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?
What is balance and proprioception?
The cranial nerve that has sensory fibers for taste and fibers that result in the “gag reflex” is which nerve?
What is the glossopharyngeal nerve (CN IX)
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 stooped posture, short shuffling steps, and decreased arm swing. What type of gait is that?
What is Parkinsonian gait?
A nurse is performing a focused cranial nerve assessment on a client. The nurse observes that the client is unable to shrug their shoulders. Which cranial nerve is involved?
What is the spinal accessory nerve (CN 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.
A nurse observes a client leaning forward with arms supporting their body weight (tripod position). What disorder is most likely?
What is COPD (although this can occur in other types of respiratory distress as well)?
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. What does this score represent in the client?
What is a deep coma?
When assessing cranial nerves IX and X, what would the nurse consider as a normal finding?
What is the uvula and soft palate rising symmetrically with phonation?
A client presents with acute pancreatitis and reports pain in the shoulder. This pain pattern is best described as what?
What is referred pain?
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