2. An 80-year-old client has been diagnosed as having congestive…

2. An 80-year-old client has been diagnosed as having congestive… 2. An 80-year-old client has been diagnosed as having congestive heart failure and 3+ edema of the lower extremities.When assessing the client for 3+ edema, the nurse should expect that there would be a. a deep pitting in the legs that remains for a period of time.b. A slight swelling of the legs that is barely perceptiblec. An indentation in the skin of the legs that subsides rapidlyd. A hard swelling in the legs that resists pitting. 3. .A nurse is conducting an admission interview with a client who states . I have migraine headaches. Which of these questions if asked by the nurse would provide the greatest amount of information? a. When did your migraine headaches begin?b. What concerns do you have about your migraine headaches?c. How often do you have migraine headaches?d. What can you tell me about your migraine headaches? 4. A pregnant woman admitted to the labor unit hyperactive patellar knee jerk reflexes bilaterally. Because of this finding, which of these actions should the nurse take?a. check for ankle clonusb. perform the heel- to- shin testc. use reinforcement techniques to suppress the activityd. assess vibratory sensation in the feet 5. A nurse is assessing children at a wellness clinic, which child should the nurse follow up first?a. A child who is 24 months old and whose feet pronateb. A child who is 12 months old and whose anterior fontanel is palpablec. A child who is 18 months old and has legs that bowd. A child who is 6 weeks old and has one leg shorter than the other 6.. A man comes to the primary care group for an employment physical. The client says, “I may have a hernia” When the nurse is assessing for the presence of a hernia,a. The client should be asked to stand for the examinationb. The client should be asked to avoid straining or coughingc. The nurse should apply a warm pack to relax the muscles in the aread. The nurse should apply a stain to the skin to highlight the area. 7. When a nurse examining the head of a newborn, the most important aspect is the inspection ofa . hair distributionb . sizec. shaped . symmetry 8.  A nurse in the pediatric clinic examines the ears of a 2-year -old child.In performing the otoscopic examination correctly, the nurse should take which of these actions?a. Have the child’s head turned towards the opposite shoulder.b. Hold the otoscope handle downward and brace it against the child’s neck.c. Pull the pinna up and back to straighten the canal.d. Insert the otoscope horizontally using the eyebrow as a landmark. 9. Two nurses present a summary of information on documentation during a nursing conference. Which of these statements definitely needs further discussion?a. Draw pictures of findings only if one is artistic b. Record assessment findings by body systemsc. Document promptly to decrease the chance for memory lapsed. Print or write assessment findings legibly 10. A nurse assesses the skin of a 78 year old client. Which of these findings should the nurse follow up?a. Several small dark brown areas on the dorsal surface of both hands b. A variegated pigmentation with regular borders on the left handc. An elevated round red area on the left armd. Yellow waxy deposits on both eyelids  11. When a nurse percusses a client’s throat using the indirect technique, the movement in the striking hand should originate from the nurses?a. Shoulder.b. Upper hand.c. Elbow d. Wrist. 12. A nurse assesses the pulses rate in all of these individuals.Which of these assessment findings would indicate a need for the client to be referred to a physician?a. A pulse rate of 54 in a cross-country runnerb. A pulse rate of 68 in an elderly manc. A pulse rate of 56 in a known cardiac clientd. A pulse rate of 90 in a 2-year-old child 13. A split S2 heart sound is generally heard in which of these areas?a. Pulmonicb. Apexc. Tricuspidd. Mitral  Health Science Science Nursing NURS 5220 Share QuestionEmailCopy link Comments (0)

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