The.nurse.is.performing.a.thoracic.assessment.on.a.client.with.chronic.asthma.an d.hyperinflation.of.the.lungs..Which.finding.should.be.expected.for.this.client?.-....ANSWER................Barrel.chest The.nurse.is.assessing.bowel.sounds.for.a.hospitalized.client..The.nurse.has.heard .bowel.sounds.in.the.right.upper.quadrant..What.action.should.the.nurse.take.ne xt?.-....ANSWER................Note.the.character.and.frequency.of.bowel.sounds During.inspection.of.a.client's.mouth.and.pharynx,.the.nurse.places.a.tongue.bla de.on.the.back.of.the.tongue.which.causes.the.client.to.gag..After.removing.the.t ongue.blade,.what.action.should.the.nurse.take?.-....ANSWER................Document .an.intact.gag.reflex.When.teaching.a.client.how.to.perform.a.monthly.breast.self- assessment,.the.nurse.should.tell.the.client.that.it.is.most.important.to.assess.wh ich.part.of.the.breast.more.closely.for.changes?.-....ANSWER................Upper.oute r.quadrant. 1 / 3
The.nurse.is.assessing.a.postmenopausal.client.who.has.a.BMI.of.32..The.client.h as.a.chest.measurement.of.42.inches,.waist.measurement.of.45.inches,.and.hip.measurement.of.50.inches..What.important.message.should.the.nurse.explain.to.the.client.to.promote.health.promotion?.-....ANSWER................A.waist.circumfere nce.is.greater.than.35.inches.in.women.puts.you.at.higher.risk.for.type.2.diabetes .and.heart.disease." The.nurse.performs.a.physical.assessment.on.an.older.female.client..Which.chang e.from.the.prior.exam.may.be.an.indication.of.osteoporosis?.-....ANSWER................Height.reduction.of.1.5.inches.While.conducting.an.interview.to.obtain.a.health.history,.the.nurse.notices.that.t he.client.pauses.frequently.and.looks.at.the.nurse.expectantly..Which.response.is .best.for.the.nurse.to.provide?.-....ANSWER................Sit.quietly.to.allow.the.client .to.respond.comfortably.A.client.is.in.the.clinical.for.a.yearly.physical.examination..Which.action.should.th e.nurse.take.when.preparing.to.examine.the.client's.abdomen?.-....ANSWER................Ask.the.client.to.urinate.before.beginning.the.examination. 2 / 3
Which.respiratory.condition.should.the.nurse.document.after.measuring.a.respira tory.rate.of.8.breaths/minute?.-....ANSWER................Bradypnea.Which.procedure.should.the.nurse.use.to.assessfor.a.pulse.deficit?.-....ANSWER................Measure.the.apical.pulse.and.compare.it.to.the.peripheral.pulse.*A.pulse.deficit.is.a.palpable.difference.between.the.apical.pulse.at.the.point.of.maximal.impulse.and.the.radial.pulse.palpated.at.the.wrist.A.client.has.been.diagnosed.with.bilateral.lower.lobe.atelectasis..What.percussio n.sound.should.the.nurse.expect.to.hear.when.percussing.over.the.client's.lower.lobes?.-....ANSWER................Dull,.thud-like.A.client.is.being.assessed.upon.admission.to.the.medical- surgical.unit..The.nurse.is.preparing.to.complete.a.head-to- toe.assessment.and.will.begin.at.the.head.of.the.client..Which.technique.should.t he.nurse.use.to.begin.the.assessment?.-....ANSWER................Inspect.the.hair.and .skin.
- / 3