What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks
... [Show More] gestation?
A. Maternal blood pressure
B. Level of pain sensation
C. Station of preseneting part
D. Variability of fetal heart rate A. Maternal blood pressure
The nurse observes that a client is experiencing melena. What serum laboratory test should the nurse monitor in response to this finding?
A. White blood cell count WBC
B. Blood urea nitrogen BUN
C. Glucose
D. Hematocrit A. White blood cell count
The nurse is performing a cranial nerve exam on an 87-year-old client. The nurse notes that the client has a reduced upward gaze, a decreased corneal reflex, a high frequency hearing loss, and a reduced gag reflex. What action should the nurse take next?
A. Continue the assessment of the next pairs of cranial nerves
B. Assess the spinal reflexes for demyelination symptoms
C. Implement neural vital signs every 2 hours to detect Cushing's Triad
D. Review past history for any episodes of a cerebral cortex lesion C. Implement neural vital signs every 2 hours to detect Cushing's Triad
The nurse assesses a male client who is brought to the ED by his family who believe he is having a heart attack. Which finding is the best indicator that a client is experiencing an acute coronary syndrome (ACS)?
A. Chest pain that intensifies upon chest excursion
B. Localized sternal border pain intensified by palpation
C. Pain in the neck, jaw, or medial side of the left arm
D. Anterior thorax pain that radiates between the scapulae C. Pain in the neck, jaw, or medial side of the left arm
The nurse is reviewing the health history of a client who had osteoarthritis. During the physical assessment, the nurse identifies the presence of Heberden's nodes. Which finding should the nurse document in the client's medical record?
A. A firm ganglion mass that is fluid filled over the dorsum of the wrist
B. Swollen nodes at the middle proximal interphalangeal joints
C. Palpable nodes at the distal interphalangeal joints with joint deviation
D. Weakness of hand muscle strength and poor grip when picking up a cup C. Palpable nodes at the distal interphalangeal joints with joint deviation
During an abdominal assessment, a client with a temp of 103F experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement.
A. Nothing by mouth
B. Complete bed rest
C. Monitor urinary output
D. Electrocardiogram A. Nothing by mouth
A 29-year-old male client informs the nurse that he came to the clinic to see if, "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." Which computer documentation of this client's concerns should the nurse enter?
A. Expresses concern of "lung cancer" symptoms for last 6 weeks
B. Presents with a hacking non-productive cough of 6 weeks duration
C. Describes having a "body-wracking dry cough" of 6 weeks duration
D. Young adult male presents with fears that he has "lung cancer" C. Describes having a "body-wracking dry cough" of 6 weeks duration
When assessing a client's skin, which finding should the nurse report to the healthcare provider?
A. Bluish discoloration of the nail beds
B. Multiple yellow lesions with a grainy surface
C. Multiple silver striae on the abdomen
D. Large, flat, dark red irregular area on the neck A. Bluish discoloration of the nail beds
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?
A. Ask the client if he took any pain medication at home
B. Observe for nonverbal signs to measure pain intensity
C. Use a standard pain assessment questionnaire and scale
D. Collect a urine sample and strain for granules of calculi D. Collect a urine sample and strain for granules of calculi
The nurse enters a client's room and notes that the formerly alert client is now lethargic and only mutters incomprehensible sounds. In gathering additional data related to these findings, which tool should the nurse use?
A. SBAR format
B. Braden scale
C. Mini-mental status exam
D. Glasgow coma scale D. Glasgow come scale
A client who recently underwent a routine surgical procedure made a clinic appointment. To elicit the most information, which question is best for the nurse to ask this client?
A. "When did your surgery take place?"
B. "What type of surgery did you have?"
C. "Are you having any pain?"
D. "What brought you to the clinic?" D. "What brought you to the clinic?"
While completing an admission assessment for a client with rectal bleeding, the nurse observes dried, dark red blood on surface of a purple, shiny tissue mass that extrudes from the anal opening. When documenting in client's electronic medical record, which finding should the nurse enter in the client's physical assessment?
A. Dried dark red blood on swollen external hemorrhoids
B. Serosanguineous and purple to exudate from anus
C. Anal mucosa prolapse and loose sphincter tone
D. Tears of the anal mucosa with old blood around anus D. Tears of the anal mucosa with old blood around anus
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?
A. Have the client lay flat while listening to the anterior surface of the chest
B. Press the stethoscope's diaphragm firmly on the skin over each lung field
C. Shave all chest hair that may distort sounds heard through the diaphragm
D. Use the bell of the stethoscope to listen to the lung fields over lower lobes B. Press the stethoscope's diaphragm firmly on the skin over each lung field
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 this observation?
A. Ask about recent abdominal trauma
B. Observe the midline for scarring
C. Document the normal finding
D. Palpate the area for masses C. Document the normal finding
The nurse hears bilateral louder, longer and lower tones when percussing over the lungs of a 4-year old child. What should the nurse do next?
A. Palpate over the area for increased pain and tenderness
B. Ask the child to take shallow breaths and percuss over the area again
C. Refer the child immediately because of an increased amount of air in the lungs
D. Consider this a normal finding for a child this age and proceed with the examination D. Consider this a normal finding for a child this age and proceed with the examination
A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After putting a call in to the physician and placing the patient on oxygen, which of these is the best action for the nurse to take when assessing the patient further?
A. Count the patients respiration's
B. Percuss the thorax bilaterally, noting any differences in percussion tones
C. Call for the chest x-ray and wait for the results before beginning an assessment
D. Inspect the thorax for any new masses and bleeding associated with respirations B. Percuss the thorax bilaterally, noting any differences in percussion tones
The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use?
A. The slope of the earpieces should point posteriorly (toward the occiput)
B. The stethoscope does not magnify sound but does block out extraneous room noise
C. The fit and quality of the stethoscope are not as important as its ability to magnify sound
D. The ideal tubing length should be 22 inches to dampen distortion of sound B. The stethoscope does not magnify sound but does block out extraneous room noise
When performing a physical assessment, the technique the nurse will always use first is:
A. Palpation
B. Inspection
C. Percussion
D. Auscultation B. Inspection
Then inspection phase of the physical assessment:
A. Yields little information
B. Takes time and reveals a surprising amount of information
C. May be somewhat uncomfortable for the expert practitioner
D. Requires a quick glance at the patient's body systems before proceeding on with palpation B. Takes time and reveals a surprising amount of information [Show Less]