B. Obtain impedance plethysmography
C. Monitor Homan's sign
D. Apply cold therapy to the affected leg
Answer:
A. Obtain a venous duplex ultrasound
QUESTION
After abdominal surgery, what patient assessment finding alerts the nurse to the fact that peristaltic movement is returning?
A) Passing flatus
B) Reports of hunger
C) Absence of nausea
D) Presence of normal bowel sounds
Answer:
A) Passing flatus
QUESTION
A nurse is providing discharge teaching to a client who has peripheral arterial disease (PAD). Which of the following instructions should the nurse include in the teaching?
A. Apply a heating pad on a low setting to help relieve leg pain
B. Adjust the thermostat so that the environment is warm
C. Wear antiembolic stockings during the day
D. Rest with the legs above heart level
Answer:
B. Adjust the thermostat so that the environment is warm [Show Less]