answers
The nurse notes documentation that a client is exhibiting Cheyne-
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Stokes respirations. On assessment of the client, the nurse should
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expect to note which finding?
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1. Increasing rate and depth of respirations with periods of apnea
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2. Regular rapid and deep, sustained respirations
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3. Totally irregular respiration in rhythm and depth
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4. Irregular respirations with pauses at the end of inspiration and
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expiration -
|/\ |/\ |/\ CORRECT ANSWERS ✔✔1. Increasing rate and |/\ |/\ |/\ |/\ |/\
depth of respirations with periods of apnea. pg. 434
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A client diagnosed with conductive hearing loss (physical
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obstruction) asks the nurse to explain the cause of the hearing
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problem. The nurse plans to explain to the client that this condition
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is caused by which problem?
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1. A deficit in the cochlea
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2. A deficit in cranial nerve VIII
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1
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,3. A physical obstruction to the transmission of sound waves
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4. A defect in the sensory fibers that lead to the cerebral cortex -
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|/\ CORRECT ANSWERS ✔✔3. A physical obstruction to the |/\ |/\ |/\ |/\ |/\ |/\ |/\
transmission of sound waves
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The nurse is testing the extra ocular movements in a client to assess
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for muscle weakness in the eyes. The nurse should implement
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which assessment technique to assess for muscle weakness in the
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eye?
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1. Test corneal reflexes
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2. Test 6 cardinal positions of gaze
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3. Test visual acuity, using Snellen eye chart
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4. Test sensory function by asking client to close the eyes and then
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lightly touching the forehead, cheeks, chin -
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ CORRECT ANSWERS |/\
✔✔2. Test 6 cardinal positions of gaze
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A client with a diagnosis of asthma is admitted to the hospital with
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respiratory distress. Which type of adventitious lung sounds
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should the nurse expect to hear when performing a respiratory
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assessment on this client?
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2
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, 1. Stridor
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2. Crackles
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3. Wheezes
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4. Diminishe -
|/\ |/\ |/\ CORRECT ANSWERS ✔✔3. Wheezes |/\ |/\ |/\
high pitched squeaking sound |/\ |/\ |/\
The nurse is reviewing a client's record and notes that the result of
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a vision test using a Snellen chart is 20/30. How should the nurse
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explain these results to the client?
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1. You have normal vision
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2. You have some degree of blindness
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3. You can read at a distance of 20 ft what a person with normal
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vision can read at 30 ft
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4. You can read at a distance of 30 ft what a person with normal
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vision can read at 20 ft -
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ CORRECT ANSWERS ✔✔3. You can read |/\ |/\ |/\ |/\ |/\
at a distance of 20 ft what a person with normal vision can read at
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30 ft
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The nurse performing a neurological exam is assessing eye
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movement to evaluate cranial nerves III, IV, VI. Using a flashlight,
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the nurse would perform which action to obtain assessment data?
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3
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