REALIZAR TEST
Título del test:
Capitulo 29
Descripción:
Enfermeria
Autor:
Mofongo
(Otros tests del mismo autor)
Fecha de Creación:
19/03/2020
Categoría:
Otros
Número preguntas: 30
No hay ningún comentario sobre este test.
Temario:
The nurse is preparing to perform an interview to obtain information about the client. Which are classified as secondary sources of information? Standard Text: Select all that apply. 1. The client’s wife. 2. The client’s medical record from his last hospital admission. 3. The client. 4. The client’s daughter. 5. The client’s physical therapist.
The nurse is interviewing the
client. Which interaction could lead to a communication breakdown between the nurse and client? Standard Text: Select all that apply. 1. The client is a Native American and the nurse is of Northern European descent. 2. During the interview, the nurse is trying to remember what the healthcare provider asked her to do earlier in the day 3. The young nurse creates an informal atmosphere to discuss safe sexual practices with a teenaged client 4. The young nurse uses a serious and respectful tone to
discuss erectile dysfunction with an older client. 5. The nurse states, “So, you experience pain with micturition.”.
The client weighs 224 pounds. How many kilograms does the client weigh? _____ kilograms. Standard Text: Round to the nearest tenth. 101.8 kilograms N/A.
The client weighs 145 kilograms. The client is 1.75 meters. What is this client’s body mass index (BMI) using the following formula: BMI = weight (kg)/height2 (meters)? ______. Standard Text: Round to the nearest whole
number. N/A 47.
The nurse is interviewing the client and learns that the client has an open leg wound that has been draining a moderate amount of yellowish drainage over the last 3 days. Prior to assessing the client’s wound, which piece of personal protective equipment is most important for the nurse to wear based on the principles of standard precautions? 1. Fluid-resistant gown. 2. Shoe covers. 3. Mask. 4. Gloves.
The nurse is performing a physical assessment of the client. Which pieces
of information are examples of objective data? Standard Text: Select all that apply. 1. Apical pulse is 94 beats per minute. 2. Blood pressure in right arm is 118/74. 3. The client has a nonproductive cough. 4. The client reports that his pain is severe and throbbing. 5. Respiratory rate is 18 breaths per minute.
The student nurse is preparing to assess the client while the more experienced nurse assists. Prior to the physical assessment, the client complains of left lower quadrant abdominal
pain. Which statement by the student nurse indicates that the student nurse requires further education prior to performing this part of the assessment? 1. “I’m going to start by percussing and palpating the client’s left lower quadrant first.” 2. “I will start the abdominal assessment by inspecting the client’s abdomen.” 3. “I’m going to auscultate the abdomen prior to percussing the abdomen.” 4. “I need to ask the client about the characteristics of his pain.”.
The nurse is performing a
physical assessment on a client in an outpatient clinic. The nurse is inspecting and palpating the client’s face, skin folds, axillae, palms, and soles of the feet. The nurse determines the client is diaphoretic. Which client statement supports this finding? Standard Text: Select all that apply. 1. “Your elevator is out and I had to climb three flights of stairs.” 2. “I’ve been running a fever for the last few days.” 3. “I think I have hypothyroidism.” 4. “I’m in a lot of pain today.” 5. “I
heard a rumor at work yesterday that layoffs were inevitable.”.
Which location will the nurse palpate when assessing a client’s preauricular lymph nodes? 1. A. 2. B. 3. C. 4. D.
The student nurse is preparing to insert the otoscope into the adult client’s ear. Which statement by the student nurse indicates the need for further education? 1. “I’m going to use the largest speculum that will fit easily into the ear canal.” 2. “I’m going to prepare to insert the otoscope by pulling the pinna
down and back.” 3. “The tympanic membrane should look gray and translucent.” 4. “I will ask the client to perform the Valsalva maneuver so that I can see how well the tympanic membrane moves.”.
The nurse holds the tuning fork by the handle and gently strikes the fork on the palm of the hand. Then, the nurse places the base of the fork on the client’s mastoid process. The nurse requests that the client indicate when the sound can no longer be heard. Which test is the nurse performing? 1.
Weber. 2. Whisper. 3. Rinne. 4. Romberg.
During the physical assessment of the client, the nurse notes that the client is able to shrug the shoulders bilaterally. Based on this data, which nerve is intact? 1. Cranial nerve I (olfactory). 2. Cranial nerve II (optic). 3. Cranial nerve VII (facial). 4. Cranial nerve XI (spinal accessory).
The nurse is assessing the function of the client’s cranial nerve XII (hypoglossal). Which activity will allow the nurse to assess this nerve during the
client’s physical assessment? 1. “Can you stick out your tongue?” 2. “I’m going to ask you to taste something and tell me what you think it is.” 3. “Close your eyes and tell me when you feel me touch your face with this wisp of cotton.” 4. “I’m going to lightly touch the back of your throat with this tongue depressor.”.
The nurse is performing a physical assessment of the client. Which is the location for the costovertebral angle? 1. A. 2. B. 3. C. 4. D.
The nurse is auscultating the
client’s lungs and is able to auscultate bronchovesicular sounds over the client’s left lung. Which location would the nurse use when auscultating this type of lung sound? 1. A. 2. B. 3. C. 4. D.
The nurse is assessing the client’s cardiovascular system. The nurse is preparing to assess the client for the presence of a lift or heave. Which directions should the nurse provide for the client? Standard Text: Select all that apply. 1. “I am going to put you into a position where your feet are
actually above your head.” 2. “I need you to turn to your left side.” 3. “Can you please turn onto your stomach?” 4. “I need you to sit up straight.” 5. “I am going to elevate your head to a 30-degree angle while you lie on your back.”.
The nurse is assessing the client’s cardiovascular system during the physical assessment. Which location will the nurse use to palpate the point of maximal impulse/apical pulse? 1. A. 2. B. 3. C. 4. D.
The nurse is performing a physical assessment for the
client and identifies a venous hum while auscultating the client’s abdomen. Which statement by the nurse is the most consistent with this type of vascular sound? 1. “The sound is a blowing, pulsing sound.” 2. “The sound is soft and constant. The pitch of the sound is low.” 3. “It is grating, rough sound.” 4. “It is tinkling and has a high pitch. The sound is sort of gurgling and irregular.”.
The nurse percusses the client’s abdomen. Which piece of information accurately reflects that tympany
is present? 1. “The sound is low-pitched, loud, and hollow-sounding.” 2. “It is a high-pitched, soft sound that doesn’t last very long.” 3. “The sound is very loud and has a low tone. The sound has a long duration.” 4. “It sounds like a drum, is loud, and high-pitched.”.
The nurse is assessing the client’s neurologic system. The nurse tests the client’s ability to perform stereognosis. Which activity will accurately test this? 1. The nurse places a vibrating tuning fork over the client’s
ankle and asks the client to indicate when the vibration can no longer be felt. 2. The nurse asks the client to close her eyes and writes the number ‘7’ in the client’s palm with the base of the nurse’s pen. The nurse asks the client to identify what was written. 3. The nurse asks the client to close her eyes and places a pen in the client’s hand. The nurse asks the client to name the object in her hand. 4. The nurse asks the client to close her eyes and indicate where the nurse is touching the
client.
The nurse has palpated an abnormal mass within the client’s scrotum. Which assessment activity is appropriate for the nurse to perform next? 1. The nurse should percuss the client’s scrotum. 2. The nurse should attempt to transilluminate behind the area in which the abnormal mass was palpated. 3. The nurse should inspect the inguinal area. 4. The nurse should gently squeeze the mass between the fingers.
The nurse is performing a physical assessment of a male client. The nurse must
assess the client’s sacrococcygeal area. Which position will allow the nurse to assess this area adequately? 1. Orthopneic position. 2. Semi-Fowler’s position. 3. Lithotomy. 4. On his left side with his knees drawn up.
The nurse is performing an assessment of the female client’s genitalia. The nurse has inserted a speculum and notices that the client has a frothy greenish-yellowish discharge present within the vagina. Based on this data, which condition does the nurse suspect? 1.
Trichomoniasis. 2. Gonorrhea. 3. Chlamydia. 4. Candidiasis.
The nurse is documenting information about the client using Problem-Oriented Charting and the acronym SOAP. Rank the following pieces of information in the order that they should be documented. Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list. 1. The client’s skin is cool and dusky. Poor capillary refill noted. Oxygen saturation level is 90% on room air. The
client was diagnosed with COPD in 1993. 2. The nurse will apply oxygen at two liters per minute per healthcare provider’s orders, when the client’s oxygen saturation level is below 92%. 3. The client states, “I am so tired all of the time. I feel like I’m not getting enough air into my lungs.” 4. The client is most likely experiencing an exacerbation of a chronic lung disease. 3, 1, 4, 2.
When conducting a health history for a pediatric client, which action by the nurse is appropriate? 1.
Asking the client which grade they are in. 2. Monitoring the client’s vital signs. 3. Assessing the cardiovascular system. 4. Documenting immunizations administered during the visit.
Which action is appropriate for the nurse to include in the client’s health history portion of the nursing assessment? 1. Monitoring blood pressure. 2. Assessing lung sounds. 3. Discussing cultural traditions. 4. Monitoring temperature.
The nurse is discussing the results of recent laboratory tests with a
female client, who tested positive for a sexually transmitted infection. Which statement by the nurse is the most therapeutic? 1. “If you did not sleep around, this would not be happening.” 2. “The best way to prevent this from happening again is to not have sex until you are married.” 3. “I understand that this result is concerning. I would like to discuss how to prevent this from occurring again.” 4. “You may never be able to have children because of this diagnosis.”.
The nurse is providing
care to an adolescent female who seeks care due to experiencing a change in vaginal discharge. The client is not sexually active, but states, “There is white stuff in my panties that looks like cottage cheese.” Based on this data, which condition does the nurse suspect? 1. Gonorrhea. 2. Chlamydia. 3. Yeast infection. 4. Pelvic inflammatory disease.
The nurse is preparing to conduct an abdominal assessment for a client who is denying abdominal pain. Which assessment will the nurse perform
first? 1. Auscultate the abdomen for bowel sounds. 2. Palpate the abdomen for masses or tenderness. 3. Palpate for hernias. 4. Percuss the abdomen in all quadrants.
The nurse is assessing a client’s musculoskeletal system. Which action will the nurse perform first? 1. Assist the client to a standing position. 2. Assess the skin on the posterior legs. 3. Perform the Romberg. 4. Test range of motion and strength in the hips, knees, ankles, and feet.