Duplicate of Duplicate of Exam 4

RN performing complete exam in older pt. Which of the following is a normal age associated change

Adult pt seen for severe infection in left foot Which of these findings should the nurse expect to see during assessment

RN testing reflexes on adult pt when stroking up lateral side of sole and ball of foot RN sees plantar flexion of toes..

Which collection of sign/symptoms is most consistent with acute coronary syndrome?

True or false the PMI should be palpable at 5-6th ICS at anterior axillary line

The RN is assessing for PAD and calculates an ankle brachial index of 0.8. The nurse knows

When assessing cerebellum function on adult pt RN should ask pt to…

RN using Phalen test in exam of pt with “hand pain”. What instruction should RN give pt to preform test?

A pt with peripheral arterial disease and associated paresthesia is most likely to report what during health history?

The RN is preforming a CN exam on on a pt who had a stroke 2 days prior. How should the nurse assess CN X?

The RN is examining a 1 hour old baby. Which finding is most concerning?

RN examining pt with systolic dysfunction. Using bell nurse hears extra early diastolic sound at apex of heart. Sound?

An RN is auscultating apical and palpate radial pulse simultaneously and note apical pulse is faster what does this mean

RN preparing to auscultate for heart sounds in an elderly client presenting with cough & fatigue Which technique is best

RN assessing carotid arteries on a pt. The RN should do all of the following except?

During cardiac auscultation of healthy adult RN hears intermittent extra early diastolic sound at 2nd L ICS. Next step?

During health history interview pt with hyperlipidemia feels pressure in chest during activity and stops after rest

The RN is preparing to preform a cardiovascular exam on elderly pt. What age associated change does RN expect to find?

During check up exam of 86 year old pt the RN assess a slower gait, slower pupillary response and 1+ DTR. How RN note?

RN is assessing 36 wk pregnant pt & hears extra early diastolic sound at apex of heart. This sound is most likely?

RN assessing pt with “left shoulder pain” to assess for rotator cuff injury what should RN do?

Which deformity is not typically associated with Rheumatoid arthritis?

RN examining pt w/ diastolic dysfxn Auscultation w/ bell RN hears late diastolic sound at 5th ICS L midclavicular line

The RN is educating post menopausal women on ways to prevent osteoporosis. Which is best way to prevent bone loss?

The RN is preforming a complete neuro exam on an adult. How should RN assess cognitive function?

Pt presents to clinic with swelling in legs Exam reveals distended neck veins and pansystolic murmur at 4th ICS????

Which of the following is not a type of murmur?

If an S2 split is physiologic the sound should appear only with:

RN examining elderly pt with HTN. During cardiac auscultation using bell RN hears extra late diastolic sound at apex

RN is reviewing risk factors for venous disease. Which of these situations best describes a person at risk for venous dz

RN examining school aged child Using bell, RN hears midsystolic soft blowing whooshing at L middle sternal border……

RN hears loud rumbling murmur right after S2 at apical site. Palpable thrill present. How would RN document?

The RN notes a 10 degree lateral rotation to the spine. The RN knows

The left ventricle normally pumps blood directly to the

The RN wants to examine a pt’s apical impulse, where should this be found?

During assessment of pt at annual exam RN unable to palpate ulnar pulses. Cap refill is 1 sec. What should RN do next?

The RN is preforming a neuro assessment on a 7 year old. What would the RN include in the cranial nerve portion of exam?

What should RN incorporate when assessing motor coordination of a 10 month old infant?

A pregnant female in her third trimester is in clinic for “leg pain and swelling” How should RN assess for DVT?

A healthy 75 year old male asks RN why he is getting shorter as he ages. How should RN respond?

During assessment with Glasgow coma scale nurse depresses clients sternum and notices flexion and upper extremities

During a cardiac assessment on pt with “chest pain” nurse finds bilateral JVD, dependent edema, and distended abdomen

During an exam the RN notices severe nystagmus in both eyes of pt. What conclusion by the nurse is correct?

RN preforming assessment on elderly pt with limited ROM in knee. Which assessment finding is consistent with this data?

A pt is reporting pain in most of his joints worse in the morning but gets better after moves around. RN assess for what

During assessment pt reports being treated for osteoarthritis What finding alerts RN to presence of Bouchard’s nodes?

Adult pt with flank pain and blood in urine. During exam RN notices hard painless nodules on great toe, one burst…

RN testing DTR on adult for annual physical. What response does RN expect to find when testing Achilles reflex?

An RN is auscultating with diaphragm and hears an S1 split. Where in cardiac cycle would this be found?

RN is assessing the jugular veins, which technique is correct?

Which sign or symptom is most consistent with severe mitral valve stenosis?

RN examining pt with severe HTN and coronary artery disease. How should RN auscultate for S4 gallop?

Which of the following is not a component of the GCS?

RN preparing to examine client with stage 3 lymphedema affecting the right leg. What does the nurse expect to find?

While performing a head to toe assessment on a bedridden pt with diabetes, RN unable to palpate pedal pulses. Next step?

Using the diaphragm the RN hears intermittent extra early diastolic sound at base of the heart. This is most likely

RN examining pt admitted for pancreatitis. Vital signs are 98.6 F pulse 98 respirations 18 & cap refill 4 sec bilateral

Which statement best describes the S1 heart sound?

When assessing 68 year old pt presenting with L leg pain RN notes L femoral pulse is very weak. What should Rn do next?

RN completing neuron exam on elderly pt. Which finding is expected?

RN completing neuro assessment of 68 yo pt with “difficulty walking” How should RN assess muscle tone in this pt?

A nurse is assessing a pt admitted for severe hyperthyroidism. When assessing pt pulses, what should nurse expect?

Which is not a symptom of L sides heart failure?

A pt tells RN that her fingers often “go numb & then burn” when she is very stressed or goes out in colder weather. ????

Pt recover from MI & complains of “sharp chest pain” on exam RN hears high pitch scratchy sound during S1 & S2 at apex..

When the RN is testing the biceps reflex what is the expected response?

Pt presents to clinic with a “swollen knee”. What test should RN use to check for large amounts of fluid around patella?

RN preparing to preform modified Allen test on hospitalized pt. A nursing student asks why test is necessary. RN says?

RN examining a newborn who was born with assistance of forceps. Which finding alerts RN to possible fractured clavicle?

During an assessment of a 67 year old man RN notices pt has stooped posture, shuffling gait and resting hand tremor…

The nurse is gathering a health history nurse. Which of following is a risk factor for peripheral vascular disease?

A nurse is caring for a stable pt with significant swelling from a musculoskeletal injury. The nurse would be prudent to

RN auscultate loud murmur after S2 over pulmonic valve area. Slight thrill palpated over area. Nurse documents

A positive Homan’s sign might indicate what?

RN examine pt w/ “leg weakness” Guillian Barre is suspected What might RN find when testing reflexes in lower extremitie

A pt complains of leg pain waking at night but pain disappears when dangles them over the bed & sore on great toe. ?????

Assessment of pt with “fatigue” RN notes apical impulse easily palpable over 5th and 6th ICS anterior axillary line…??

A pt has been diagnosed with tricuspid stenosis. What s/s would the nurse expect?

During exam of pt with “back pain’ after car accident RN notices lateral lifting & forward flexion of spine. RN suspect?

The RN preparing to assess posterior tibialis artery. Where is correct location for palpation?

Which sign or symptom is most consistent with left sided heart failure?

RN preparing to examine pt with severe HTN and coronary artery disease. How should nurse auscultate for S4 gallop?

The RN places a key in the hand of a pt and he identifies it as a marble. What term would RN use to describe finding?

Which pt should you preform a complete musculoskeletal exam on?

During an assessment of a health pt where would RN expect to palpate the point of maximal impulse?

During neuro assessment of pt with a stroke RN places two pins on client skin pt feel 16 mm one point on R index finger

While assessing a 3 month old infant RN offers finger to baby’s palm and baby tightly grasps it. How RN report findings

When auscultating over a patients femoral arteries the RN notices the presence of a bruit on the left side Which is true

Where would the nurse expect to hear the loudest sound from S2?

RN preforming exam on pt who says “always dropping things & tripping” RAM are slow and frequently misses. RN suspects?

RN examining 3 month old because he “isn’t gaining weight”, to screen for cardiac dysfunction what question is important

When RN is auscultating the carotid artery for bruits which of these statements reflects the correct technique?

RN testing function of CN III. Which best describes the response the nurse should expect if this nerve is intact?

During systole which valves are heard closing?

A 65 year old pt experiencing pain in left calf when he exercises which disappears after resting for a few minutes….

While assessing a 7mo infant nurse clasps hands and notices abduction and flexion of arms & legs & bring legs to body…

Exam of older pt presenting with “cough & weight gain” reveals bilateral edema in legs. What should RN do next?

RN is auscultating a pt with the bell of stethoscope and hears early diastolic sounds which is S3 what does this mean?

When assessing muscle strength RN observes pt maintain bicep flexion against resistance. How should RN document strength

When listening to heart sounds which valve closures are heard best at apex of the heart?