tympany - CORRECT 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 - CORRECT 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) - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT ANSWER -A 3-month-old girl has been diagnosed with
congenital hip dislocation. What is a confirmatory test for this disease?
, use environmental cues - CORRECT 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 - CORRECT 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 -
CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT ANSWER -how many cranial nerves are there?