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NR304 EXAM 1 AND 2
Terms in this set (43)
What is atelectasis?
is a complete or partial collapse of the entire lung or area (lobe) of the lung
A nurse is caring for a client who has a lacerated spleen and has been on bedrest for several days, the nurse auscultates decreased breath sounds in the lobes of both lungs, the nurse should realize that this finding is most likely an indication of?
Which statement by the nurse correctly decribes the mechanism of venus blood return to the heart?
The intraluminal valve controls the flow in one direction towards the heart
While performing a peripheral vascular and lymphatic assessment on an older adult client, which physiological changes should be expected?
Loss of lymphatic tissue
loss of elasticity in the arteries
enlargement of calf veins
deposition of fatty plaques on the entema of the arteries
The nurse is caring for a client with arterial insufficiency, which characteristics of the pulse would the nurse expect to find in this client?
a weak gritty pulse
During a physical assessment of a client, a nurse assesses a leg ulcer that is pale, well defined edges, and no evidence of bleeding, Which additional assessment data should the nurse expect to find?
decreased peripheral pulses
Which test should the nurse perform to assist in determining if the client has arterial obstruction of the right ulnar artery?
Modified Allen Test
During the initial assessment of a client who is 30 mins post op following femoral surgery, the nurse palpates the dorsalis pedis at 2+. Which action should the nurse take first, when 2 hours later, the pulse is no longe palpable?
Assess the pulse with a doppler probe
An older adult client is being admitted to the hospital with tender swollen right calf that is warm to touch and tender, the nurse understand which normal physiological change in the older adult may have contributed to the client's problem?
Enlargement of the calf vein
Which additional assessment finding would the nurse anticipate observing a client with an ulcer that has bloody drainage, wet wound base, and uneven edges?
Pain relieved with elevation
(because of venous insufficiency)
Which client statement indicates to the nurse that the client may have Raynaud's Disease?
"My fingers turn blue when i go out in the cold"
A client has pain while walking, that is relieved with rest, based on the client's clinical manifestations, which assessment findings should the nurse expect?
Feet that are cold to touch w/ diminished pulses
The RN is educating the nursing student during an abdominal assessment of a patient who had abdominal surgery 1 day ago from periostitis. Which statement is correct in regards to auscultation of bowel sounds?
Normal bowel sounds are high pitched, gurgling, and occur 5-30 times per minute.
The nurse is teaching a client with diabetes about foot care, which statement provided to the patient would best explain why this client is at high risk for impaired skin integrity?
Diabetes is often associated with decreased circulation
A charge nurse is observing a nurse auscultating a client's bowel sounds, which of the following actions requires intervention by the charge nurse?
The nurse palpating the abdomen prior to performing auscultation
A nurse is completing a client assessment for admission to the medical unit, which of the following abdominal assessment findings require further investigation by the nurse?
You are assessing a client with severe pain in the right upper abdomen, that reaches to the right shoulder, The client reports that this started after eating a fatty meal, what is the correct finding?
(inflammation of the gall bladder, usually after a fatty meal)
A nurse is interviewing a client who has acute pancreatitis, which of the following factors should the nurse anticipate finding in the client's history?
What happens with the calf pump or the peripheral heart and the legs?
When walking, the calf muscles alternately contracts (directing blood flow proximally to the heart)
A client's annual physical examination reveals a lateral curvature of the thoracic lumbar segments of his spine, however this curvature disappears before bending. How should the nurse document this finding?
A nurse is preparing a client for ambulation, which of the following actions should the nurse take to determine the client's level of strength?
Ask the client to push their feet against the nurse's palm
Which lobe of the brain is responsible for the perception and interpretation of sound in determination of the source would be?
A male client presents tot he ER with the following signs and symptoms.... slowness with moving, stiffness, riggidity, tremors of the upper extremities, and postural instability. The nurse would suspect this client has?
During a breast examination of a healthy female, the nurse recognizes this finding as normal....
Super numerary nipple along the milk line
The nurse is teaching the patient about the best time to perform a breast exam, which of the following instructions would the nurse give to the patient?
Performed right after the menstrual period
Which position would the nurse place a female position in to complete a vaginal exam?
A nurse is assessing a client who has a cast in place for a fractured tibia. Which of the following actions should the nurse take first?
Check capillary refill
During the assessment of a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to touch, which of the following complications should the nurse suspect?
A nurse at the providers office is collecting a heath history from a client who is at risk for primary osteoporosis, which of the following findings is a risk factor for the development of osteoporosis?
A sedentary lifestyle
(little or no physical activity)
A nurse is completing a physical assessment of a client who has early osteoarthritis, which of the following manifestations should the nurse expect?
pain worsens with activity
A nurse is caring for a client who has an un-repaired femur fracture 0f the mid-shaft, which of the following techniques should the nurse use when performing an assessment f the client's neurovascular status?
Instruct the client to wiggle his toes
A nurse is assessing a client who has a left lower arm fracture, which of the following findings indicates impaired venous return in the client's affected arm?
A nurse in a provider's office is assessing a client who has RA, which of the following findings is a late manifestation of this condition?
(late manifestations would be physical findings)
A nurse is assessing a client who has a herniated cervical intervertebral disk, which of the following findings should the nurse expect?
tingling in the upper extremities
An adult male client presents to the clinic with pain to his joint, he knows the joint involvement is symmetric an bilateral with heat, redness, swelling, and painful motion to the affected joint. What disease process would the nurse think is contributing to the clients problem?
A 33 year old client presents to the OBGYN clinic with postural changes due to pregnancy. What would be the postural changes?
The nurse is performing a physical assessment on a patient and identifies both hebruden and Bouchard's node, The nurse understands that these findings are consistent with what disease?
A 54 y/o male client presents to the ER saying that he is experiencing a gout attack in the right foot, What assessment find would the nurse typically find in a patient identified with gout?
redness, extreme pain, and swelling
a 76 y/o Caucasian female client diagnosed with osteoporosis was admitted to the medical surgical unit, the nurse understands that the patient is at risk for fractures. Which site would the client be an increased risk of developing a fracture?
An adolescent male presents to the clinic with complaints of enlarged breast tissue, which statement by the nurse would be correct?
"This is a temporary position called gynecomastia"
An obgyn nurse is educating a teenage female client on pap testing. At what age should the nurse note that pap testing begins for the average female client?
A nurse is instructing a patient on performing a self breast exam, which quadrant of the breast should the nurse inform the patient where tumors are found?
The nurse is preparing to teach her client about the warning signs of a stroke. She would include which of the following signs and symptoms?
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