A 29 year old male client informs Describe having a "body-wracking dry cough" of 6 weeks duration.
the nurse that he came to the clinic
to see if, "Maybe I have lung
cancer or something," and wants to
get checked out since, "I can't
seem to get rid of this body-
wracking dry cough that has been
hanging around for the last six
weeks." Which computer
documentation of this client's
concerns should the nurse enter?
A 75-year-old client with a recent Hyperactive response consistent with an upper motor neuron
history of a cerebrovascular disorder.
accident (CVA) presents with right
hemiparesis. The nurse tests the
deep tendon reflexes on the right
side and elicits a brisk 4+ response.
Which interpretation of this finding
is accurate?
After a young adult woman Apex of the heart at the left fifth intercostal space at the midclavicular
describes feeling palpitations line.
when she lies on her left side it is
most important for the nurse to
auscultate heart sounds at which
anatomical location?
,After checking a client's pupillary Assess the client's visual fields.
response to light, the practical
nurse (PN) tells the nurse that the
client's pupils are constricted with
minimal response to light. Before
verifying the PN's findings, which
action should the nurse take?
After placing a client in a supine Auscultate the remaining two quadrants.
position, the nurse uses the
diaphragm of the stethoscope to
auscultate bowel sounds and hears
a loud, high pitched almost
continuous gurgling in two
quadrants. What action should the
nurse implement?
Venous leg ulcers usually develop on the
A. What type of ulcer is this? Which
inner lower leg, above the medial
pathophysiology? venous or
malleolus.
arterial?
- This is used to test for brain damage or
upper motor neuron damage. It is
Babinski sign considered positive if the toes flare up
upon stroking the plantar aspect of the
foot.
, Arterial wounds occur most often on the
foot, in between or at the tips of the toes,
B. What type of ulcer is this? Which
at pressure points from foot wear, on the
pathophysiology? venous or
heels and around the lateral malleolus
arterial?
(the bone on the outside of the ankle
joint).
A client comes to the clinic due to Hold arms up at 90 degree while arms are pushed downward.
shoulder discomfort and
intermittent pain while swimming
today. To assist normal range of
motion (ROM) of the client's
shoulder, which assessment
techniques should the nurse ask
the client to perform?
A client is being evaluated for Intranasal edema and swelling of turbinates.
environmental allergies. While
examining the client's nasal
passage, which finding suggests to
the nurse that the client is
experiencing allergic rhinitis?
the nurse that he came to the clinic
to see if, "Maybe I have lung
cancer or something," and wants to
get checked out since, "I can't
seem to get rid of this body-
wracking dry cough that has been
hanging around for the last six
weeks." Which computer
documentation of this client's
concerns should the nurse enter?
A 75-year-old client with a recent Hyperactive response consistent with an upper motor neuron
history of a cerebrovascular disorder.
accident (CVA) presents with right
hemiparesis. The nurse tests the
deep tendon reflexes on the right
side and elicits a brisk 4+ response.
Which interpretation of this finding
is accurate?
After a young adult woman Apex of the heart at the left fifth intercostal space at the midclavicular
describes feeling palpitations line.
when she lies on her left side it is
most important for the nurse to
auscultate heart sounds at which
anatomical location?
,After checking a client's pupillary Assess the client's visual fields.
response to light, the practical
nurse (PN) tells the nurse that the
client's pupils are constricted with
minimal response to light. Before
verifying the PN's findings, which
action should the nurse take?
After placing a client in a supine Auscultate the remaining two quadrants.
position, the nurse uses the
diaphragm of the stethoscope to
auscultate bowel sounds and hears
a loud, high pitched almost
continuous gurgling in two
quadrants. What action should the
nurse implement?
Venous leg ulcers usually develop on the
A. What type of ulcer is this? Which
inner lower leg, above the medial
pathophysiology? venous or
malleolus.
arterial?
- This is used to test for brain damage or
upper motor neuron damage. It is
Babinski sign considered positive if the toes flare up
upon stroking the plantar aspect of the
foot.
, Arterial wounds occur most often on the
foot, in between or at the tips of the toes,
B. What type of ulcer is this? Which
at pressure points from foot wear, on the
pathophysiology? venous or
heels and around the lateral malleolus
arterial?
(the bone on the outside of the ankle
joint).
A client comes to the clinic due to Hold arms up at 90 degree while arms are pushed downward.
shoulder discomfort and
intermittent pain while swimming
today. To assist normal range of
motion (ROM) of the client's
shoulder, which assessment
techniques should the nurse ask
the client to perform?
A client is being evaluated for Intranasal edema and swelling of turbinates.
environmental allergies. While
examining the client's nasal
passage, which finding suggests to
the nurse that the client is
experiencing allergic rhinitis?
