The nurse is assessing a client complaining of swelling in the neck. While palpating
the neck, the nurse finds a 2-cm lump that is fixed and hard. Why does this finding
require emergency investigation?
This could be a sign of cancer
This could be a sign of pneumothorax
This could be a sign of a parotid stone
This could be a sign of an embolus - ANSWER This could be a sign of cancer
A client in the ED tells the nurse that she is having difficulty breathing. What term
would the nurse use in documenting this finding?
Tachypnea
Eupnea
Anxiety
Dyspnea - ANSWER Dyspnea
The nurse is reviewing the following vital signs of a client who is lying in bed. Which
of the following would the nurse identify as being ABNORMAL?
Oral temperature 36.6 C (98.4 F)
Radial pulse 110 beats/minute
Oxygen saturation 93%
Respirations 20 breaths/minute - ANSWER Radial pulse 110 beats/minute
Medications should be scheduled to minimize sleep disruptions during
hospitalization.
True or False? - ANSWER True
Which vital sign is consistent with tachypnea?
BP 150/90
T 104.2
RR 33
P 112 - ANSWER RR 33
,A nurse is examining a young boy who is complaining that he cannot hear as well
out of one ear as he used to. The nurse suspects that it is just ear wax that is the
problem, but needs to view the ear canal and tympanic membrane to make sure.
Which piece of equipment should the nurse use to do this?
stethoscope
otoscope
sphygmomanometer
opthalmascope - ANSWER otoscope
Data collection occurs where in the nursing process?
Implementing
Diagnosis
Assessment
Planning - ANSWER Assessment
Symptoms commonly associated with nutritional issues include:
Select all that apply::
loss of appetite
weight changes
increased energy level
dysphagia - ANSWER loss of appetite
weight changes
dysphagia
The nurse understands that when performing a health history it is important to
include subjective data, which includes:
Select all that apply.
lab reports from the chart
vital signs
symptoms that the client reports
symptoms that the nurse observes - ANSWER symptoms that the client reports
Which tool would be the best choice to assess pain levels in a newborn baby?
Faces chart
FLACC scale
Assessment of volume of crying
Numeric pain scale 1-10 - ANSWER FLACC scale
When documenting an eye assessment what does the A in PERRLA stand for?
assessment
astigmatism
accommodation
annulus - ANSWER accommodation
, A nurse is gathering data from a client during a health assessment. Which
assessment finding should the nurse document as objective data?
Select all that apply.
What types of exercise the client engages in at home.
Whether the client has adequate support at home.
The client's measured urine output following surgery.
The clients weight measured with shoes off. - ANSWER The client's measured urine
output following surgery.
The clients weight measured with shoes off.
The retina is a critical structure in the eye which:
maintains the shape of the eye
refracts and focuses light
regulates the amount of light allowed into the inner eye
receives & transmits visual stimuli to the optic nerve and on to the brain - ANSWER
receives & transmits visual stimuli to the optic nerve and on to the brain
Place each dermatology term into the correct category:
1. cyst
2. nodule
3. hematoma
4. vesicle
5. bulla
6. purpura
7. ecchymosis
Fluid Filled _______
Solid ________
Blood filled ____________ - ANSWER 1. cyst - fluid filled
2. nodule - solid
3. hematoma - blood filled
4. vesicle - fluid filled
5. bulla - fluid filled
6. purpura - blood filled
7. ecchymosis - blood filled
You observe a cloudy, opaque lens in your client's right eye. This is usually a sign of
which eye condition?
nystagmus