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GRADED A+.
1. Which of the following is an expected finding in a healthy client on assessment
of Stensen's ducts? (2 Points)
red glow is
present midline
and symmetric
saliva is
present
redness is
present
2.
The client has a new diagnosis of right sided heart failure. The nurse understands a
client with right sided heart failure may have edema and jugular vein distension.
(2 Points)
Tru
e
Fals
e
5.
,The nurse performs the Romberg test to
assess for: (2 Points)
balance
hearing
vision
loss
cranial nerve 6
dysfunction 6.
Which of the following techniques will the nurse perform to assess for signs of
breast abnormalities? (2 Points)
inspection, palpation, and auscultation
inspection and palpation
inspection, palpation, and
percussion palpation and
auscultation
7. The nurse is caring for a client with obesity. The nurse places the client in which
of the following positions to best hear heart sounds?
supi
ne
pron
e
sitting upright
lef t
lateral
,Which of the following clients is a priority for the nurse to perform an assessment
for respiratory expansion?
(2 Points)
70 year old client with a history of smoking and new
diagnosis of COPD 16 year old client with a broken finger,
with a history of asthma
A client with a new diagnosis of bronchitis and reporting fatigue
client in a motor vehicle accident with tracheal deviation
8.
State at which location(s) the S1 sound (lub) is heard loudest on cardiac
auscultation. State why the S1 is loudest at these locations. (Write 1-2 sentences).
If you are you are at the proper location, you will hear the
sound the loudest. (2 Points)
9.
The older adult client is admitted with new onset pain and pressure to their eyes.
On inspection, the sclera is red and the pupil is an irregular shape to the left eye.
The nurse should further assess for:
(2 Points)
macular
degeneration
cataracts
, presbyopia
Glaucoma BOOK REF.
PG 253 11.
The client is seen in the urgent care center with a suspected fungal infection to the
fingernails. The nails are thick, yellow, and lifting off the nail bed. The nurse
documents this finding as:
(2
Points)
clubbin
g
Onycholysis BOOK
REF PG. 203 beau's lines
splinter
hemmorage 12.
The nurse assesses the client's radial pulses and documents these findings: 68
beats per minute, regular, 2+, symmetrical. The physician asks the nurse, "What
was the client's pulse amplitude?" The best response of the nurse:
(2 Points)
"68 beats per
minute" "regular"
"2+" BOOK REF PG 404
"symmetri
cal" 13.
The nurse is performing a cardiac auscultation and hears a harsh, blowing sound
that is very loud at the 4th ICS, left sternal border. No thrill is present. The nurse