Basic Physical Assessment NCLEX

The nurse plans to obtain client information from a primary source. Which of the following is a primary information source? - Answer- 3. The client An adolescent client seeks medical attention because of a sore throat and probable mononucleosis. The nurse palpates the client's submandibular lymph nodes for enlargement. Identify the area where the nurse should palpate to best feel these nodes. - Answer- The submandibular lymph nodes are located beneath the mandible, or lower jaw, halfway to the chin. These nodes may be enlarged in a client with a throat infection or mononucleosis. To help assess a client's cerebral function, the nurse should ask: - Answer- 1. "Have you noticed a change in your memory?" The nurse is assessing an elderly client. When performing the assessment, the nurse should consider that one normal age-related change is: - Answer- 3. diminished reflexes. A client complains of lower abdominal pressure. The nurse notes a firm mass extending above the symphysis pubis. Which condition is the most likely cause of these findings? - Answer- 4. Distended bladder Which reaction is a normal response to a corneal sensitivity test? - Answer- 2. Blinking To evaluate a client's posterior tibial pulse, where should the nurse palpate? - Answer- 3. On the inner aspect of the ankle, below the medial malleolus When an emergency department nurse enters the room, the client complains that she's spitting up blood when she coughs. The nurse performs a quick review of the client's pertinent health history, which should include: - Answer- 2. the history of the present problem, allergies, medications, and recent major operations. A newly hired licensed practical nurse (LPN) is helping the charge nurse admit a client. The charge nurse asks the LPN if she understands the facility's rules of ethical conduct. Which statement by the LPN indicates the need for further teaching? - Answer- 4. "I don't discuss advance directives unless the client initiates the conversation." An elderly client who is 5' 4" and weighs 145 lb is admitted to the long-term care facility. The admitting nurse takes this report: The client sits for long periods in his wheelchair and has bowel and bladder incontinence. He is able to feed himself and has a fair appetite, eating best at breakfast and poorly thereafter. He doesn't have family members living near by and is often noted to be crying and depressed. He also frequently requires large doses of sedatives. Which factors place the client at risk for developing a pressure ulcer? - Answer- 2. Incontinence, 3. Sitting for long periods of time, 4. Sedation