Questions And All Actual Answers.
tympany - Answer A student is performing a physical assessment on a patient. While assessing the
abdomen, the student percusses the spleen. What sound would be normal for the student to hear?
appendicitis - Answer An emergency department nurse is caring for a 17 year old patient who has
severe pain in the umbilical area. Documentation shows that the patient exhibits "Rovsing's sign." What
might this patient's medical diagnosis be?
shingles (herpes zoster) - Answer When assessing a clinic patient, the nurse asks if the patient has ever
had varicella. The nurse knows that varicella always precedes what?
partial intestinal obstruction - Answer While auscultating a patient's abdomen, the student notes
abnormal bowel sounds. The nurse's preceptor asks the student to describe the sounds. The student
describes them as high-pitched, rushing sounds. The preceptor, an experienced nurse, would know that
these sounds indicate what?
colorectal cancer, food-borne illness, and hepatitis - Answer What does Healthy People have as its
focus areas for the GI tract? (Mark all that apply.)
the fracture crosses the part of the bone where the bone lengthens - Answer A 13-year-old boy is
brought to the emergency department with an injury to his left ankle after a skateboard accident.
Diagnostic films show a fracture across the epiphyses. The doctor explains that the patient may not have
full ROM and that his left leg may be shorter than his right leg. The parents ask why one leg may be
shorter than the other. What would be the nurse's best answer?
trendelenberg test - Answer A 3-month-old girl has been diagnosed with congenital hip dislocation.
What is a confirmatory test for this disease?
use environmental cues - Answer A patient is admitted to the unit. The nurse notes that the medical
record for this patient lists a fall risk of 75% per the Morris Fall Risk scale. What would be an appropriate
nursing intervention?
, C7 and T1 spinous processes prominent. Paravertebral, sternocleidomastoid, and trapezius muscles fully
developed, symmetrical and nontender - Answer A nurse has just finished assessing a patient's spine
and neck muscles. How would the nurse document normal findings?
open all packages and arrange the meal tray while communicating actions to the patient - Answer An
87-year-old patient has been admitted to the unit. This patient has problems with fine motor movement.
What would be important to do for this patient?
Lock the fingers together and pull against each other, reinforces enhancing the reflex response in the
legs - Answer A nurse is having difficulty eliciting a patellar reflex. Which of the following would be
most appropriate for the nurse to have the patient do?
balance; balance and coordination are functions of the pyramidal and extrapyramidal tracts of the motor
and cerebellar systems - Answer A nurse is preparing to assess a patient's cerebellar function. Which of
the following would the nurse expect to test?
ask the patient to identify scents, which can be done by having the patient occlude one nostril and
identify a scent - Answer A nurse is preparing to assess the cranial nerves of a patient. The nurse is
about to test CN I. which of the following would the nurse do?
31 pairs of spinal nerves - Answer A nursing instructor is describing the peripheral nervous system to a
group of students; the instructor would explain that there are how many pairs of spinal nerves?
12 - Answer how many cranial nerves are there?
cerebellar ataxia - Answer During the romberg's test, a patient is unable to stand with his feet together
and demonstrates a wide-based, staggering, unsteady gait. The nurse would identify this as which of the
following?
spastic hemiparesis - Answer characterized by a flexed arm held close to the body while the patient
drags the toes of the leg or circles it stiffly outward and forward
parkinsonian gait - Answer a "shuffling" gait