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NUR 3094C Health Assessment FINAL
EXAM Latest 2024.2025 FSCJ 100%
GRADED A+
The nurse is performing a neurological check on a client with a head injury from a motor vehicle accident four hours ago. The nurse suspects the client has developed increased intracranial pressure. Which of the following would lead the nurse to suspect this diagnosis? Fixed and dilated pupils The nurse notes decorticate posturing in a client following a traumatic brain injury. Which of the following assessments by the nurse would be consistent with this posturing? Flexion of the elbows The nurse is performing hourly assessments of the client's level of consciousness. During the assessment, the client remains unresponsive after multiple attempts of the nurse calling their name. Which of the following would the nurse perform next? Gently shake the client's shoulders.
The nurse is assessing a client's cranial nerves XI (spinal accessory). Which of the following would the nurse expect to observe? The client is able to shrug shoulders against resistance The nurse is preparing to assess the abstract reasoning of a client who has a diagnosis of early stage Alzheimer disease. Which of the following questions would be most appropriate for the nurse to ask? "How are an apple and orange the same?" As part of a mental status assessment, the nurse asks the client how they would respond if they found a wallet lying on the sidewalk. This will allow the nurse to assess which domain of mental status? Judgment The nurse records a client's visual acuity as 20/50 using the Snellen eye chart. The nurse correctly interprets the finding as which of the following? The client can read at 20 feet what a person with normal vision can read at 50 feet.
A nurse in the emergency department assesses a client's pupillary reaction and observes bilateral pinpoint pupils. The nurse interprets this finding as suggesting which of the following? Narcotic use The nurse is assessing the client's eyes and vision. When performing the confrontation test for peripheral vision, which of the following would the nurse ask after covering one of the client's eyes? Ask the client to state when they can see the nurse's finger enter their visual field. The nurse is testing for accommodation during a client's eye examination. The nurse correctly performs the exam when they demonstrate which of the following? The nurse asks the client to focus on the penlight, and then asks the client to follow the penlight to about 7 cm from the nose. During a routing eye assessment of a 55-year-old client, the client states they see "floaters" in their eyes. Which of the following actions by the nurse would be most appropriate? Document this as a normal physiological change with aging
The nurse is performing the positions test on a client. During the assessment, the nurse notes oscillating movements of the client's eyes. The nurse would correctly document this finding as which of the following? Nystagmus The nurse is assessing the external eye structures of an elderly client. Which of the following age-related findings would the nurse anticipate observing? Arcus senilis The nurse has completed the assessment of a client's direct pupillary response and is now assessing consensual response. To test for consensual response, the nurse would use which of the following techniques? Observe the pupil reaction when a light is shone into the opposite eye The nurse is testing a client's equilibrium with the Romberg test. Which client action would indicate a negative (normal) Romberg test? Maintaining the position during the exam
The nurse is inspecting the oral cavity of a client. Which of the following findings would the nurse report for immediate medical follow-up? Leukoplakia A client comes to the clinic complaining of a sore throat. After assessing the throat, the nurse documents the tonsils as 2+. The nurse explains to the client that "2+ tonsils" are which of the following? Visible beyond the anterior pillars During the examination of the client's mouth, the nurse notes a decrease in tongue strength. The nurse interprets this finding as a problem with which of the following? Cranial nerve XII (hypoglossal) A client has just been diagnosed with a sinus infection accompanied by large amounts of exudate. Which of the following assessment findings should the nurse anticipate along with this condition? Crepitus over the maxillary sinuses
A nurse is preparing a program on osteoporosis for a local women's group. Which of the following would the nurse cite as a modifiable risk factor? Smoking During the assessment of a client's deep tendon reflexes, the nurse notes a few short taps while dorsiflexing the foot. The nurse would document this finding as which of the following? 4+ The nurse is using COLDSPA to assess a client's history of back pain. Which statement by the client best addresses "S" in the assessment model? "My pain is a 7 out of 10." The nurse has completed a focused assessment of an adult client's mouth, nose, and throat. Which finding would the nurse interpret as being normal? Pink, spongy soft palate
The nurse is preparing to obtain information about a client's mental and psychological status. Which of the following actions would the nurse take first? Explain the purpose of the exam and the types of questions that will be asked The nurse is examining the mouth of an elderly client. Which of the following findings by the nurse would be considered a normal age-related change? Worn tooth surfaces The nurse is caring for a client who has been experiencing dysphagia secondary to a stroke. What nursing diagnosis should the nurse associate with this health problem? Risk for Aspiration related to decreased swallowing ability We have an expert-written solution to this problem! A nurse is integrating health promotion education into the assessment of a client's mouth, nose, and throat. Which interview question is most likely to identify a risk factor for oral cancer? "Do you use chewing or smoking tobacco?"
A client tells the nurse that she is having a hard time bringing her hand to her mouth during meals. To assess the client's range of motion in the elbow, the nurse would have the client demonstrate which of the following? Flexion The nurse is assessing the client's temporomandibular joint (TMJ). Which of the following findings by the nurse would be documented as normal? Clicking when the mouth opens The nurse suspects a client has carpal tunnel syndrome and asks her to perform Tinel's test. To perform this test, the client would demonstrate which of the following? Tap the inner aspect of the wrist over the median nerve The nurse is performing the ballottement test during the assessment of a client's knee. The nurse understands that performing this test would give further information on which of the following? Whether the client is experiencing increased fluid in the knee joint
While examining the muscle tone of a client, the nurse finds only a slight flicker of contraction. The nurse would document this finding on the strength table as which of the following? 1 The nurse asks a client to bring his hands together behind his lower back with his elbows flexed. Which range of motion movement is the nurse assessing? Internal Rotation The nurse is assessing the motor function of a client's cranial nerve V (trigeminal). Which of the following actions would the nurse take? Palpate temporal and masseter muscles while client clenches the teeth. The nurse is preparing to infuse a liter of Dextrose 5% in ½ Normal Saline (hypertonic solution) for a client in diabetic ketoacidosis. The nurse understands that infusing this solution would help pull fluid from the _________ space to the ___________ space. Intracellular; intravascular
The nurse is administering intravenous magnesium sulfate to a pregnant client to stop premature labor. When performing a check on the IV pump, the nurse realizes the infusion is running too fast, and suspects the client has developed hypermagnesemia. What assessment finding by the nurse would help confirm this suspicion? Absent deep tendon reflexes (DTRs) The nurse is caring for a client admitted with severe vomiting and dehydration. The client's lab results show a sodium level of 130. Which of the following complications would the nurse assess for? Seizure activity A client comes to the clinic with complaints of muscle weakness, leg cramps, and fatigue. The nurse anticipates the lab results to confirm which of the following? Hypokalemia The nurse is reviewing a client's arterial blood gas (ABG) and notes the following: pH 7.49; PaCO2 30; HCO3- 20. The nurse correctly identifies that the client is experiencing which of the following? Partially compensated respiratory alkalosis
The nurse is caring for a client with a spinal cord injury following a motor vehicle accident. The client tells the nurse that he continues to "wet the bed" without having any sensation that he needs to void. The nurse would suspect this client is experiencing which type of urinary incontinence? Reflex A client in the clinic complains that his urine has turned a dark red color. When reviewing the client's current medications, which medication would the nurse suspect as the cause of the red urination? Warfarin (anticoagulant) A client is admitted to the clinic with concerns about a possible urinary tract infection (UTI). Which of the following signs and symptoms would not be associated with a lower UTI? Flank pain The nurse is providing care for elderly clients in a long-term care facility. Which of the following would the nurse not anticipate as a change in urinary elimination due to aging? Decreased frequency of urination
The unit nurse is reviewing the physician orders for each of her clients. For which of the following clients would the nurse question the physician's order for an indwelling catheter (which client does not need a catheter)? A client admitted for 23 hour observation with bathroom privileges The nurse is caring for several clients on the medical-surgical unit. Which of the following clients would the nurse recognize as having the greatest risk for developing a urinary tract infection (UTI)? A 60-year-old postmenopausal female admitted with diabetic ketoacidosis A nurse has instructed a client at the clinic about collecting a specimen for a routine urinalysis. Which of the following statements, if made by the client, would indicate a need for further teaching? "I will keep the toilet paper in the specimen." The nurse is preparing to discharge a male client following outpatient surgery. The client tells the nurse he is unable to void while lying supine. What can the nurse do to facilitate his voiding? Assist him to a standing position.
A nursing student is preparing to perform an abdominal assessment on a client. The student performs the assessment correctly when they demonstrate the techniques in which order? Inspect, auscultate, percuss, palpate To promote relaxation of the client's abdominal muscles during examination, which of the following would be most appropriate for the nurse to do? Place a pillow under both of the client's knees The nurse suspects intra-abdominal bleeding in a client who was recently involved in a motor vehicle accident. Which of the following findings would most likely lead the nurse to this suspicion? Cullen's sign The nurse is evaluating a new nursing graduate's ability to perform a rebound tenderness test for suspected appendicitis. The nurse identifies correct technique when the new graduate is observed pressing deeply at which abdominal location? Right lower quadrant
The nurse is auscultating a client's abdomen and is unable to discern any bowel sounds. How should the nurse proceed with the assessment? Listen for at least five minutes before documenting absence of bowel sounds When assessing a client's abdomen, the nurse palpates a pulsating, nontender, 6-centimeter mass above the umbilicus. Which of the following actions should the nurse take next? Stop palpating and call the physician A client expresses concerns over having black stools. The fecal occult test (guaiac) is negative. Which response by the nurse is most appropriate? "Do you take iron supplements?" The nurse is planning a bowel training program for a client with a spinal cord injury. Which of the following expected outcome would the nurse include in the care plan? Have a soft, formed stool at regular intervals without a laxative
