NR304- Exam 1 Edapts Week 1-3 Health Assessment II
Questions With Complete Solutions
Analyzing Cues
Indicate if the clinical manifestation is expected with sexually
transmitted infection and/or urinary tract infection. Each finding
may be seen in more than one condition.
Sexually Transmitted Infection (STI)
or Urinary Tract Infection
Pain after sex
Dysuria
Irregular menses
Odorous vaginal discharge
Skin rash
Symptoms of a sexually transmitted infection:
pain after sex, dysuria, irregular menses, odorous vaginal
discharge, and skin rash.
Symptoms of a urinary tract infection:
dysuria
Assessment
Select assessment data the nurse would expect to find in an older
adult with a urinary tract infection.
Low-grade fever
Dysuria
,Frequency
Urgency
Negative urine culture
Hepatomegaly
Bacteriuria
Low-grade fever, dysuria, frequency, urgency, and bacteriuria.
Assessment Findings
The nurse is assessing a client admitted for oliguria of unknown
origin. Which factors affect urine output? Select all that apply.
Bladder size
Bowel patterns
Medications
Fluid intake
Respirations
Bladder size
Medications
Fluid intake
Abnormal/Normal Findings
Indicate if the findings are considered Normal Findings
or Abnormal Findings
Hematuria with or without pain
Foul-smelling greenish vaginal drainage
,Slight breast asymmetry
Asymmetric palpable enlarged inguinal lymph nodes
Cloudy dark amber urine
Normal Findings:
slight breast asymmetry
Abnormal findings: hematuria with or without pain, foul-
smelling greenish vaginal drainage, asymmetric palpable
enlarged inguinal lymph nodes, cloudy dark amber urine
Abnormal Assessment Finding
The client reports having low back suprapubic pain. The
healthcare provider interprets that this finding could indicate a
problem of which structure?
Bladder
Intestine
Adrenal gland
Kidney
Bladder
A client living with peripheral arterial disease (PAD) in the
lower extremities asks the nurse what causes their pain at rest.
What is the best response provided by the nurse?
"Disease in the arteries causes decreased arterial blood flow to
, the nerves in your legs."
"The cause is a vasospasm of small cutaneous arteries in the
feet."
"An increase in retrograde venous blood flow in the legs puts
pressure on the arteries."
"Your muscles do not get enough arterial blood when you
exercise. When you rest, the blood flow increases, causing the
pain you feel."
"Disease in the arteries causes decreased arterial blood flow to
the nerves in your legs."
The nurse caring for a client hospitalized with infective
endocarditis is told by an unlicensed assistive personnel (UAP)
that the client is reporting sudden left leg pain with pallor,
paresthesia, and a loss of peripheral pulses. What action should
the nurse take first?
Start anticoagulant therapy with IV heparin.
Elevate the leg to promote venous return.
Notify the client’s healthcare provider of the change in
peripheral perfusion.
Complete a focused neurovascular assessment.
Complete a focused neurovascular assessment.
Which observed assessment finding of the lower extremities
may result from a peripheral vascular disorder?
The skin is red in color, with peeling skin and sores.
Questions With Complete Solutions
Analyzing Cues
Indicate if the clinical manifestation is expected with sexually
transmitted infection and/or urinary tract infection. Each finding
may be seen in more than one condition.
Sexually Transmitted Infection (STI)
or Urinary Tract Infection
Pain after sex
Dysuria
Irregular menses
Odorous vaginal discharge
Skin rash
Symptoms of a sexually transmitted infection:
pain after sex, dysuria, irregular menses, odorous vaginal
discharge, and skin rash.
Symptoms of a urinary tract infection:
dysuria
Assessment
Select assessment data the nurse would expect to find in an older
adult with a urinary tract infection.
Low-grade fever
Dysuria
,Frequency
Urgency
Negative urine culture
Hepatomegaly
Bacteriuria
Low-grade fever, dysuria, frequency, urgency, and bacteriuria.
Assessment Findings
The nurse is assessing a client admitted for oliguria of unknown
origin. Which factors affect urine output? Select all that apply.
Bladder size
Bowel patterns
Medications
Fluid intake
Respirations
Bladder size
Medications
Fluid intake
Abnormal/Normal Findings
Indicate if the findings are considered Normal Findings
or Abnormal Findings
Hematuria with or without pain
Foul-smelling greenish vaginal drainage
,Slight breast asymmetry
Asymmetric palpable enlarged inguinal lymph nodes
Cloudy dark amber urine
Normal Findings:
slight breast asymmetry
Abnormal findings: hematuria with or without pain, foul-
smelling greenish vaginal drainage, asymmetric palpable
enlarged inguinal lymph nodes, cloudy dark amber urine
Abnormal Assessment Finding
The client reports having low back suprapubic pain. The
healthcare provider interprets that this finding could indicate a
problem of which structure?
Bladder
Intestine
Adrenal gland
Kidney
Bladder
A client living with peripheral arterial disease (PAD) in the
lower extremities asks the nurse what causes their pain at rest.
What is the best response provided by the nurse?
"Disease in the arteries causes decreased arterial blood flow to
, the nerves in your legs."
"The cause is a vasospasm of small cutaneous arteries in the
feet."
"An increase in retrograde venous blood flow in the legs puts
pressure on the arteries."
"Your muscles do not get enough arterial blood when you
exercise. When you rest, the blood flow increases, causing the
pain you feel."
"Disease in the arteries causes decreased arterial blood flow to
the nerves in your legs."
The nurse caring for a client hospitalized with infective
endocarditis is told by an unlicensed assistive personnel (UAP)
that the client is reporting sudden left leg pain with pallor,
paresthesia, and a loss of peripheral pulses. What action should
the nurse take first?
Start anticoagulant therapy with IV heparin.
Elevate the leg to promote venous return.
Notify the client’s healthcare provider of the change in
peripheral perfusion.
Complete a focused neurovascular assessment.
Complete a focused neurovascular assessment.
Which observed assessment finding of the lower extremities
may result from a peripheral vascular disorder?
The skin is red in color, with peeling skin and sores.
