NURS 190 Physical Assessment MIDTERM Exam, Kim Hein.(Latest 2021/2022)

1.The nurse is performing a comprehensive skin assessment. Which of the following pieces of equipment is appropriate to use during the skin assessment? (2 Points) doppler Wood's lamp Reflex hammer Goniometer 2. Which of the following is an expected finding in a healthy client on assessment of Stensen's ducts? (2 Points) red glow is present midline and symmetric saliva is present redness is present 3. Which of the following signs or symptoms does the nurse recognize in a client with hypothyroidism? (Select all that apply) (2 Points) Fatigue intolerance to cold increased cardiac output constipation 4. The client has a new diagnosis of right sided heart failure. The nurse understands a client with right sided heart failure may have edema and jugular vein distension. (2 Points) True False 5. The nurse performs the Romberg test to assess for: (2 Points) balance hearing vision loss cranial nerve 6 dysfunction 6. Which of the following techniques will the nurse perform to assess for signs of breast abnormalities? (2 Points) inspection, palpation, and auscultation inspection and palpation inspection, palpation, and percussion palpation and auscultation 7. The nurse is caring for a client with obesity. The nurse places the client in which of the following positions to best hear heart sounds? supine prone sitting upright lef t lateral 8. State at which location(s) the S1 sound (lub) is heard loudest on cardiac auscultation. State why the S1 is loudest at these locations. (Write 1-2 sentences). If you are you are at the proper location, you will hear the sound the loudest. (2 Points) 9. The nurse palpates an enlarged lymph node at the back of the ear, over the mastoid bone. The nurse documents this location as: (2 Points) posterior auricular submental posterior occular occipital 10. The older adult client is admitted with new onset pain and pressure to their eyes. On inspection, the sclera is red and the pupil is an irregular shape to the left eye. The nurse should further assess for: (2 Points) macular degeneration cataracts presbyopia Glaucoma BOOK REF. PG 253 11. The client is seen in the urgent care center with a suspected fungal infection to the fingernails. The nails are thick, yellow, and lifting off the nail bed. The nurse documents this finding as: (2 Points) clubbing Onycholysis BOOK REF PG. 203 beau's lines splinter hemmorage 12. The nurse assesses the client's radial pulses and documents these findings: 68 beats per minute, regular, 2+, symmetrical. The physician asks the nurse, "What was the client's pulse amplitude?" The best response of the nurse: (2 Points) "68 beats per minute" "regular" "2+" BOOK REF PG 404 "symmetrical" 13. The nurse is performing a cardiac auscultation and hears a harsh, blowing sound that is very loud at the 4th ICS, left sternal border. No thrill is present. The nurse understands this murmur is graded as: (2 Points) grade 4 grade 2 grade 3 grade 5