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NURSING 101 PRACTICE EXAM
A nurse is caring for a client with paraplegia. Using observation to examine the
client's skin, what finding might indicate the presence of a pressure injury?
A circular red, scaly area that itches on the top of the forearm arm.
An intact faded purple area on the shoulder blades, with a yellowish tint.
An intact red area on the buttocks.
An area of swollen, pale red bumps on the front of the neck.
An intact red area on the buttocks.
The gerontologic nurse is inspecting the genitalia of an older adult female client.
Which assessment findings are of the most concern? Select all that apply.
Increased size of the labia unilaterally
Smooth skin and slightly drier mucosa
,Darker pigmentation to vulva
Decreased amount of pubic hair
Scant red vaginal discharge
Increased size of the labia unilaterally
Scant red vaginal discharge
During a head-to-toe assessment of a client, the nurse carefully palpates the client's
nails. Which is the best rationale for this technique?
To assess capillary refill and oxygenation
To assess for edema
To assess for infection
To assess for melanoma
To assess capillary refill and oxygenation
Upon admission to the hospital, the client states, "I am having surgery to correct
my back. I have pain in the lower back and the health care provider is going to do a
lumbar laminectomy." This statement reflects the client's:
symptoms.
review of systems.
chief concern.
objective assessment.
chief concern.
,The nurse detects a weak, thready pulse found from a client palpating peripheral
pulses. What condition does the nurse suspect the client is experiencing?
Hypertension and circulatory overload
Decreased cardiac output
Impaired kidney function
Inflammation of a vein
Decreased cardiac output
While assessing a client's temporal mandibular joint (TMJ), the nurse feels grating
and hears noise when the client opens and closes their jaw. The nurse should
document what finding?
inflammation
arthritis
crepitus
fremitus
crepitus
A gerontologic nurse is inspecting the genitalia of an older adult male client.
Which assessment findings are of the most concern? Select all that apply.
Bulge to the left inguinal area
Decreased penis size
Less firmness of the testes
Scant amount of pubic hair
Scant yellow discharge
, Bulge to the left inguinal area
Scant yellow discharge
The client was admitted to the psychiatric unit 3 days ago with a diagnosis of
major depressive disorder. The client answers assessment questions with barely
audible "yes" or "no" responses and tells the nurse that they have been depressed
for a long time. The client wants the door closed and the curtains drawn to darken
the room. The client refuses visitors, eats only 25% of meals, and tells the nurse
that the food makes them nauseous. The nurse observes the client biting their
fingernails. The client cries often and sleeps a lot. The nurse documents which
client action(s) as objective assessment data? Select all that apply.
The client answers questions in a barely audible voice.
The client states that they have been depressed for a long time.
The client bites their fingernails.
The client eats 25% of meals.
The client says that the food makes them nauseous.
The client sleeps a lot.
The client answers questions in a barely audible voice.
The client bites their fingernails.
The client eats 25% of meals.
The client sleeps a lot.
A client admitted to the emergency department is bleeding from a cut on the head
and their skin color is pale, with diaphoresis. What nursing action should be
performed first?
Provide a warm, quiet, dimly lit room