NUR 2830 Final Updated 2024/2025 Actual Questions and answers with complete solutions

A client presents in a semi-comatose state, unable to comprehend or respond to any instruction. You notice his respiratory rate is about 28 with a harsh, high pitched sound. You recognize this as what? - respiratory stridor A technique used by nurses to create vibrations and evaluate an organ or fluid is what? - percussion Performing a neurological assessment on a comatose patient should include what scale? - glascow coma scale The nurse hears an adventitious sound at the second intercostal space, right sternal border. This is recognized as what? - aortic murmur The nurse places an object in the clients hand, has them close their eyes, and identify the object. This is known as what? - stereognosis Upon assessing the abdomen, you notice an umbilical bulge that occurs whenever your client coughs. You recognize these findings as what? - hernia Upon assessing your client you discover a full-thickness pressure ulcer on your client's coccyx, involving damage to the subcutaneous tissue. What stage will you document? - 3 Upon assessment of the abdomen, the nurse discovers a pulsating mass near the umbilicus with extending striae. It is noted that this could be what? - abdominal aortic aneurysm Upon assessment, the nurse notes a change in the patient's level of consciousness. This is noted as an early indication of what? - altered cerebral function Upon assessment, you notice your client is exhibiting involuntary movements of the eyeball in a horizontal direction. You recognize this as what? - nystagmusUpon assessment, you notice your client is short of breath on exertion, is fatigued, gray in color, has a systolic murmur, and has gained 5 lbs in the last 24 hours. You call the physician with your findings and expect him to what? - assess for congestive heart failure Upon examination, you notice a 1 inch irregular-shaped, elevated area on the patient's abdomen, the patient is concerned as it appeared after a cholecystectomy. You recognize this area as what? - keloid When assessing a patient with rheumatoid arthritis, the nurse may find? - boutonniere/swan's neck deformity When assessing your new client, she tearfully tells you that she has had an unbearable headache for the last 3 days. She says it started in the movie theater where she noticed a strange halo around all the lights. What other symptoms might you expect this client to present with? - dizziness, sensitivity to light/sound, nausea, vomiting, depression, irritability When performing a history, your client states he has smoked cigarettes, 2 packs a day for 35 years. He is grey in color and you notice he is short of breath with even the slightest exertion. What other assessment findings might you expect? - barrel chest, clubbing, tripod position, pursed lip breathing, 1:1 AP ratio You are assessing your new client when you ask the client to stare straight ahead, then you shine a penlight onto the bridge of your client's nose. You are performing what? - corneal light reflex You are at the beach and notice your friend has a dark black, asymmetrical, flat, scaly spot on his scapular area. You suggest to your friend what? - melanoma You assess your client and note a yellowish color in the sclera. You recognize this as what? - jaundice You assess your client by placing your hands on their shoulders and asking them to shrug. You are assessing what cranial nerves? - spinal accessory XIYou client is a 32-year-old who was involved in a MVA that resulted in crushing injuries with a bilateral BKA. He is complaining of pain 10/10 in his toes bilaterally. The nurses have been holding his pain mends stating that he really doesn't need them. You recognize these symptoms as what? - phantom pain You note your client has a BMI of 35, he has SOB with any exertion and complains of inability to tie his own shoes, yet his legs and arms appear normal in size and shape. You document this client has having what? - morbidly obese You observe your colleague placing one finger along the right and then the left medial sternocleidomastoid muscle of the client. You recognize that the nurse if palpating what? - carotid arteries Your 30-year-old patient presents with fatigue and shortness of breath. Upon assessment, you discover a raspy, blowing sound upon auscultation. You recognize this as an abnormal sound and ask the patient regarding what childhood diseases? - rheumatic fever Your 38-year-old client presents with complaints of knee discomfort. Upon assessment, you move the joint and notice a crackling sound. You recognize this finding as what? - osteoarthritis