Fundamentals Week 3_KLIPPMANN

Question 1

the patient is taking dietary supplements in addition to prescribed medications. What is the primary concern?

Accepted Answer

They may interact with prescribed medications and affect drug action.

Question 2

Which findings should the nurse expect when auscultating and percussing a client’s abdomen?

Accepted Answer

High‑pitched clicks, Tympany

Question 3

Which assessments should be performed to test the client’s balance in a neurologic examination?

Accepted Answer

romberg test, Heel‑to‑toe walk

Question 4

Which actions should the nurse take when is assessing an adult client’s internal ear canals with an otoscope?

Accepted Answer

Use the light to visualize the tympanicmembrane in a cone shape, Insert the speculum slightly down and forward, make sure the speculum doesnot touch the ear canal

Question 5

“I have felt tired during the day & cannot sleep at night.” Which responses should be asked when collecting data?

Accepted Answer

“Do you drink caffeinated drinks? If so, how many cups per day?”, “Tell me about any personal stressyou are experiencing.”, “Have your working hours changed recently?”, “Has anyone ever told you that you stop breathing for secs while you sleep

Question 6

When explaining rapid eye movement (REM) sleep, which of the following characteristics should the nurse include?

Accepted Answer

vivid dreams are common during REM sleep, REM sleep provides cognitive restoration, It is difficult to awaken a person in REM sleep

Question 7

An American Indian patient has been admitted with abdominal pain. after an assessment, the nurse should also perform a

Accepted Answer

Cultural assessment

Question 8

What are the possible causes of abdominal distention where the protrusion is midline & the skin over the area is taut.

Accepted Answer

Flatus

Question 9

Which findings should the nurse expect during an assessment of a client’s skin?

Accepted Answer

Thick skin on the soles of the feet, Capillary refill less than 3 seconds, Numerous macules on the face darker than the surrounding skin color

Question 10

To determine the strength of a patient’s lower extremities during a neuro examination, the nurse asks the patient to:

Accepted Answer

Push against his hand with the sole of one foot and then the other.

Question 11

Which tests should be preformed on a postoperative circulation assessment of lower extremities after knee surgery.

Accepted Answer

Skin temperature, Edema, Skin color

Question 12

Which findings should you expect on a breast exam for an older adult client who is postmenopausa?

Accepted Answer

Smaller nipples, Nipple inversion, more pendulous

Question 13

An older adult patient says she has been using herbal products. Why would the nurse be concerned

Accepted Answer

They may have other diseases that could cause a drug reaction.

Question 14

A patient’s capillary refill took 5 seconds for the color to return. The most appropriate intervention is to

Accepted Answer

Repeat the assessment

Question 15

Appropriate teaching for a patient who is planning to use herbal products should include which of the following?

Accepted Answer

Take the smallest amount possible when starting herbal therapy

Question 16

A nurse is documenting the pain that brought the patient in. The best description is:

Accepted Answer

“Periumbilical sharp pain at 7 to 8 for 3 hrs, started 2 hours after lunch

Question 17

When assessing a client’s neurologic system, the client should close their eyes and identify which items?

Accepted Answer

A familiar object the nurse places in the hand

Question 18

what does a client’s visual acuity of 20/30 on a Snellen eye test results mean?

Accepted Answer

“your eyes see at 20 feet what visually unimpaired eyes see at 30 feet.”

Question 19

A nurse is performing an integumentary assessment for a group of clients. Which findings are of immediate concern?

Accepted Answer

Cyanosis

Question 20

Which is an indication of understand the instructions of self‑management of narcolepsy?

Accepted Answer

“I’ll take a short nap whenever I feel a little sleepy.”

Question 21

A nurse is performing skin assessments on a group of clients. Which lesions should the nurse identify as vesicles?

Accepted Answer

Herpes simplex, varicella

Question 22

a client reports pain with internal rotation of the right shoulder. This discomfort can affect ability to perform?

Accepted Answer

Fastening or zipping closures on the back while dressing

Question 23

Which of the following recommendations should the nurse give to the client to promote sleep and rest?

Accepted Answer

Exercise each morning, Limit fluid intake at least 2 hrbefore bedtime, Alter the sleep environment for comfort, Practice muscle relaxation techniques

Question 24

How is a visual acuity test using the Snellen eye preformed?

Accepted Answer

stand 20 feet away from the chart while I test each of your eyes

Question 25

the client usually takes a bath before bed and now is having difficulty sleeping. Which action should be taken

Accepted Answer

Allow the client to take a bath in the evening

Question 26

What is is the nurse auscultating with the diaphragm on the left midclavicular line at the fifth intercostal space?

Accepted Answer

Closure of the mitral valve, Apical heart rate

Question 27

Which findings should be expected as changes associated with aging as part of a neurologic examination?

Accepted Answer

Slower fine finger movement, Slower light touch sensation, Some short‑term memory decline, Some vision and hearing decline

Question 28

What should be documented when both pupils constrict, regardless of which eye is stimulated by the light?

Accepted Answer

Consensual reflex

Question 29

Which findings should the nurse expect when assessing a young adult client’s musculoskeletal system?

Accepted Answer

muscles slightly larger on the dominant side, Concave lumbar spine posteriorly

Question 30

Which findings should the nurse expect when they auscultate and percuss a client’s thorax?

Accepted Answer

Bronchovesicular sounds, resonance

Question 31

Which of the following directions should the nurse include when testing cranial nerve v?

Accepted Answer

“raise your eyebrows.”, “Clench your teeth.”

Question 32

Which age‑related findings should the nurse expect on a head and neck exam of an older adult?

Accepted Answer

Thickened eardrums, Glare intolerance, Tooth loss

Question 33

Which factors should be considered as a cause for significant tenting of the skin over the forearm of an older adult

Accepted Answer

Dehydration, Diminished skin elasticity, Loss of adipose tissue

Question 34

A nurse is assessing a client’s thyroid gland Which findings should the nurse expect?

Accepted Answer

Palpating the thyroid in the lower half of the neck, Feeling the thyroid ascend as the client swallows, Finding symmetric extension off thetrachea on both sides of the midline

Fundamentals Week 3_KLIPPMANN

Questions 34

Fundamentals Week 3_KLIPPMANN

Questions 34