Nurs 4455 quiz3 updated 2024
A patient has an exaggerated lumbar curve to the lower spine. This
would be documented as: Selected Answer: Lordosis
You note from the patient's history that she has had pain with internal
rotation of her right shoulder. This will most likely affect which of the
following activities?
Reaching an item o ff the top shelf of her closet, over her head.
True or False: When assessing for a patient's response to painful stimuli,
the nurse should always begin with the least noxious stimulus first,
before proceeding to more painful means. True
A woman brings her 69-year-old husband to the clinic for an evaluation
because he has become increasingly forgetful. Which of the following
would lead the nurse to suspect that the client has Alzheimer's
disease? Select the one answer that does notindicate that he may have
Alzheimer’s disease.
A. “He got lost walking to the pharmacy around the corner the other
day.”
C. “I have to balance the checkbook now because he just won't do it.”
D. “If I don't tell him when to shower, he won't and will fight me on it.”
E. “He repeats the same story, word for word, over and over again.”
A female in Tanner stage 5 would have which sexual characteristics?
Adult Configuration; projection of nipple, areola receded
When the nurse palpates the abdomen of a preschool boy, he begins to
giggle and draw his legs up onto his abdomen, and says you’re tickling
him. Which of the following would be most appropriate for the nurse to
do? Palpate with the child’s hand under the nurse’s hand
As part of a mental status assessment, the nurse asks a client to draw
the face of a clock. This will allow the nurse to assess which of the
following domains of mental status? Visual perceptual + Constructional
Ability
A client's recent episode of becoming lost near his home has prompted
the nurse to use the Saint Louis University Mental Status (SLUMS)
Assessment Tool. The nurse should begin this assessment by asking
what question? “Can I ask you some questions about yourmemory?”
,An emergency department nurse has utilized the Confusion
Assessment Method (CAM) in the assessment of a 79-year-old client
with a new onset of urinary incontinence. This assessment tool will
allow the nurse to confirm the presence of what health problem?
Delirium
When auscultating the left carotid artery, the nurse notes a swishing
sound. What would thissuggest? A narrowed vessel
A nurse assesses a client's capillary refill and finds it to be less than 2
seconds. Which of the following should the nurse do next? Document
this finding as normal.
The nurse is assessing the various lobes of the client's lungs. To gather
accurate data, the nurse must assess which lobe anteriorly, since this
lobe does not extend to the posterior chest? Right middle lobe
The nurse is listening to the precordium, and identifies a heart murmur
so loud it can be heard with the stethoscope not in full contact with the
chest. What rating would this murmur merit? Grade 5/6
The nurse is analyzing the data from the assessment of a client's heart
and neck vessels. The client's first heart sound corresponds with what
event in the cardiac cycle? Closure of the atrioventricular valves
Assessment of a client's radial pulse reveals that it is bounding and
does not disappear with moderate pressure. The nurse documents the
pulse amplitude as which of the following? +3
On auscultation of valvular sounds over the precordium, what area is
auscultated at the third to fifth intercostal space at the left sternal
border? Erb's Point
On auscultation of valvular sounds over the precordium, what area is
auscultated at the second or third intercostal space at the left sternal
border?
Pulmonic
, The nurse is listening to the precordium, and identifies a heart murmur
so loud it can be heard with the stethoscope not in full contact with the
chest. What rating would this murmur merit? Grade 5/6
Because of calcification of the costal cartilage and loss of accessory
musculature, the older adult may have decreased chest expansion
when breathing, but the chest expansion should be symmetrical : true
On examination, the nurse would expect what finding if a client is in
right-sided failure: Increased jugular venous pressure
In many situations nurses elect to take blood pressure in the legs
(ankle) , often because thearms have IVs or other lines. How does the
ankle blood pressure value compare with the brachial blood pressure?
The ankle pressure will be higher since it is further from the heart and
pressure has to be higher to reach the feet. In patients with peripheral
vascular disease it will be even higher.
The nurse is preparing to auscultate the client's thorax. Which of the
following actions is important during this component of assessment?
Listen at each site for at least one complete respiratory cycle
(inhalation and exhalation).
While auscultating a client's lungs, the nurse notes the presence of
adventitious sounds. Which of the following actions should the nurse
do first? Have the client cough, then listen again
On auscultation of valvular sounds over the precordium, what area is
auscultated at the fourth or fifth intercostal space at the left lower
sternal border? Tricuspid
On auscultation of valvular sounds over the precordium, what area is
auscultated at the fifth intercostal space near the left midclavicular
line-the apex of the heart? Mitral
A patient has an exaggerated lumbar curve to the lower spine. This
would be documented as: Selected Answer: Lordosis
You note from the patient's history that she has had pain with internal
rotation of her right shoulder. This will most likely affect which of the
following activities?
Reaching an item o ff the top shelf of her closet, over her head.
True or False: When assessing for a patient's response to painful stimuli,
the nurse should always begin with the least noxious stimulus first,
before proceeding to more painful means. True
A woman brings her 69-year-old husband to the clinic for an evaluation
because he has become increasingly forgetful. Which of the following
would lead the nurse to suspect that the client has Alzheimer's
disease? Select the one answer that does notindicate that he may have
Alzheimer’s disease.
A. “He got lost walking to the pharmacy around the corner the other
day.”
C. “I have to balance the checkbook now because he just won't do it.”
D. “If I don't tell him when to shower, he won't and will fight me on it.”
E. “He repeats the same story, word for word, over and over again.”
A female in Tanner stage 5 would have which sexual characteristics?
Adult Configuration; projection of nipple, areola receded
When the nurse palpates the abdomen of a preschool boy, he begins to
giggle and draw his legs up onto his abdomen, and says you’re tickling
him. Which of the following would be most appropriate for the nurse to
do? Palpate with the child’s hand under the nurse’s hand
As part of a mental status assessment, the nurse asks a client to draw
the face of a clock. This will allow the nurse to assess which of the
following domains of mental status? Visual perceptual + Constructional
Ability
A client's recent episode of becoming lost near his home has prompted
the nurse to use the Saint Louis University Mental Status (SLUMS)
Assessment Tool. The nurse should begin this assessment by asking
what question? “Can I ask you some questions about yourmemory?”
,An emergency department nurse has utilized the Confusion
Assessment Method (CAM) in the assessment of a 79-year-old client
with a new onset of urinary incontinence. This assessment tool will
allow the nurse to confirm the presence of what health problem?
Delirium
When auscultating the left carotid artery, the nurse notes a swishing
sound. What would thissuggest? A narrowed vessel
A nurse assesses a client's capillary refill and finds it to be less than 2
seconds. Which of the following should the nurse do next? Document
this finding as normal.
The nurse is assessing the various lobes of the client's lungs. To gather
accurate data, the nurse must assess which lobe anteriorly, since this
lobe does not extend to the posterior chest? Right middle lobe
The nurse is listening to the precordium, and identifies a heart murmur
so loud it can be heard with the stethoscope not in full contact with the
chest. What rating would this murmur merit? Grade 5/6
The nurse is analyzing the data from the assessment of a client's heart
and neck vessels. The client's first heart sound corresponds with what
event in the cardiac cycle? Closure of the atrioventricular valves
Assessment of a client's radial pulse reveals that it is bounding and
does not disappear with moderate pressure. The nurse documents the
pulse amplitude as which of the following? +3
On auscultation of valvular sounds over the precordium, what area is
auscultated at the third to fifth intercostal space at the left sternal
border? Erb's Point
On auscultation of valvular sounds over the precordium, what area is
auscultated at the second or third intercostal space at the left sternal
border?
Pulmonic
, The nurse is listening to the precordium, and identifies a heart murmur
so loud it can be heard with the stethoscope not in full contact with the
chest. What rating would this murmur merit? Grade 5/6
Because of calcification of the costal cartilage and loss of accessory
musculature, the older adult may have decreased chest expansion
when breathing, but the chest expansion should be symmetrical : true
On examination, the nurse would expect what finding if a client is in
right-sided failure: Increased jugular venous pressure
In many situations nurses elect to take blood pressure in the legs
(ankle) , often because thearms have IVs or other lines. How does the
ankle blood pressure value compare with the brachial blood pressure?
The ankle pressure will be higher since it is further from the heart and
pressure has to be higher to reach the feet. In patients with peripheral
vascular disease it will be even higher.
The nurse is preparing to auscultate the client's thorax. Which of the
following actions is important during this component of assessment?
Listen at each site for at least one complete respiratory cycle
(inhalation and exhalation).
While auscultating a client's lungs, the nurse notes the presence of
adventitious sounds. Which of the following actions should the nurse
do first? Have the client cough, then listen again
On auscultation of valvular sounds over the precordium, what area is
auscultated at the fourth or fifth intercostal space at the left lower
sternal border? Tricuspid
On auscultation of valvular sounds over the precordium, what area is
auscultated at the fifth intercostal space near the left midclavicular
line-the apex of the heart? Mitral
