NUR 3065 Questions (Exam 2) Questions With Complete
Solutions
A 22-year-old man comes to the clinic for an examination after
falling off his motorbike and landing oh his left side on the
handlebars. The nurse suspects the patient may have injured his
spleen. Which of these statements is true regarding the
assessment of the spleen in this type of situation. The spleen can
become ruptured, not enlarged, as result of trauma.
A 25-year-old male is brought to the emergency department by
ambulance after being involved in a motor vehicle accident. You
find that he has decreased breath sounds over the left lung fields.
What might you suspect is the cause? Pneumothorax
A client comes into the clinic with complaints of sever right
sided flank pain, nausea, vomiting, and restlessness. The client
appears slightly pale and diaphoretic. His vital signs are BP
140/90, HR 118, respirations 33, and temperature 98 degrees
Fahrenheit. Which piece of objective data supports a diagnosis
of renal stones? Dark, scanty urine output
A client patellar reflex is normal (Expected) for the right side
but diminished on the left. Using the scale for grading reflexes,
how should the nurse document this finding?Right knee +2, Left
Knee +1
0= no response; always abnormal
1+= a slight but definitely present response; may or may not be
normal
2+= a brisk response; normal
, 3+= a very brisk response; may or may not be normal
4+= a tap elicits a repeating reflex (clonus); always abnormal
A new client is admitted to a long term car facility. The nurse
assesses the client with an unsteady gait and incontinence.
Which problem should the nurse address when planning care for
this client? Falls
A nurse assesses a client who reports abdominal pain. Which
technique should the nurse use during the physical examination
to detect tenderness? Light palpation
A nurse conducts a physical examination of the musculoskeletal
system of a client who reports upper arm pain. Which
instruction should the nurse provide the client when assessing
flexion of the elbow? "Bend you elbow"
A nurse is assessing a client for abnormalities of gait due to a
concern that the client is at increased risk for a fall. Which
instruction should the nurse give the client first? "Walk across
the room and back"
A nurse is palpating a patient's leg bilaterally with the back of
her hands and notes that one leg is colder than the other. The
nurse knows that this may indicate which of the following?
Inadequate arterial circulation
A nurse provides prevention strategies to a group of clients who
are identified as at risk for hypertension. Which strategies
should the nurse include? Walk briskly 30 minutes per day.
Solutions
A 22-year-old man comes to the clinic for an examination after
falling off his motorbike and landing oh his left side on the
handlebars. The nurse suspects the patient may have injured his
spleen. Which of these statements is true regarding the
assessment of the spleen in this type of situation. The spleen can
become ruptured, not enlarged, as result of trauma.
A 25-year-old male is brought to the emergency department by
ambulance after being involved in a motor vehicle accident. You
find that he has decreased breath sounds over the left lung fields.
What might you suspect is the cause? Pneumothorax
A client comes into the clinic with complaints of sever right
sided flank pain, nausea, vomiting, and restlessness. The client
appears slightly pale and diaphoretic. His vital signs are BP
140/90, HR 118, respirations 33, and temperature 98 degrees
Fahrenheit. Which piece of objective data supports a diagnosis
of renal stones? Dark, scanty urine output
A client patellar reflex is normal (Expected) for the right side
but diminished on the left. Using the scale for grading reflexes,
how should the nurse document this finding?Right knee +2, Left
Knee +1
0= no response; always abnormal
1+= a slight but definitely present response; may or may not be
normal
2+= a brisk response; normal
, 3+= a very brisk response; may or may not be normal
4+= a tap elicits a repeating reflex (clonus); always abnormal
A new client is admitted to a long term car facility. The nurse
assesses the client with an unsteady gait and incontinence.
Which problem should the nurse address when planning care for
this client? Falls
A nurse assesses a client who reports abdominal pain. Which
technique should the nurse use during the physical examination
to detect tenderness? Light palpation
A nurse conducts a physical examination of the musculoskeletal
system of a client who reports upper arm pain. Which
instruction should the nurse provide the client when assessing
flexion of the elbow? "Bend you elbow"
A nurse is assessing a client for abnormalities of gait due to a
concern that the client is at increased risk for a fall. Which
instruction should the nurse give the client first? "Walk across
the room and back"
A nurse is palpating a patient's leg bilaterally with the back of
her hands and notes that one leg is colder than the other. The
nurse knows that this may indicate which of the following?
Inadequate arterial circulation
A nurse provides prevention strategies to a group of clients who
are identified as at risk for hypertension. Which strategies
should the nurse include? Walk briskly 30 minutes per day.
