Upgrade to remove ads
Only $2.99/month

Assessment Exam I PrepU Questions

Terms in this set (146)

The nurse demonstrates appropriate technique when using what part of the hand to assess for fremitus in a client?
palmar base
During the assessment of a client with a pneumothorax, what change should the nurse anticipate when auscultating for fremitus?
decreased
A client presents to the health care facility with sudden onset of shortness of breath, inability to lie flat, and a deep, wet cough. A nurse observes a respiratory rate of 18 breaths per minute, use of accessory muscles to breathe, and inability to cough up secretions. Which nursing diagnosis can be confirmed with this data?
ineffective airway clearance
The nurse obtains a flat sound when percussing the right lower lobe of a patient. What does this assessment finding indicate to the nurse?
pleural effusion
Which of the following occurs in respiratory distress?
skin between the ribs moves inward with inspiration
Which lung sound possess the following characteristics? Expiration is longer than inspiration; the sound is louder and higher in pitch with a short silence between inspiration and expiration.
bronchial
A nurse is auscultating the bronchi of a client. The nurse understands that the bronchi are located in which of the following locations in the body?
in the mediastinum
A nurse is interviewing a client who complains of dyspnea of sudden onset. Based on this finding, the nurse should suspect which of the following causes?
bacterial infection
A nurse is assessing a client with acute asthma. Which adventitious breath sound should the nurse expect to hear in this client?
sibilant wheezes heard primarily during expiration but may also be heard on inspiration
The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what?
funnel chest
The client tells the nurse that he has been coughing up pink, frothy sputum. The nurse notifies the health care provider because the client may have what condition?
pulmonary edema
A hospitalized client experiences respiratory distress. The nurse should include which most appropriate client outcome in the plan of care?
airway patent, breathing quiet, denies dyspnea
What replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space?
dullness
The clavicles extend from the acromion of the scapula to the part of the sternum termed the
manubrium
The thin double-layered serous membrane that lines the chest cavity is termed
parietal pleura
Under normal circumstances, the strongest stimulus to breath is
hypercapnia
The nurse assesses an adult client's thoracic area and observes a markedly sunken sternum and adjacent cartilages. The nurse should document the client's
pectus excavatum
The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should
ask the client to breathe deeply through her mouth
A new nurse on the telemetry unit is reviewing information about how to correctly read electrocardiograms. The nurse is expected to know that the PR interval represents what event?
the time from firing of the sinoatrial (SA) node to the beginning of depolarization in the ventricle
A client who just underwent hip replacement surgery reports pain at a 10 on a scale of 0 to 10 and receives 4 mg of morphine. A nurse on the orthopedic unit enters the client's room and finds that the client has a respiratory rate of 7 breaths/min. The client is groggy and hard to arouse. What could be contributing to the client's findings?
opiates, which may cause hypoventilation
A client in the ED tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding?
dyspnea
What would the nurse expect to hear when auscultating the lungs of a client diagnosed with pleuritis?
friction rub
Which characteristic associated with respiratory effort should be considered when planning care for a client diagnosed with a brainstem injury?
there is loss of involuntary respiratory control
What should be the nurse's initial intervention when adventitious sounds are heard during auscultation of a client's lungs?
have the client cough and then listen again
Which action by a nurse demonstrates proper technique for assessment of chest expansion?
Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath
When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields?
resonance
A client presents to the health care facility with sudden onset of shortness of breath, inability to lie flat, and a deep, wet cough. A nurse observes a respiratory rate of 18 breaths per minute, use of accessory muscles to breathe, and inability to cough up secretions. Which nursing diagnosis can be confirmed with this data?
ineffective airway clearance
The nurse obtains a flat sound when percussing the right lower lobe of a patient. What does this assessment finding indicate to the nurse?
pleural effusion
A 47-year-old receptionist comes to the office with fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only worsened despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol level. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. Examination reveals a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated at 101 degrees Farenheit. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examination are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms?
pneumonia
A 62-year-old construction worker presents to the clinic reporting almost a chronic cough and occasional shortness of breath that have lasted for almost 1 year. Although symptoms have occasionally worsened with a cold, they have stayed about the same. The cough has occasional mucus drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married with two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. Examination reveals a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his symptoms?
COPD
A client complains of shortness of breath for the past few days. Examination reveals late inspiratory crackles in the lower third of the chest that were not present 1 week ago. What is the most likely explanation?
heart failure
(late inspiratory crackles, which appeared suddenly, would be most consistent with heart failure.)
When percussing the posterior lung fields, which of the following findings is expected?
resonance over all lung fields
Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing?
narrowing or partial obstruction of an airway passage
Which of the following statements relating to assessment of the lungs and thorax is most accurate?
Bronchitis is characterized by excess mucus production and chronic cough.
A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse?
Instruct the client to cough forcefully
The apex of each lung is located at the
area slightly above the clavicle
The staff educator from the hospital's respiratory unit is providing a public educational event. The educator is talking about health promotion activities for people with respiratory diseases or those who are at high risk for respiratory complications. What would the educator include in the presentation?
Teaching strategies to reduce complications of existing diagnoses
When auscultating a client's lungs, the nurse hears a sound like Velcro being pulled apart over the client's right middle lobe. How should the nurse document this finding?
Coarse crackles
The nurse auscultates the base of the lungs to assess for what reason?
It is where fluid occurs with pulmonary edema
The thoracic cavity contains which of the following organs? Select all that apply.
heart, lungs, most of the esophagus
A nurse is receiving report from the night shift about four clients. Which client would the nurse see first?
A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min
A client arrives in the emergency department after a severe motor vehicle accident. The nurse observes irregular respirations of varying depth and rate followed by periods of apnea. What pathophysiological process is likely the cause of this breathing pattern?
Severe brain damage
A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation?
Observe for the use of accessory muscles
Which of the following on thoracic inspection of adult clients would the nurse consider an expected finding?
The client's lateral diameter is larger than the anteroposterior diameter.
During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched, bubbling, moist sounds that persist from early inspiration to early expiration. How should the nurse document these sounds?
Coarse crackles
A nurse is palpating the sternum of a client. If the client is healthy, which of the following would characterize his costal angle?
less than 90 degrees
To assess bronchophony, the nurse should ask the client to
repeat the phrase "ninety-nine"
A triage nurse is working in the emergency department of a busy hospital. Four patients have recently been admitted. Patient A has an arrhythmia diagnosed as atrial fibrillation; Patient B is in chronic congestive heart failure; Patient C is assessed and found to have a probable pulmonary embolism; Patient D complains of chest pain relieved by nitroglycerin and rest. Which patient would be the nurse's highest priority?
Patient C
It is a cardiac emergency
Which accessory muscles are most important when considering inspiratory breathing needs during exercise?
sternocleidomastoids
A client comes to the clinic and states, "I have a bad cold and am having trouble breathing." The nurse checks the client's breath sounds and hears bilateral fine crackles at the base. Of what is this finding indicative?
Fluid in the alveoli
Which characteristic of a cough should alert the nurse to assess the client for other findings of sinusitis?
Nighttime when lying down
A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough?
"Are you taking any medications on a regular basis?"
(A persistent cough without any other respiratory symptoms could be related to new medications, especially beta blockers or angiotensin converting enzyme (ACE) inhibitors)
A 21-year-old college senior presents to the clinic reporting shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory, gastrointestinal, and urinary symptoms and says she has no chest pain. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray; she takes no other medications. She has had no surgeries. Her mother has allergies and eczema; her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and has recently started a job as a bartender in town. On examination she is in no acute distress. Temperature is 98.6, blood pressure is 120/80, pulse is 80, and respirations are 20. Head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this presentation best describe?
Asthma
A grandmother brings her 13-year-old grandson for evaluation. She noticed last week when he took off his shirt that his breastbone seemed collapsed. He seems embarrassed and says that it has been that way for awhile. He states he has no symptoms from it and that he just tries not to take off his shirt in front of anyone. He denies any shortness of breath, chest pain, or lightheadedness on exertion. His past medical history is unremarkable. He is in sixth grade and just moved in with his grandmother after his father was transferred for a work contract. His mother died several years ago in a car accident. He states that he does not smoke and has never touched alcohol. Examination shows a teenage boy appearing his stated age. Visual examination of his chest reveals that the lower portion of the sternum is depressed. Auscultation of the lungs and heart is unremarkable. What disorder of the thorax best describes these findings?
Funnel chest (pectus excavatum)
In palpating the chest of a client, a nurse feels a U-shaped indentation on the superior border of the manubrium. The nurse recognizes this landmark as which of the following?
Suprasternal notch
The nurse has assessed the respiratory pattern of an adult client. The nurse determines that the client is exhibiting Kussmaul respirations with hyperventilation. The nurse should contact the client's physician because this type of respiratory pattern usually indicates
diabetic ketoacidosis
The nurse assesses an adult client and observes that the client's breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a physician for possible
chronic bronchitis
After percussing a client's lung fields the nurse suspects a client has a chronic lung disease. What sound did the nurse hear to make this clinical determination?
hyperresonance
A client experiences increasing difficulty taking in a deep breath. For which health problem should the nurse focus when assessing this client?
chronic obstructive lung disease
A client reports sharp and stabbing chest pain that worsens with deep breathing and coughing. A cardiac cause to this pain is ruled out. The description of the pain is consistent with what respiratory condition?
Pleurisy
When preparing to examine a client's thoracic cage, the nurse would locate which landmark as most helpful in determining where to start?
sternal angle
Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis?
Unequal expansion of the chest
An elderly client reports a feeling of dyspnea with normal activities of daily living. What is an appropriate action by the nurse?
Observe the client's respiratory rate and pattern
When assessing a patient with asthma, the nurse would expect to hear wheezing.
True
While inspecting the thorax, the nurse views it from posterior and lateral positions to assess which of the following?
anteriorposterior to lateral diameter
A client is brought to the emergency department by ambulance after being involved in a motor vehicle accident. The nurse finds that he has decreased breath sounds over the left lung fields. What might the nurse suspect is the cause?
pneumothroax
While assessing an adult client's lungs during the postoperative period, the nurse detects coarse crackles. The nurse should refer the client to a physician for possible
pneumonia
The client reports severe pain when breathing in deeply. The description suggests to the nurse that the client is experiencing which respiratory condition?
inflammation of the parietal pleura
Which observation confirms to the nurse that the client is experiencing a normal inspiration?
the thoracic cavity enlarges
A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action?
Inspect the area
An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse?
The client has chronic hypoxia
A decrease in oxyhemoglobin will result in documentation of pallor.
True
Local redness of the skin warns of impending necrosis.
True
The nurse is beginning the examination of the skin of a 25-year-old teacher. She previously visited the office for evaluation of fatigue, weight gain, and hair loss. The previous clinician had a strong suspicion that the client has hypothyroidism. What is the expected moisture and texture of the skin of a client with hypothyroidism?
dry and rough
A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on a ventilator for 3 weeks. The nurse is completing an initial assessment and evaluating the client's skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter with damage to the subcutaneous tissue. The underlying muscle is not affected. What is the stage of this pressure ulcer?
stage 3
A nurse observes the presence of hirsutism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process?
Cushing's disease
A client presents to the health care clinic with reports of new onset of generalized hair loss for the past 2 months. The client denies the use of any new shampoos or other hair care products and claims not to be taking any new medications. The nurse should ask the client questions related to the onset of which disease process?
hypothyroidism
A nurse cares for a client of Asian descent and notices that the client sweats very little and produces no body odor. What is an appropriate action by the nurse in regards to this finding?
Document the findings in the client's record as normal
A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCDE" characteristic of malignant melanoma?
Asymmetrical shape
A nurse is instructing a client on how to assess himself for herpes simplex lesions by their configuration. Which configuration should the nurse tell the client to look for?
Clustered
Upon assessing the skin, the nurse finds pustular lesions on on the face. The nurse identifies that these could be what?
Acne
A client's skin color depends on melanin and carotene contained in the skin, and the
volume of blood circulating in the dermis
To assess for anemia in a dark-skinned client, the nurse should observe the client's skin for a color that appears
ashen
While assessing the nails of an older adult, the nurse observes early clubbing. The nurse should further evaluate the client for signs and symptoms of
hypoxia
A client who is an active outdoor swimmer recently received a diagnosis of discoid systemic lupus erythematosus. The client visits the clinic for a routine examination and tells the nurse that she continues to swim in the sunlight three times per week. She has accepted her patchy hair loss and wears a wig on occasion. A priority nursing diagnosis for the client is
risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions
The nurse is admitting a 79-year-old man for outpatient surgery. The patient has bruises in various stages of healing all over his body. Why is it important for the nurse to promptly document and report these findings?
The patient may have been abused
A client who is bedfast responds only to painful stimuli, never eats a complete meal, and moves occasionally in bed. Which term should the nurse use to describe this client's risk for skin breakdown?
high
Mrs. Anderson presents with an itchy raised rash that appears and disappears in various locations. Each lesion lasts for many minutes. Which most likely accounts for this rash?
urticaria or hives
Hair follicles, sebaceous glands, and sweat glands originate from the
dermis
Squamous cell carcinoma is associated with
overall amount of sun exposure
The nurse is assessing a dark-skinned client who has been transported to the emergency room by ambulance. When the nurse observes that the client's skin appears pale, with blue-tinged lips and oral mucosa, the nurse should document the presence of
a great of degree of cyanosis
While assessing the skin of an older adult client, the nurse observes that the client has small yellowish brown patches on her hands. The nurse should instruct the client that these spots are
caused by aging of the skin in older adults
To assess an adult client's skin turgor, the nurse should
use two fingers to pinch the skin under the clavicle
A new nurse on the long-term care unit is learning how to assess a patient's risk for skin breakdown. What would be the most likely instrument this nurse would use?
Braden scale
When documenting that a patient has freckles, the appropriate term to use is
macules
A patient recovering from a burn injury is told by the health care provider that hair will no longer grow on the body part that was burned. When the patient questions why this is true, the nurse will base the response on what physiological event that occurred as a result of the burn?
Destruction of hair follicles located in the dermis layer
The nurse is preparing an educational program on effective hygiene methods for a group of highschool teens. When discussing the need for antiperspirants and effective bathing, the nurse will focus on which layer of the skin?
dermis
A client has a 7-mm lesion with irregular borders and color variation that has grown over the last several weeks. The nurse knows that this lesion could possibly be what type of cancer?
melanoma
A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions?
psoriasis, fungal infections, trauma
A client presents to the health care clinic with reports of changes in the skin. Which data should the nurse document as objective with regards to the skin?
skin warm and dry to the touch
What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?
Wood's light
The nurse is preparing to perform a physical examination of a client who is an Orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client, based on his religious beliefs?
have a nurse who is the same sex as the client examine him
A golden yellow pigment that is heavily keratinized and is found in subcutaneous fat is called what?
carotene
The nails, located on the distal phalanges of the fingers and toes, are composed of
keratinized epidermal cells
When assessing for apocrine gland function, the nurse would assess for moisture where on the client's body?
underarms
The nurse notes that a client's nails are greater than a 160-degree angle. What should the nurse assess as a priority for this client?
pulse oximetry
Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?
dermis
Parents bring a child to the clinic and report a "rash" on her knee. On assessment, the nurse practitioner notes the area to be a reddish-pink lesion covered with silvery scales. What would the nurse practitioner chart?
psoriasis
Which of the following assessment findings most likely constitutes a secondary skin lesion?
keloid formation at the site of an old incision
Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV.
-intact, firm skin with redness
-ulceration involving the dermis
-full-thickness skin loss
-necrosis with damage to underlying muscle
A client shows the school nurse a rash that has developed on the back of her left hand. The school nurse assesses the rash as a depigmented macular area. What might the nurse suspect?
vitiligo
The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the
areola of the breast
An adult female client visits the clinic for the first time. The client has many bruises around her neck and face, and she tells the nurse that the bruises are the "result of an accident." The nurse suspects that the client may be experiencing
domestic abuse
The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's
vesicles
Recommended protective measures to avoid skin cancer include which of the following?
avoiding sun exposure
The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions?
distribution
A nurse is teaching a group of 5th grade children about characteristics of the skin. Which of the following should she mention? Select all that apply.
Largest organ of the body
Protects against damage to the body from sunlight
Helps make vitamin D in the body
Aids in maintaining body temperature
A client tells the clinic nurse that his feet and lower legs turn a blue color. On assessment, the nurse notes that the patient's oxygenation level is within normal levels. The nurse knows that the blue color the patient described is caused by what?
peripheral cyanosis
Short, pale, and fine hair that is present over much of the body is termed
vellus
An adult male client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. The nurse should further assess the client for
symptoms of stress
A 20-year-old client visits the outpatient center and tells the nurse that he has been experiencing sudden generalized hair loss. After determining that the client has not received radiation or chemotherapy, the nurse should further assess the client for signs and symptoms of
hypothyroidism
A client visits the clinic for a routine physical examination. The nurse prepares to assess the client's skin. The nurse asks the client if there is a family history of skin cancer and should explain to the client that there is a genetic component with skin cancer, especially
malignant melanoma
A nurse is providing client teaching to the parents of a preschooler who experiences chronic epistaxis. What would the nurse identify as the area where most nosebleeds originate?
Kiesselbach's plexus
The nursing instructor is discussing the administration of nasal spray with the nursing students. What information is most important to include in this discussion?
overuse of nasal spray may cause rebound congestion
A client arrives complaining of nasal congestion, drainage of a thick, yellow discharge from the nose, difficulty breathing through the nose, headache, and pressure in the forehead. The nurse suspects sinusitis. Which of the following risk factors should the nurse assess for in this client?
asthma
The teeth are composed of what three layers? Select all that apply.
neck, root, crown
The submandibular glands open under the tongue through openings called
Wharton ducts
The nurse has assessed the nose of an adult client and has explained to the client about her thick yellowish nasal discharge. The nurse determines that the client understands the instructions when the client says that the yellowish discharge is most likely due to
an upper respiratory infection
A nurse finds crepitus when palpating over a client's maxillary sinuses. Which of the following should the nurse most suspect in this client?
a large amount of exudate in the sinuses
A client who is taking antibiotics for a sinus infection presents with a white coating on the tongue and complains of a burning sensation on the tongue. Which instructions are most appropriate for this client?
rinse mouth with antifungal medication as prescribed
A client diagnosed with Sjogren syndrome should be given which instructions?
eye drops and sucking on hard candy may be used to relieve dryness
A hospitalized client continues to exhibit residual effects of a stroke. Which symptom is the priority concern?
dysphagia
During an oral assessment, the nurse identifies that client has white patches in his mouth. How would this be documented in the medical record?
leukoplakia
A patient is found to have a smooth, glossy tongue. What vitamin deficiency might this indicate?
vitamin B12 deficiency
A staff educator from the hospital is providing an event for the hospital staff. The educator is talking about health promotion activities for people with diseases of the nose, mouth, throat, and sinuses. What would the educator include in the presentation?
how to reduce periodontal disease
A nurse is examining the nose of a client diagnosed with an upper respiratory tract infection. Which characteristics of the nasal mucosa should the nurse expect to find during assessment of a client with an upper respiratory tract infection?
red, swollen, with purulent discharge
A 58-year-old man who is HIV-positive has presented with thick, white plaques on his oral mucosa. What diagnosis would the nurse first suspect?
thrush
On examining a client, the nurse detects a foul odor to the breath. The nurse recognizes this finding as a characteristic of what disease process?
respiratory infection
A nurse is working with a client who has an impaired ability to move the tongue. He explains that he was in an automobile accident many years ago and suffered nerve damage that resulted in this condition. Which nerve should the nurse suspect was damaged in this client?
cranial nerve XII (hypoglossal)
The nurse identifies this as trapping debris and propelling it toward the nasopharynx.
cilia
When visualizing the structures of the nose, the nurse recalls that air travels from the anterior nares to the trachea through the:
vesitbule, nasal passages, and nasopharynx
What is the purpose of the vascular and ciliated mucous lining of the nasal cavities?
warm and humidify inspired air
A nurse is assessing a small child who has lead poisoning. Which characteristic of the gums should the nurse expect this client?
a grey-white line
A client presents to the health care clinic with reports of a 3-day history of fever, sore throat, and trouble swallowing. The nurse notes that the client is febrile, with a temperature of 101.5°F, tonsils are 2+ and red, and transillumination of the sinuses is normal. Which nursing diagnosis should the nurse confirm based on this data?
acute pain
The rich blood supply of the nose serves to
warm the inspired air
The nurse should explain to the client that 4+ tonsils are present when the nurse observes tonsils that are
touching each other
THIS SET IS OFTEN IN FOLDERS WITH...