MK
When the nurse moves the client’s arm away from the midline of the body, the nurse is performing
abduction.
The nurse documents “Romberg test positive” on a client’s medical record. What did the nurse most likely assess in this client?
Swaying
The cranial nerve that has sensory fibers for taste and fibers that result in the “gag reflex” is the
glossopharyngeal.
To palpate the spleen of an adult client, the nurse should begin the abdominal assessment of the client at the
left upper quadrant.
A client in the ED tells the nurse that they are having difficulty breathing at rest. What term would the nurse use in documenting this finding?
Dyspnea
Loss of bone density that occurs with greatest frequency in postmenopausal women is called?
Osteoporosis
On assessment of a client, the nurse finds that the client has difficulty in producing and understanding language. How should the nurse document this finding in the client's record?
The nurse should document difficulty in producing and understanding language as aphasia
What task should a nurse ask a client to perform to assess the function of cranial nerve XI?
shrug shoulders against resistance
The nurse is percussing a client's abdomen. What predominant sound should the nurse expect to hear over the majority of the abdomen?
Tympany
What characteristic nail color should the nurse recognize as an indication of hypoxia?
Cyanotic
The client is facing the nurse with his forearm turned so that his palm is up. What movement is the client exhibiting?
Supination
Examination of a client's gait reveals that the client is stooped over when walking and that he slowly shuffles. As well, the client maintains a stiff posture when walking. The nurse should document what type of gait?
Parkinsonian gait
A nurse is performing a focused cranial assessment on a client. The nurse observes that the client is unable to shrug their shoulders. The nurse documents this as a dysfunction of which cranial nerve?
XI
The nurse performing an abdominal assessment should proceed in what order?
Inspection is followed by auscultation for bowel sounds before percussion and palpation. Failure to adhere to this order may result in the alteration of bowel sounds from either percussion or palpation, leading to inaccurate findings.
Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would most likely suspect the client is compensating for what pathophysiological disorder?
COPD
A client comes to the clinic and reports a sore knee. The nurse notes popping and cracking noises when the client attempts to bend the knee. The client exhibits signs of pain by facial expression. The nurse knows that the popping and cracking noises should be charted as what?
Crepitus
A client is in the emergency room with what could be a lumbar injury. Which deep tendon reflex would be most appropriate to test?
patellar
The nurse is assessing CN V (trigeminal nerve) in a newly admitted client. What instruction should the nurse provide to the client during this phase of assessment?
“Clench your teeth together tightly.”
The nurse has elicited a positive Murphy sign. What does the nurse recognize this indicates?
Inflammation of the gallbladder
Which of the following muscles is primarily responsible for thoracic cavity enlargement?
Diaphragm
When assessing muscle tone and strength, the nurse would document expected findings as...
“upper and lower extremity muscle strength is 5/5 bilaterally”
The nurse has completed a Glasgow Coma Scale assessment and assigns the client a score of three. Which is the best way for the nurse to assess pain in this client?
The GCS is a tool for assessing a client's response to stimuli. Scores range from 3 (deep coma) to 15 (normal). Eye opening response: Spontaneous 4 To voice 3 To pain 2 None 1 Best verbal response: Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 None 1 Best motor response: Obeys command 6 Localizes pain 5 Withdraws 4 Flexion 3 Extension 2 None 1 Total 3-15. A score of three indicates deep coma; therefore, the client is unable to verbalize pain level on numerical scale or FACES scale. A client in a coma can still experience pain.
When assessing cranial nerves IX and X, what would the nurse consider as a normal finding?
Uvula and soft palate rising bilaterally on phonation
A client complains of a sudden onset of pain in the back. On questioning the client further, the nurse learns that the cause of the pain is acute pancreatitis. The nurse recognizes that this type of pain is which of the following?
Referred pain - This is called “referred” pain because the pain is not felt at its source
The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiological process?
Air passing through constricted passageways