CH 21, 22, 23 and 24! WOW

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A nurse notices that a client has decreased range of motion with lateral bending of the cervical spine to the left side. What should the nurse do next in relation to this finding?

Compare this finding to the range of motion to the right side

Which of the following assessments is most likely to provide insight into the function of the client's CN VIII?

Test the client's hearing for lateralization and bone and air conduction.

The husband of a 65 year old female tells the nurse, "My wife is having trouble navigating the steps in our home and she needs my help to step down off a curb." What part of the nervous system should the nurse assess for a potential source of the problem?

Cerebellum

A client presents to the health care clinic with reports of a swollen, tender, reddened joint in the left big toe. The nurse recognizes this finding as an indication of what inflammatory process?

Gouty arthritis

While assessing a client's abdomen, the nurse observes involuntary reflex guarding on expiration. The nurse would interpret this as most likely indicating which of the following?

Infection

When inspecting the abdomen, which of the following client positions facilitates correct examination technique?

Supine with arms at sides or folded across chest

A 32-year-old warehouse worker presents for evaluation of low back pain. He notes a sudden onset of pain after lifting a heavier-than-usual set of boxes. He also states that he has numbness and tingling in the left leg. What test should the nurse perform to assess for a herniated disc?

Straight leg raise test

A client reports the feeling of being unsteady when walking. What is an appropriate action by a nurse to assess for a problem with gait and balance?

Ask the client to walk in a heel to toe fashion and watch for an unsteady gait

A 31-year-old woman has presented to her family physician 3 weeks after giving birth to her first child. The woman complains of exquisitely tender breasts that are reddened on inspection and warm on palpation. The client has a temperature of 37.8°C orally. Which of the following diagnoses should be first suspected?

Mastits

The lateral lymph nodes are located along the upper humerus and drain most of the arm.

True

Which of the following assessment findings is most likely benign on breast examination?

One breast larger than the other

Which of the following would the nurse interpret as a positive response to the Phalen test for a client suspected of having carpal tunnel syndrome?

Numbness

The nurse is assessing a 36-year-old woman with right lower quadrant abdominal pain. The patient has no history of prior surgeries, has no allergies, and is physically fit. Which of the following should the nurse do during the abdominal examination?

Observe the patient's face for signs of discomfort

A 21-year-old receptionist comes to the clinic reporting frequent diarrhea. She states that the stools are very loose and there is some cramping beforehand. She states this has occurred on and off since she was in high school. She denies any nausea, vomiting, or blood in her stool. Occasionally she has periods of constipation but that is rare. She thinks the diarrhea is much worse when she is nervous. Her past medical history is not significant. She is single and a university student majoring in accounting. She smokes when she drinks alcohol but denies any illegal drugs. Both of her parents are healthy. Her entire physical examination is unremarkable. What cause of diarrhea is the most likely etiology?

Irritable bowel syndrome

After teaching a group of students about the bones and their functions, the instructor determines that the teaching was successful when the students state that blood cells are produced in which of the following?

Red marrow

Which is true of women who have had a unilateral mastectomy?

They should be examined carefully along the surgical scar for masses.

A patient is in the emergency room with what could be a lumbar injury. Which deep tendon reflex would be most appropriate to test?

Patellar

When taking a health history for a female client, which factor would the nurse identify as placing the client at increased risk for breast cancer?

First child after age 30

The nurse is assessing a 51-year-old morbidly obese client who is seeking care for the recent loss of sensation in his feet and toes. The client also complains of intermittent burning and tingling in his feet that radiate up his legs. For which of the following health problems should the nurse first assess?

Diabetic peripheral neuropathy

A 49-year-old woman has visited the clinic with complaints of excessive flatus and bloating, symptoms that are causing her both discomfort and embarrassment. Which of the following questions should the nurse ask the client during assessment of the health problem?

"Do you find that any particular foods, like dairy, make the problem worse?"

During an instruction session on breast self-examination, the nurse would instruct a client to perform the exam at which time?

The best time for breast self-examination is right after menstruation or between the fourth and seventh day of the cycle is regular.

During a prenatal breastfeeding class, a participant says her breasts are not large enough to breastfeed. When responding to this client, the nurse would incorporate understanding that the functional capacity of the breast is determined by which of the following?

Amount of glandular tissue

A client is concerned about a dark skin lesion on her anterolateral abdomen. The lesion has not changed, nor is there any discharge or bleeding. On examination there is a medium brown circular lesion on the anterolateral wall of the abdomen. It is soft, has regular borders, is evenly pigmented, and is about 7 mm in diameter. What is this lesion?

Supernumerary nipple

A nurse is assessing a male client's abdomen. Which of the following would lead the nurse to suspect a problem?

Visible peristaltic waves

When the spleen enlarges, the nurse would not be surprised to percuss dullness over the stomach.

TRUE

A client is experiencing parietal abdominal pain. The nurse would expect the client to describe the pain as which type of sensation?

Steady

A group of students is reviewing information about the locations of various organs within the abdomen. The students demonstrate understanding of the material when they identify which organ as being found in the left upper quadrant?

Spleen

A client is complaining of pain in the right upper quadrant and also in the right shoulder. Which organ would the nurse suspect as being involved?

Gall bladder

To promote relaxation of the abdominal muscles, 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 assigns a nursing diagnosis of fluid volume deficit to an elderly female diagnosed with severe dehydration. Her vital signs are P 120, BP 84/52, respirations 24, and temperature 37.4°C. Which of the following interventions is appropriate for this patient?

Monitor P and BP every 15 minutes until stable

A nurse is preparing to perform a complete neurologic exam. Place the assessments in the most appropriate sequence for the nurse to perform them.

Mental Status
Cranial nerves
Motor/cerebellar function
Sensory system
Reflexes

The nurse is doing a brainstem assessment on an unconscious patient. Which of the following will the nurse examine during this part of the acute assessment?

• Corneal reflex
• Gag reflex
• Oculocephalic reflex (doll's eye maneuver)

The nurse is assessing a client's gait. Which finding would alert the nurse to the need for a referral for further evaluation.

Shuffling of feet

What is an appropriate question by the nurse to ask a client about the presence of temporomandibular joint dysfunction?

"Have you noticed a popping or grating sound when you chew?"

During the history, a young adult woman tells the nurse, "My mother has osteoporosis. What can I do to help reduce my risk?" Which response by the nurse would be most appropriate?

"Try to avoid drinking too much coffee or other caffeinated fluids."

A previously healthy 64-year-old man has been recently diagnosed with osteoarthritis. The client is motivated to maintain his quality of life and slow the progression of his new health problem. What advice can the nurse provide for the client in his efforts to minimize the effects and progression of osteoarthritis?

"It's important for you to maintain a healthy body weight."

After assessing the patient for posture and body alignment, how would the nurse document head position in relation to the spine if alignment is normal with noticeable defect?

Head is midline and aligned with the spine

A client presents to the health care clinic with reports of pain in the hands and right wrist. Additional history reveals that the client is a factory worker who spends all day performing the same repetitive task. The nurse performs the Phalen's test and Tinel's tests with positive results. The hand grips are unequal with the right weaker than the left. What nursing diagnosis can the nurse confirm from this data?

Impaired Physical Mobility

A nurse is preparing a program on osteoporosis for a local women's group. Which of the following would the nurse include as a modifiable risk factor?

Low estrogen levels

A client is brought to the health care facility with a sudden loss of movement on the right side of the body. Upon assessment, the nurse finds that the client has a slight flicker of contraction in the muscles on the right side. What should the nurse document as the muscle strength rating?

1

Which of the following would lead the nurse to suspect meningeal irritation?

Pain and flexion of the hips and knees with neck flexionain and flexion of the hips and knees with neck flexion

Which of the following would the nurse most likely expect to find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident?

Difficulty speaking

Worse in the morning

Rheumatoid arthritis

Worse at rest and at the end of the day

Osteoarthritis

GALS

Gait Arms Legs and Spine

Genu valgus

knock knee

Genu varus

bow-legged

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