Nutritional
A nurse is reviewing the laboratory test results of an adult client who has numerous chronic health challenges. Which assessment result would alert the nurse to potential malnutrition? (Quizlet)
A) Hemoglobin of 13.1 g/dL
B) Hematocrit of 40%
C) Serum albumin of 2.6 g/dL
D) Total protein of 7 g/dL
C) Serum albumin of 2.6 g/dL
A palliative care nurse is explaining the basis of pain to a group of nurses who provide care on a general medical unit. Which of the following factors would the nurse include? Select all that apply.
A) Physiologic
B) Psychosocial
C) Cutaneous
D) Somatic
E) Visceral
A) Physiologic
B) Psychosocial
A client has sustained an injury to the cerebellum. Which area should be the nurse's primary focus for assessment?
A) Vital signs
B) Respiratory status
C) Cardiac function
D) Coordination
D) Coordination
Stress incontinence
Assessment of a client reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the client's level of consciousness as which of the following?
a) Obtunded
b) Coma
c) Stupor
d) Lethargy
b) Coma
When assessing a client, which of the following would the nurse identify as an early indicator of malnutrition? (Quizlet)
A) Protein stores are lower
B) Fat is used for missing nutrients
C) Calcium levels drop
D) Hemoglobin levels decrease
A) Protein stores are lower
A nurse is admitting a client to the postsurgical unit following breast reconstruction surgery. Which of the following would the nurse use as the primary assessment for the client's pain?
A) The client's spiritual view of the pain
B) Current pain therapies used preoperatively
C) The client's report of her pain
D) Psychosocial questions related to her perceptions of pain
D) Psychosocial questions related to her perceptions of pain
A nurse is having difficulty eliciting a patellar reflex. Which of the following would be most appropriate for the nurse to have the client do?
Lock the fingers together and pull against each other.
When assessing the cervix of an older postmenopausal woman, which of the following would the nurse document as a normal finding?
C) Pale pink
A nurse wants to assess a client's orientation. The nurse recognizes that which orientation is usually lost first when the client is confused?
a) Location
b) Time
c) Place
d) Person
b) Time
A nurse determines that a client has class II obesity. Which body mass index (BMI) finding would lead the nurse to this conclusion? (Quizlet)
A) 22
B) 29
C) 36
D) 45
C) 36
When assessing pain in an older adult who is alert and oriented which assessment tool would be most appropriate?
a. numerical rating scale
b. universal pain assessment tool
c. QUESTT mnemonic
d. FLACC scale
A) numerical rating scale
evaluates cortical sensory function , use a blunt object to trace a number on the patients palm and ask patient to identify which number was traced.
Graphesthesia
In which of the following clients would the nurse consider a bluish tint to the cervix, an expected finding?
A client who is 10 weeks pregnant
During the physical examination of a client a nurse notes that a client has tenderness of the breasts. Which question should the nurse ask the client with regard to this finding?
a) "Have you ever noticed a lump in your breast?"
b) "How much do you drink or smoke?"
c) "Are you taking oral contraceptive pills?"
d) "Does anyone in your family have breast cancer?"
c) "Are you taking oral contraceptive pills?"
A group of students is reviewing information about general assessment indicators of nutritional status. The students demonstrate a need for additional review when they identify which of the following as an indicator of adequate nutritional status? (Quizlet)
A) Flat, firm abdomen
B) Brittle hair
C) Pink mucous membranes
D) Elastic skin
B) Brittle hair
when attempting to assess a client's pain which of the following would the nurse obtain first?
a. observe behaviors in the client
b. obtain a patient self report
c. search for a possible cause of pain
d. ask family members about the client's pain
a. observed behaviors in the client
When assessing cranial nerves IX and X, which of the following would the nurse consider as a normal finding?
a) Asymmetrical soft palate
b) Stationary soft palate on phonation
c) Uvula and soft palate rising bilaterally
d) Deviation of uvula when client says "ah"
c) Uvula and soft palate rising bilaterally
In what Tanner stage is pubic hair darker, coarser, and curled, spreading sparsely over the junction of the mons pubis?
Stage 3
A client reports the onset of discomfort and pain in the right upper quadrant of the abdomen after eating. The nurse should assess this finding using which test?
a) Obturator
b) Rovsing's
c) Murphy's
d) Psoas
c) Murphy's
A nurse is assessing a client for possible fluid overload. Which of the following would the nurse expect to find? (Quizlet)
A) Venous filling of 3 seconds
B) Distended neck veins with head elevated at 45 degrees
C) Moist, plump tongue
D) Boggy eyeball
B) Distended neck veins with head elevated at 45 degrees
A client who suffers from arthritis complains of sharp pain in her knees and elbows. The nurse recognizes this is what type of pain?
A) Radiating
B) Cutaneous
C) Somatic
D) Visceral
C) Somatic
When testing sensory function of the trigeminal nerve (CN V), which of the following sensations would the nurse assess?
a) Pain and light touch
b) Dull touch and vibration
c) Proprioception and extinction
d) Vibration and stereognosis
a) Pain and light touch
A client comes to the Emergency Department complaining of sudden sharp testicular pain. Further examination reveals torsion of the spermatic cord. Which of the following would the nurse expect to do next? ( I know this is male, I couldn't find any other good ones)
prepare the client for surgery
Which action by the nurse will facilitate relaxation of the abdominal muscles during examination of the abdomen?
a) Raise the client's arms or fold them behind the head
b) Provide privacy to the client and instruct him to relax
c) Avoid the use of pillow under the head during examination
d) Flex the client's legs by placing a pillow under the knees
d) Flex the client's legs by placing a pillow under the knees