1. A 29 year old male client informs the nurse that he came to the clinic to
see if, "Maybe I have lung cancer or something," and wants to get checked
out since, "I can't seem to get rid of this body-wracking dry cough that has
been hanging around for the last six weeks." Which computer
documentation of this client's concerns should the nurse enter?
A. Presents with a hacking non-productive cough of 6 weeks duration.
B. Describe having a "body-wracking dry cough" of 6 weeks duration.
C. Expresses concern of "lung cancer" symptoms for last 6 weeks.
D.Young adult male presents with fears that he has "lung cancer": Correct
answer is B, as assessment process includes chief complaint which is
how the patient describe why he is here in the hospital or clinic and
can't include diagnosis.
2. A 75-year-old client with a recent history of a cerebrovascular accident
(CVA) presents with right hemiparesis. The nurse tests the deep tendon re-
flexes on the right side and elicits a brisk 4+ response. Which
interpretation of this finding is accurate?
A. A normal reflex response.
,B. Absent or sluggish response consistent with a lower motor neuron lesion.
C. Flaccid paralysis.
D. Hyperactive response consistent with an upper motor neuron disorder.: -
Correct answer is D, brisk 4+ response is correlated with hyperactive
response.
3. The nurse examines a client's abdomen. Which finding indicates an
abnor- mal response when palpating the spleen?
A. Pain notes when palpating McBurney's point.
B. Tip of spleen palpable when client is asked to forcefully exhale.
C. Rebound tenderness with compression over right upper quadrant. D.
Firm mass palpated at bottom of left rib cage.: Correct answer is D.
McBurney's point is related to appendicitis and not spleen.
4. In auscultating for the presence of a carotid artery bruit, the nurse places
the bell of the stethoscope at which location?: *under mandible towards
lymph nodes. transverse to trachea
5. A male client arrives at the clinic for follow-up health assessment after
recent antibiotic treatment for pneumonia without hospitalization. Which
tech- nique should the nurse implement to assess for adventitious lung
sounds?
,A. Use the bell of the stethoscope to listen to the lung fields over lower lobes
B. Have the client lay flat while listening to the anterior surface of the chest.
C. Press the stethoscope's diaphragm firmly on the skin over each lung field
D. Shave all chest hair that may distort sounds heard through the
diaphragm.-
: Correct answer is C. The nurse should listen to all lungs fields during
assessment and move from side to side during auscultation.
, 6. A client with streptococcus pharyngitis reports high fever, difficulty
swal- lowing and a muffled voice. Which complication should the nurse
suspect?
A. Foreign body obstruction.
B. Laryngeal polyps.
C. Peritonsillar abscess.
D. Nasal polyps: Correct answer is C. Since infections are associated with
abscess- es and pus.
7. The nurse is obtaining a health history for a client prior to a scheduled
cholecystectomy. While interviewing the client, which assessment
technique should the nurse use when asking about the client's use of illegal
drugs and alcohol?
A. Obtain a drug using screen to verify legitimacy of client's stated history.
B. Allow the client to decline answering social questions.
C. Ask specifically about alcohol, marijuana, cocaine, her
D. Use the term illegal or illicit to describe street drug.: Correct answer is
C. When interviewing the patient, questions should be clear and
specific.
8. The nurse applies pressure over an area of the lower abdomen where
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