1.
The nurse is performing a comprehensive skin assessment. Which of the following pieces of equipment is appropriate to use during the skin assessment?
(2 Points) doppler
Wood's lamp Reflex hammer Goniometer
2.
Whi
...
1.
The nurse is performing a comprehensive skin assessment. Which of the following pieces of equipment is appropriate to use during the skin assessment?
(2 Points) doppler
Wood's lamp Reflex hammer Goniometer
2.
Which of the following is an expected finding in a healthy client on assessment of Stensen's ducts? (2 Points)
red glow is present midline and symmetric
saliva is present redness is present 3.
Which of the following signs or symptoms does the nurse recognize in a client with hypothyroidism? (Select all that apply)
(2 Points)
Fatigue
intolerance to cold increased cardiac output
constipation 4.
The client has a new diagnosis of right sided heart failure. The nurse understands a client with right sided heart failure may have edema and jugular vein distension.
(2 Points)
True False
5.
The nurse performs the Romberg test to assess for: (2 Points)
balance hearing vision loss
cranial nerve 6 dysfunction 6.
Which of the following techniques will the nurse perform to assess for signs of breast abnormalities? (2 Points)
inspection, palpation, and auscultation
inspection and palpation
inspection, palpation, and percussion palpation and auscultation
7. The nurse is caring for a client with obesity. The nurse places the client in which of the following positions to best hear heart sounds?
supine prone
sitting upright
lef t lateral 8.
State at which location(s) the S1 sound (lub) is heard loudest on cardiac auscultation. State why the S1 is loudest at these locations. (Write 1-2 sentences).
If you are you are at the proper location, you will hear the sound the loudest. (2 Points)
9.
The nurse palpates an enlarged lymph node at the back of the ear, over the mastoid bone. The nurse documents this location as:
(2 Points)
posterior auricular
submental posterior occular occipital
10.
The older adult client is admitted with new onset pain and pressure to their eyes. On inspection, the sclera is red and the pupil is an irregular shape to the left eye. The nurse should further assess for:
(2 Points)
macular degeneration cataracts
presbyopia
Glaucoma BOOK REF. PG 253 11.
The client is seen in the urgent care center with a suspected fungal infection to the fingernails. The nails are thick, yellow, and lifting off the nail bed. The nurse documents this finding as:
(2 Points) clubbing
Onycholysis BOOK REF PG. 203 beau's lines
splinter hemmorage 12.
The nurse assesses the client's radial pulses and documents these findings: 68 beats per minute, regular, 2+, symmetrical. The physician asks the nurse, "What was the client's pulse amplitude?" The best response of the nurse:
(2 Points)
"68 beats per minute" "regular"
"2+" BOOK REF PG 404
"symmetrical" 13.
The nurse is performing a.....................................CONTINUED
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