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NUTRITON EXAM QUESTION WITH CORRECT ANSWERS
A nurse is conducting a nutritional assessment of an 82 y/o client. Which of the following factorsis most likely to affect the nutritional status of an elderly person Living alone on a fixed income Increase in GI absorption Increase acuity of taste and smell Change in cardiovascular status A nurse is obtaining a history from a 30 year old female client. Which of the following questionswould the nurse ask to assess health promotion activities Have you ever noticed any lumps on your breast? Have you had any problems with nipple discharge? Do you have annual breast examinations? Do you have breast implants? During the interview process, a nurse notices discrepancy between the client’s verbal and non-verbal behaviors. Given this situation, the nurse should Change the subject and see if the behavior changes Ask someone who knows the patient Focus on the client’s verbal message Focus on the client’s nonverbal behaviors While conducting a cultural health assessment a nurse should include which of the following? Medical history Health-related beliefs Chief complaint Family history Which of the following information would a nurse collect as part of the Review of Systemsportion of a complete health history? Conjunctiva moist and pink Fractured tibia at age 15 Skin color is uniform Wheezing audible without stethoscope A client was admitted to the emergency department with a change in level of consciousness. Theclient stated that he took some pain medicine for a severe headache that was “the worse pain in the world”. The client’s respirations are 10 breaths per minute. Which of the following information is considered objective data? Severe headache “Worst pain in the world” 10 breaths per minute Took some pain medicine Upon entering the client’s room, a nurse asks the client to turn down the volume of the television. The nurse request was intended to Create a quiet environment Control the client’s behavior Manipulate the client’s responses
Uphold unit policy A postoperative client who had abdominal surgery yesterday tells the nurse “I feel pressure and Ifelt a pop in my stomach.” The nurse notes blood oozing through the dressing and that the dressing is wet. Which of the following interventions should the nurse implement first? Perform a focused abdominal assessment Instruct the client to splint the incision Remove the dressing to inspect the incision Administer pain medical intravenously A nurse calls a physician in reference to a client’s change in clinical status. Using the SBARcommunication model for a critical accident, in what sequence should the nurse report the following statements to the physician Ms. C is a 27 y/o female status post left radical mastectomy and left axillary lymph nodedissection two days ago Would you like to examine the surgical wound for bleeding? Ms. C was examined by the rapid response team, X-Rays were taken and are negative, client is resting in bed after receiving Morphine Sulfate 4 mg IM for pain. Vital signs BP = 110/70, HR 82 and regular, RR = 19. Dressing shows increased serosanguinousdrainage Ms. C fell and injured her left arm while walking unassisted to the bathroom e. 4,1, 3, 2 A nurse needs to obtain anthropometric measures of an 80 year old client. Which of the followingstatements is true regarding expected musculoskeletal changes in the older adult? Increased muscle mass will affect the mid-calf circumference measurements Muscle atrophy will increase BMI Height may decrease due to changes in bone density Increased skin elasticity will affect the waist-hip ratio When conducting a focused assessment of an older adult, the nurse would assess the client’s Physical signs of aging Immunological function Functional abilities History of chronic illness A client reports eating 3 servings a day every day for a week of the item below. How many totalcalories from fat did the client consume in 7 days?
Adventitious Bronchial Vesicular Bronchovesicular While auscultating a client’s lungs, a nurse hears adventitious breath sounds at the bases. Whichof the following would the nurse do first? Refer the client for further medical evaluation Auscultate for egophony Perform bronchophony Ask the client to cough and then listen again Which of the following respiratory assessment findings would the nurse expect in a healthy adultclient? Adventitious sounds and limited chest expansion Increased tactile fremitus and dull percussion tones Muffled voice sounds and symmetrical tactile fremitus Absent voice sounds and hyperresonant percussion tones When auscultating the lungs of an adult client, a nurse hears low-pitched, soft breath sounds overthe posterior lower lobes that are longer on inspiration than expiration. These assessment findingssuggest Tracheal breath sounds Bronchial breath sounds Vesicular breath sounds Bronchovesicular breath sounds A client was admitted to the emergency department for a suspected drug overdose. Respirationsare shallow and irregular with a rate of 9 per minute. The nurse would interpret this respiration pattern as Tachypnea Cheyne-stokes respirations Hypoventilation Agonal breathing A client who has no significant medical history is admitted to the emergency department with difficulty breathing. Which of the following assessment findings should be of most concern to thenurse?
Pulse oximetry reading of 90% Low-pitched wheezing in lower lobes Report of dyspnea on exertion Respiratory rate of 22 per minute When assessing the carotid arteries of a 72 year old client with a history of peripheral vasculardisease, a nurse would first Auscultate using the diaphragm of the stethoscope Palpate the carotid arteries simultaneously Auscultate using the bell of the stethoscope Inspect for signs of bruits During a cardiovascular assessment of an 80 year old adult a nurse should consider which of thefollowing as expected findings? Narrowing of the inferior vena cava causing bilateral lower extremity varicosities Hormonal changes causing vasodilation resulting in hypotension Peripheral blood vessels become more rigid producing a rise in systolic bloodpressure Atrophy of the muscles causing venous insufficiency Using the diagram below, identify the precordial landmark for auscultating Erb’s point 1 2 3 4 5 While performing a peripheral vascular assessment of a client, a nurse is unable to palpate ulnar pulses bilaterally. The client’s skin is warm and dry and capillary refill time is < 2 seconds. Basedon these findings the nurse would Consider the normal findings Refer the client for a vascular consult in one week Ask client if they have numbness or tingling in her left arm Check for the presence of claudication bilaterally To assess the circulation of a client’s right hand prior to obtaining an arterial blood gas samplefrom the right radial artery, a nurse should first perform the Trendelenburg test Allen test Manual compression test Doppler test A client has a history of aortic valve stenosis and murmur. What action would the nurse take toauscultate this murmur? Auscultate using the bell of the stethoscope at the 5 LICS MCL Auscultate using the bell of the stethoscope at the 2RICS-MCL Ask the client to turn on his right side and auscultate at the PMI Place the client in the supine position and auscultate at erb’s point When obtaining a cardiovascular health history the nurse should ask the client which questions?Select all that apply
Left-sided hard and fixed cervical nodes Left-sided enlarged and tender inguinal nodes Left-sided enlargement of the epitrochlear lymph nodesd. Left-sided pellet-like nodes in the supraclavicular region A nurse is performing a physical assessment on a client and notes the findings as seen in thepicture below. These findings support - Select all that apply Clubbing Bilateral 3+ edema Nail bed angle >180 degrees Neuromuscular defects Possible respiratory problems During an abdominal assessment, a nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of the followingstructures? Spleen Sigmoid Appendix Gallbladder A nurse is caring for a hospitalized client with rectal bleeding. Which of the following findingsshould the nurse report immediately to the physician? Hypertension Bloody diarrhea Rebound tenderness T=99.2 F oral The day after abdominal surgery, a nurse auscultates a client’s abdomen and notes faint bowel sounds in all four quadrants. The client also reports experiencing flatus. The nurse interprets thesefindings as: Gastroenteritis Intestinal obstruction Return of peristalsis Paralytic ileus To enhance muscle relaxation prior to an abdominal examination the nurse would Avoid examination of painful areas
Expose the chest and abdomen for examination Ensure adequate lighting Place a small pillow under the knees While conducting a physical examination of the abdomen, a nurse observes pulsations in the epigastric area. The client tells the nurse “I have a funny moving sensations in my belly.” Giventhese findings, in what order would the nurse conduct the abdominal assessment over the epigastric area? Inspection, palpation, auscultation Auscultation, inspection, palpation Inspection, auscultation, palpation Auscultation, percussion, inspection A client was admitted to the hospital with a medical diagnosis of intestinal obstruction. Which ofthe following assessment findings would a nurse expect given this diagnosis Abdominal distention, hypoactive bowel sounds, no bowel movement for 3 days Hyperactive bowel sounds, prominent abdominal veins, nausea and vomiting Abdominal distention, hyperactive bowel sounds, poor skin turgor Diarrhea for two days, round abdomen, borborygums A client complains of skin lesions covering both forearms. The nurse observes lesions that are 1 cm in diameter, elevated, and fluid filled. The nurse would describe these lesions as Vesicles Cysts Scales Wheals While performing a skin assessment of an 82 year old client, which of the following findingswould suggest possible elder abuse? Purpura on both shoulders Port-wine stain on teh forehead Wounds in various stages of healing Lichenification on the soles of both feet A client tells a nurse that “this dark spot on my left shoulder has gotten bigger, changed from a reddish to a brown color, and used to be flat but is now like a small bump.” the nurse knows thatthese findings suggest That the client does not use UV protection That there is nothing to be concerned about Normal wound healing Possible malignancy A client reports having pain when swallowing medications and food. A nurse would documentthis findings as Dysphasia Dysphagia Aphasia Odynophagia An 85 year old client is lethargic and hypotensive. When the nurse assess the client’s tongue itappears dry, cracked, with deep furrows. These findings suggest
Positive hirschberg test Negative romberg test Normal findings Impaired visual acuity While a nurse conducts the Weber test, the client states that the vibrations are louder in the right earthan the left ear. These findings suggest Sensorineural or conductive hearing loss Inflammation of the ear canal in the left ear Normal age-related findings AC>BC While performing an otoscopic examination of a client’s ears, a nurse cannot visualize the cone of light in the right ear. The cone of light in the left ear is located at the 7 o’clock position. These findingsmight suggest? Hearing loss in the left ear? Diminished hearing Perforated tympanic membrane in the left ear Otitis media in right ear Eustachian tube dystortion tinnitus Which of the following statements is true regarding the function of the brain Cerebellum regulates balance and coordination Basal ganglia are responsible for controlling voluntary movements Temporal lobe controls sensations and visual reception Hypothalamus controls speech and emotions A client tells a nurse that they are unsteady on their feet and have difficulty maintaining their balance. Based on these findings, which part of the brain would the nurse be most concerned about Extrapyramidal tract Thalamus Brainstem Cerebellum An adult client is admitted to the nursing unit with a medical diagnosis of acute stroke. The client doesnot respond to verbal stimuli. In this situation, what is the best action by the nurse to provoke a client response? Gently shake the client Squeeze the trapezius muscle Apply pressure to the temporomandibular joint (TMJ) Press hard on the client’s sternum During an assessment of neurobiological system, a nurse performs the tespictured below what termwould the nurse use to describe this technique?
Two-point discrimination Graphesthesia Stereognosis Tactile discrimination During a neurological assessment of a client with a history of diabetes, the client is unable to feel vibrations when the nurse places the tuning fork on the great toes, and ankles bilaterally but is able to feelvibrations on both patellae. Given this information, the nurse would suspect which of the following? Hyperesthesia Peripheral neuropathy Tuning fork malfunction Lesion of sensory cortex During a neurological assessment a nurse asks a client to frown, wrinkle their forehead, smile, andpuff out their cheeks. These maneuvers assess which of the following cranial nerves? CN IV (Trochlear) CN V (Trigeminal) Cranial Nerve VI (Abducens) CN VII (Facial) The nurse stands behind the client and whispers “5-B-6.” This technique is used to assess which of thefollowing cranial nerves? CN IV (Trochlear) CN VI (Abducens) CN VII (Vestibulocochlear) CN X (Vagus) A client was admitted from the emergency department with a medical diagnosis of stroke. The client opens their eyes when spoken to, has localized movements in response to painful stimuli, and their verbalresponses are not appropriate to the situation. Using the scale below, the nurse would document the client’s Glasgow Coma Scale score as GCS= GCS= GCS= 10 GCS= 9 A nurse is conducting an interview with a 75 y/o post-menopausal client. Which of the followingfocuses questions would be appropriate to assess bone health? SATA Do you exercise regularly
Consider swelling as a normal sign of aging While assessing the muscle strength of a client a nurse should Assess each muscle group for strength and range of motion Assess each muscle group for strength only Document findings using a 1 - 4 grading scale Document normal findings as grade 4 While assessing the left hip joint of a client, a nurse would consider which of the following to benormal findings? Pain score= 5 on palpation Symmetrical iliac crests, gluteal folds, and buttocks Presence of small subcutaneous nodules in the older adult Redness and swelling over the joint During inspection and palpation of the musculoskeletal system, which of the following would beconsidered abnormal findings Grade 2 muscle strength in elderly Grade 5 muscle strength Pain score = 0 on palpation Joint ROM equal bilaterally While assessing the spine of Client A, you note these findings below. While assessing the spine ofClient B you note the following findings below. These findings suggest which of the following conditions? (A, B) Client A= Scoliosis; Client B=kyphosis Client A= scoliosis; client b= lordosis Client A=kyphosis; client b=scoliosis Client A=Lordosis; client b=Kyphosis The movement of the leg in the picture below is referred to as Adduction Abduction Extension Flexion
While assessing a client’s wrist and hand, a nurse asks him to turn his hand palm upward and then toturn his hand palm downward. These positions of the hand are referred to as 1= flexion; 2=extension 1=extension; 2= flexion 1=pronation; 2 = supination 1=supination; 2= pronation A school nurse notices that an 18 y/o girl in gym class is unable to move her arms to effectively jumprope. In order to jump rope, the shoulder must be capable of Adduction Pronation Circumduction Abduction Summer 2017 What type of data does the nurse see during the interview portion of a comprehensive healthassessment Subjective Historical Objective Physical A nurse ask a student to describe abdominal borborygmi. The student's response should includewhich of the following? Loud constant hum Peritoneal friction rub Hyperactive bowel sounds
A nurse needs to obtain anthropometric measurement of an 80 year old client. Which of thefollowing statements is true regarding this situation? Increased muscle mass will affect the mid calf circumference measurements Muscle atrophy will increase BMI Height may decrease due to changes in bone density Increase skin elasticity will affect the waist to hip ratio When conducting a focused assessment of an older adult the nurse would assess the client’s: Physical signs of aging Immunological function Functional abilities History of chronic illness While assessing an adult clients cardiovascular system,where should the nurse palpate pulsationsin the pulmonic area? Left second intercostal space Right second intercostal space Left fifth intercostal space Right fifth intercostal space A client reports eating 3 servings a day every day for a week of the chart below. How many totalcalories from fat did the client consume in 7 days. 164 calories 227 calories 1462 calories 1701 calories
When evaluating a client's reports of acute pain in the lower back, pain score = 8, a nurse shouldconsider which of the following as the most likely source of the pain? Fibromyalgia Lordosis Kidney stones Arthritis A client arrives in the ED via ambulance with the following signs; ptosis of left eye, increase left sided nasolabial fold, and slurred speech. What priority level should the nurse take for this client? First level priority Second level priority Third level priority Routine A nurse assess four clients. Which client assessment will require the nurse to perform immediatefocused assessment? Difficulty sleeping at night 3+ edema in the ankles Lack of bowel movement in 2 days Blanchable erythema in the sacral area A nurse is educating a group of older adults about weight management using the BMI scale.Which of the following client has a health BMI? 70 y/o female with a weight of 128 and height of 70 inches
Refer the client for further medical evaluation Auscultate for egophony Perform bronchophony Ask the client to cough and then listen again Which of the following respiratory assesment findings in expected in a healthy adult client? Adventurous sounds and limited chest expansion Increased tactile fremitus and dull percussion sounds Muffled voice sounds and symmetrical tactile fremitus Absent voice sounds and hyperresonance percussion notes A nurse suspects that a client has cholecystitis. Which of the following test should the nurseperform to assess the client's abdomen? Obturator test Rebound tenderness Murphy sign Iliopsoas muscle test A client was admitted to the ED for suspected drug overdose. Respirations are shallow andirregular with a rate of 9 bmp. The nurse would interpret the respirations as Tachypnea Cheyne stokes respirations Hypoventilation Agonal breathing A client who has no significant medical history is admitted to the ED with difficulty breathing. Which of the following assessment findings should be of most concern to the nurse Pulse oximetry reading 90% Low pitched wheezing in lower lobes Report of dyspnea on exertion RR of 22 bmp When assessing the carotid arteries of a 72 y/o with history of peripheral vascular disease a nursewould first Auscultate using the diaphragm of the asthoscopr Palpate the carotid arteries simultaneously Auscultate using the bell of the stethoscope Inspect for signs of bruits During a cardiovascular assessment of an 80 y/o adult a nurse should consider which of thefollowing as expected findings? Narrowing of the inferior vena cava causing bilateral extremities varicosities Hormonal changes causing vasodilation resulting in hypotension
Peripheral blood vessels become more rigid producing a rise in systolic bloodpressure Atrophy of the muscles causing venous insufficiency Using the diagram below, identify the landmarks for auscultating the tricuspid valve 1 2 3 4 5 While performing a peripheral vascular assessment of a client, a nurse is unable to palpate ulnarpulses bilaterally. The clients skin is warm and dry capillary refill time is <2 seconds. Based onthese findings the nurse would? Consider these normal findings Refer the client for a vascular consult in one week Ask client if they have numbness or tingling in her left arm Check for the presences of claudication bilaterally A nurse is assessing a client for dehydration. Which of the following findings should the nurseexpect if dehydration is present? Protruding eyeballs Dry furrows in the tongue Elevated blood pressure
