Exam 1
A client is diagnosed with a stage __ pressure ulcer.
(Picture on snip)
Stage III
A Stage III pressure ulcer has full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. A Stage I pressure ulcer has intact skin with non-blanchable redness of a localized area usually over a bony prominence. A Stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. This wound may also present as an intact or open/ruptured, serum-filled blister. A Stage IV pressure ulcer has full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.
You’re performing a head-to-toe assessment on a patient admitted with abdominal pain. During inspection of the abdomen, you note the abdominal contour to be round and distended with no masses or lesions present. The patient reports that their last bowel movement was one hour ago, and the stool was loose. In addition, the patient states that the abdominal pain is located below the umbilicus and is sharp in quality. After inspection of the abdomen, you will:
A.Perform light palpation on the abdomen, followed by deep palpation.
B.Percuss the abdomen.
C.Auscultate for bowel sounds by starting in the right lower quadrant.
D. Palpate for bruits and rebound tenderness.
C.Auscultate for bowel sounds by starting in the right lower quadrant.
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?
A. Dyspnea
B. Tachypnea
C. Anxiety
D. Shortness of breath
A. Dyspnea
To palpate the spleen of an adult client, the nurse should begin the abdominal assessment of the client at the
A. right lower quadrant.
B. left lower quadrant.
C. right upper quadrant.
D. left upper quadrant.
B. left upper quadrant.
Short, pale, and fine hair that is present over much of the body is termed:
A. dermal
b. lanugo
c. vellus
d. terminal
c. vellus
A nurse is performing percussion on a client's back to assess the lungs, and hears a loud, low-pitched, hollow sound, indicating normal lungs. Which of the following describes this finding?
A. Resonance
B. Dullness
C. Tympany
D. Hyper-resonance
Resonance is a loud, low-pitched, hollow sound normally percussed over an area that is part air and part solid, which is expected over normal lung fields. Hyper-resonance is a very loud, low-pitched sound that is normally heard in lungs with a lot of air such as in emphysema. Tympany is a very loud, high-pitched, drum-like sound that is heard over an air-filled structure, such as the stomach. Dullness is a medium-pitched, thud-like sound that is percussed over solid tissue such as the liver.
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?
A. Localized pain
B. Chronic pain
C. Referred pain
D. Radiated pain
C. Referred pain
A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what?
A. Stridor
B. Crackles
C. Wheezes
D. Rales
A. Stridor
The client complains of pain and numbness in his left lower leg. The nurse identifies on assessment that the left leg is cool and gray in color. The nurse suspects what?
A. Arterial occlusion
B. Deep vein thrombosis
C. Pulmonary embolism
D. Venous thromboembolism
A. Arterial occlusion
You’re performing a head-to-toe assessment on a patient. While palpating the lymph nodes of the neck, the patient reports tenderness behind the ear. When you document the findings of the head-to-toe assessment, you will note that the patient felt tenderness at which lymph node site?
A. Preauricular
B. Submandibular
C. Superficial cervical
D. Postauricular
D. Postauricular
The nurse observes a student nurse performing a focused assessment on a client presenting with signs and symptoms of appendicitis. The nurse should intervene when the student nurse is observed performing which of the following actions on the client’s abdomen?
A. moderate palpation
B. light palpation
C.deep palpation
D. direct palpation
Deep or bimanual palpation is contraindicated in clients presenting with signs and symptoms of appendicitis, enlarged spleen, or abdominal aortic aneurysm (AAA). Deep palpation may cause rupture of the organ or artery. Moderate palpation should be performed; the client will most likely present with rebound tenderness. Light palpation may be performed to assess rigidity and warmth. Direct percussion is performed to produce sound or elicit pain to assess underlying structures, for example, sinuses and the thorax.
The nurse is planning to assess a client’s abdomen for rebound tenderness. The nurse should:
A. palpate deeply while quickly releasing pressure.
B. perform this abdominal assessment first.
C. ask the client to assume a side-lying position.
D.palpate lightly while slowly releasing pressure.
A. palpate deeply while quickly releasing pressure.
The nurse notes that a client’s heart rate speeds up with inspiration and slows down with expiration. What should the nurse suspect this client is demonstrating?
A. premature ventricular contractions
B. sinus arrhythmia
C. atrial fibrillation
D. premature atrial contractions
B. sinus arrhythmia
On inspection of a client's legs, the nurse has found varicose veins. Which test should the nurse next perform to determine the competence of the saphenous vein valves?
A. Ankle-brachial pressure index (ABPI)
B. Position change test
C. Trendelenburg test
D. Allen test
C. Trendelenburg test
If the client has varicose veins, perform the Trendelenburg test to determine the competence of the saphenous vein valves and the retrograde (backward) filling of the superficial veins.
The nurse is preparing for a physical examination of a client. The first thing a nurse should do is?
A. Gather equipment
B. Hand hygiene
C. Meet the patient
The nurse should perform hand hygiene before beginning the physical assessment. This includes prior to gathering equipment. Auscultation and palpitation should not occur until after hand hygiene has been performed.
A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What should the nurse do before auscultating?
A. Disinfect the stethoscope before touching the client
B. Disinfect the stethoscope after touching the client
C. Put on a personal protection gown
D. Make sure the stethoscope is placed directly on the client's skin so that there is complete contact with the skin surface
A. The nurse makes sure to disinfect the stethoscope between clients to avoid the spread of pathogens. Disinfecting the stethoscope after touching the client does not answer the question being asked. Placing the stethoscope directly on the client's skin does not answer the question being asked. Nothing noted in the question would require the nurse to wear a personal protection gown.
While assessing an older adult client, the nurse detects a bruit over the carotid artery. The nurse should explain to the client that a bruit is
A. associated with occlusive arterial disease.
B. heard when the artery is almost totally occluded.
C.a wheezing sound.
D. a normal sound heard in adult clients.
A. associated with occlusive arterial disease.
A client has been diagnosed with venous insufficiency. Which of the following findings should the nurse expect on interviewing this client?
A. Shiny skin, with loss of hair over the lower legs
B. Warm skin and brown pigmentation around the ankles
C.Cold, pale skin on the extremities
D.Clammy skin on the extremities
B. Warm skin and brown pigmentation around the ankles
Warm skin and brown pigmentation around the ankles are associated with venous insufficiency. Cold, pale, clammy skin on the extremities and thin, shiny skin with loss of hair, especially over the lower legs, are associated with arterial insufficiency.
A client asks why gloves are being worn during the physical examination. What should the nurse respond to this client?
A. “It’s a policy I have to follow.”
B. "They help me feel your body parts under your skin better.”
C. “Since we don’t know what’s wrong with you, I wear gloves to make sure I don’t get sick.”
D. “They make sure that any microorganisms on my hands do not touch your skin.”
D. One reason to wear gloves is to prevent the transmission of flora from health care workers to clients. Wearing gloves is more than just following a policy. Gloves hinder the ability to discern body parts and positions. Although the client may have a communicable illness, the nurse should not make a statement that could cause the client anxiety about being ill.
Which situations should the nurse identify as being risk factors of the development of pressure sores? Select all that apply.
A. friction created by dragging the skin against bedlinen
B. moisture being allowed to accumulate on the skin
C. restlessly changing position frequently
D. pressure that impairs capillary blood flow to the skin
E. shearing that occurs when sliding down in bed
A.B.D.E. not C.
Pressure sores result when sustained compression obliterates arteriolar and capillary blood flow to the skin. Sores may also result from the shearing forces created by bodily movements. When a person slides down in bed from a partially sitting position or is dragged rather than lifted up from a supine position, for example, the movements may distort the soft tissues of the buttocks and close off the arteries and arterioles. Friction and moisture further increase the risk. Changing position frequently will assist in preventing pressure sores.
A client complains of epigastric pain and tarry stools. The nurse should suspect which of the following as the underlying cause?
A. Crohn's disease
B. Gastroesophageal reflux
C. Gastric ulcer
D. Pancreatitis
C. Gastric ulcer
Which statement is true regarding client positioning when attempting to identify intercostal spaces during a respiratory assessment?
A. A man's 7th intercostal space is identified best when lying in a lateral position.
B. A prone position allows for accurate assessment of the anterior attachment of the 11th and 12th ribs.
C. Always position the client for easy access to the posterior surface of the chest.
D. Women should be assessed while in a supine position.
D.Women should be assessed while in a supine position.
It is easier to identify intercostal spaces in women when they lie down, as the supine position displaces breast tissue across the chest. The 11th and 12th ribs, the “floating ribs,” have no anterior attachments. The remaining options present incorrect statements.
The nurse is planning to perform the Trendelenburg test on an adult client. The nurse should explain to the client that this test is used to determine the:
A. degree of arterial occlusion that exists.
B. severity of thrombophlebitis.
C. pulse of a client with poor elasticity
D. competence of the saphenous vein valves.
D. competence of the saphenous vein valves
If the client has varicose veins, perform the Trendelenburg test to determine the competence of the saphenous vein valves and the retrograde (backward) filling of the superficial veins.
Which of the following assessment findings most likely constitutes a secondary skin lesion?
A. Psorasis
B. Keloid formation at the site of an old incision
C. Acne
D. Lesion
A secondary lesion emerges from an existing primary lesion, such as the keloids that can emerge from the site of a healed wound. Acne and the lesions associated with psoriasis and herpes do not meet this criterion.