NURS 190 PHYSICAL ASSESSMENT FINAL EXAM 2 LATEST

NURS 190 PHYSICAL ASSESSMENT FINAL EXAM 2 LATEST

VERSIONS 2023-2024 REAL EXAM 200 QUESTIONS AND

CORRECT ANSWE RS|AGRADE

VERSION A

• The nurse is caring for a client who was admitted to the medical unit. The nurse notes in the physical exam done by the physician

that the client has a positive Romberg. When meeting elimination needs for this client, the nurse would perform which of the following interventions?

• obtain an order for a catheter
• limit fluid intake
• obtain a bedside commode
• allow the client to walk independently

• The nurse observes drainage from a client’s ears after a head injury, and suspects a cerebral spinal fluid (CSF) leak. The nurse

would document which of the following descriptions of the drainage?

• blood-tinged without sediment
• pink without sediment
• yellow without sediment
• clear, colorless

• The nurse is performing a neurological assessment on a client and needs to use seterognosis. Which of the following instructions

would the nurse provide for the client?

• “Identify the number being traced in your hand with your eyes closed.”
• “Identify the object in your hand with your eyes closed.”
• “Tell me if you feel one or two objects touching you with your eyes closed.”
• “Open and close your hand each time I tell you to.”

• The nurse notes fanning of the toes when the sole of the foot is stimulated during assessment of the plantar reflex. The nurse would

correctly chart which of the following?

• Brudzinski sign
• nuchal rigidity
• hyperreflexia
• Babinski response

• The nurse is assessing a female client and notes facial hirsutism. The client asks the nurse why this has happened to her. The nurse

would correctly respond with which of the following statements?

• “Your diet is not nutritionally balanced.”
• "You need to take vitamins.”
• “There is not a known cause for this condition.”
• “You may have some hormone imbalances.”

• The nurse is assessing the patellar reflex on a client and obtains no reflective activity. The client is alert and oriented. The nurse

should do which of the following in this situation?

• look at the medication records for central nervous system depressants
• retest the reflex after having the client use distraction during the exam
• notify the physician immediately
• document the findings as normal
• The nurse is caring for a client that insists on having their food very hot and very cold at each meal. The nurse correctly recognize

this as a health belief in which of the following cultural groups?

• Chinese Americans 1 / 3

• Native Americans
• Cuban Americans
• Jewish Americans 2 / 3

• The nurse is caring for a client who is a long-time smoker and notes clubbing of the fingers. The nurse utilized which of the

following techniques to validate this assessment?

• place two of the same fingers from each hand together
• place the hands out straight with the palm sides down
• place two index fingers together tip to tip
• place two thumbs touching side by side

• A 24-year-old client reports difficulty with near vision during an interview with the nurse. The nurse realizes the finding is

consistent with:

• hyperopia
• presbyopia
• astigmatism
• aging

• The nurse is performing a neurological assessment on a client experiencing anosmia. The nurse would suspect cranial nerve

involvement in which of the following?

• trigeminal, cranial nerve V
• trochlear, cranial nerve IV
• olfactory, cranial nerve I
• oculomotor, cranial nerve III

• The nurse is assessing the visual fields of a 38-year-old female who reports recent changes in visual abilities. Which of the

following statements would be appropriate for the nurse to use with this client?

• “These changes are probably related to your age.”
• "It is possible you have taken narcotics recently?”
• “The changes could be related to increased pressure within your eye.”
• “These changes require a prescription for glasses.”

• The nusse assesses a client and finds that a grating sound is present when a joint is bent and straightened. The nurse would

correctly document this finding as which of the following?

• joint noise
• grating
• crepitation
• grinding

• The nurse is planning care for a client with hypothyroidism. Which of the folliwng would be the priority nursing diagnosis for this

client?

• altered nutrition, less than body requirements
• risk for constipation related to metabolic imbalance
• risk for injury related to confusion and lethargy
• activity intolerance related to fatigue

• The nurse is assessing the pulses of a client and palpates the area behind the client’s knee. The nurse would choose which of the

following names to document this pulse?

• radial
• brachial
• popliteal
• dorsalis pedis

• The nurse is assessing cranial nerve XI (spinal accessory). Which of the following statements would the nurse use to the client?
• “Smell these items and identify what they are.”
• “Shrug your shoulders and turn your head against my head.”
• “Stick out your tongue and move it from side to side.”
• “Taste these foods and decide which is sweet and which is sour.”
• / 3