NUR 216 Exam 3 Questions and Answers | Latest
Update
A nurse is assessing a client's cranial nerves. Which of the following client
actions is an indication that cranial nerve 1 is intact?
A. The client can stick their tongue out
B. The client can smile symmetrically
C. The client can hear whispered words
D. The client can identify a minty scent
D. The client can identify a minty scent
Rationale- Cranial nerve 1, the olfactory nerve, controls the sense of smell. To test
this nerve's function, the nurse should ask the client to identify a nonirritating
aroma, such as mint or coffee
A nurse is performing a respiratory assessment on a client. The nurse
auscultates a wet, popping sound upon inspiration of the clients breathing. The
nurse should identify this observation as which of the following findings?
A. Crackles
B. Stridor
C. Wheezes
D. Friction Rub
A. Crackles
,Rationale- crackles, sometimes called rales, are wet, popping sounds created by
air moving through liquid or by collapsed alveoli snapping open on inspiration.
They are most common at the end of inspiration of breathing.
A nurse is performing a cardiovascular assessment on a client which of the
following findings should the nurse expect?
A. A continuous sensation of vibration felt over the second and third left
intercostal spaces
B. A high-pitched, scraping sound heard in the third intercostal space to the left of
the sternum
C. A brief thump felt near the fourth or fifth intercostal space near the left mid
clavicular line
D. A whooshing or swishing sound over the second intercostal space along the left
arsenal border
C. A brief thump felt near the fourth or fifth intercostal space near the left mid
clavicular line
Rationale- This is where you would inspect and palpate for the point of maximal
impulse. Also called an apical pulse station, it occurs as the Apex of the heart
bumps against the chest wall with each heartbeat. The apical impulse is not
always visible but can be felt as a brief thump. This is an expected finding and
should be performed when you are preparing to auscultate the apical pulse.
The nurse is preparing to perform a comprehensive physical assessment on a
client. Which of the following actions should the nurse plan to take first?
A. Document accurate data
,B. Develop a plan of care
C. Validate previous data
D. Evaluate outcomes of care
B. Develop a plan of care
Rationale- The first action the nurse should take using the nursing process is to
assess the client and develop a plan of care. The nursing process follow the steps
of assessment, analysis, planning, implementation, and evaluation.
A nurse is palpating a tender area of a clients abdomen. The nurse slowly applies
pressure over the area with their fingertips, then quickly releases it. The client
reports increased pain on the release of pressure. Which of the findings should
the nurse document?
A. Borborygmi
B. Rebound Tenderness
C. Tympany
D. Abdominal Guarding
B. Rebound Tenderness
Rationale- The nurse should document that the client is experiencing rebound
tenderness, which is an increase in pain when deep palpation over a tender area
is released. Rebound tenderness is in the right lower quadrant at McBurney's
point (one-third the distance from the anterior iliac crest to the umbilicus) is an
indication of acute appendicitis.
, A nurse is performing a physical examination of the spine for an older adult client.
The nurse should identify that which of the following findings is common with
aging?
A. Lordosis
B. Kyphosis
C. Ankylosis
D. Scoliosis
B. Kyphosis
Rationale- kyphosis, a pronounced "hunchback" curvature of the spine, is an
abnormal angulation of the posterior curve of the thoracic spine, usually a result
of osteoporosis. It is most common in older adults and tends to increase with
aging. This pronounced convexity of the thoracic spine is also common in older
clients who have had vertebral fractures.
Disorders in which parts of the ear usually result in earaches?
A. Inner and middle ear
B. Inner and external ear
C. Middle and external ear
D. Travis and eardrum
B. Inner and external ear
Eye discharge is usually associated with:
A. Hypertension (HTN)
B. Conjunctivitis
Update
A nurse is assessing a client's cranial nerves. Which of the following client
actions is an indication that cranial nerve 1 is intact?
A. The client can stick their tongue out
B. The client can smile symmetrically
C. The client can hear whispered words
D. The client can identify a minty scent
D. The client can identify a minty scent
Rationale- Cranial nerve 1, the olfactory nerve, controls the sense of smell. To test
this nerve's function, the nurse should ask the client to identify a nonirritating
aroma, such as mint or coffee
A nurse is performing a respiratory assessment on a client. The nurse
auscultates a wet, popping sound upon inspiration of the clients breathing. The
nurse should identify this observation as which of the following findings?
A. Crackles
B. Stridor
C. Wheezes
D. Friction Rub
A. Crackles
,Rationale- crackles, sometimes called rales, are wet, popping sounds created by
air moving through liquid or by collapsed alveoli snapping open on inspiration.
They are most common at the end of inspiration of breathing.
A nurse is performing a cardiovascular assessment on a client which of the
following findings should the nurse expect?
A. A continuous sensation of vibration felt over the second and third left
intercostal spaces
B. A high-pitched, scraping sound heard in the third intercostal space to the left of
the sternum
C. A brief thump felt near the fourth or fifth intercostal space near the left mid
clavicular line
D. A whooshing or swishing sound over the second intercostal space along the left
arsenal border
C. A brief thump felt near the fourth or fifth intercostal space near the left mid
clavicular line
Rationale- This is where you would inspect and palpate for the point of maximal
impulse. Also called an apical pulse station, it occurs as the Apex of the heart
bumps against the chest wall with each heartbeat. The apical impulse is not
always visible but can be felt as a brief thump. This is an expected finding and
should be performed when you are preparing to auscultate the apical pulse.
The nurse is preparing to perform a comprehensive physical assessment on a
client. Which of the following actions should the nurse plan to take first?
A. Document accurate data
,B. Develop a plan of care
C. Validate previous data
D. Evaluate outcomes of care
B. Develop a plan of care
Rationale- The first action the nurse should take using the nursing process is to
assess the client and develop a plan of care. The nursing process follow the steps
of assessment, analysis, planning, implementation, and evaluation.
A nurse is palpating a tender area of a clients abdomen. The nurse slowly applies
pressure over the area with their fingertips, then quickly releases it. The client
reports increased pain on the release of pressure. Which of the findings should
the nurse document?
A. Borborygmi
B. Rebound Tenderness
C. Tympany
D. Abdominal Guarding
B. Rebound Tenderness
Rationale- The nurse should document that the client is experiencing rebound
tenderness, which is an increase in pain when deep palpation over a tender area
is released. Rebound tenderness is in the right lower quadrant at McBurney's
point (one-third the distance from the anterior iliac crest to the umbilicus) is an
indication of acute appendicitis.
, A nurse is performing a physical examination of the spine for an older adult client.
The nurse should identify that which of the following findings is common with
aging?
A. Lordosis
B. Kyphosis
C. Ankylosis
D. Scoliosis
B. Kyphosis
Rationale- kyphosis, a pronounced "hunchback" curvature of the spine, is an
abnormal angulation of the posterior curve of the thoracic spine, usually a result
of osteoporosis. It is most common in older adults and tends to increase with
aging. This pronounced convexity of the thoracic spine is also common in older
clients who have had vertebral fractures.
Disorders in which parts of the ear usually result in earaches?
A. Inner and middle ear
B. Inner and external ear
C. Middle and external ear
D. Travis and eardrum
B. Inner and external ear
Eye discharge is usually associated with:
A. Hypertension (HTN)
B. Conjunctivitis
