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?
, NSG 200 Final Exam
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?
cerebellar ataxia - ✔✔ correct answer During the romberg's test, a patient is unable to stand with his
feet together and demonstrates a wide-based, staggering, unsteady gait. The nurse would identify
this as which of the following?
spastic hemiparesis - ✔✔ correct answer characterized by a flexed arm held close to the body while
the patient drags the toes of the leg or circles it stiffly outward and forward
parkinsonian gait - ✔✔ correct answer a "shuffling" gait
scissors gait - ✔✔ correct answer a short, stiff gait with the thighs overlapping each other with each
step
3+ - ✔✔ correct answer The nurse is assessing brisk reflexes in a patient. The nurse would document
this finding as which of the following?