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NUR 216 Exam 3 With Actual Questions and answers | With complete solution | Updated 2024/25
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NUR 216 Exam 3 With Actual Questions and answers | With complete solution | Updated 2024/25
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NUR 216 Exam 3 With Actual Questionsand answers | With complete solution |
Updated 2024/25
A nurse is assessing a client's cranial nerves. Which of the following client actions is an
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indication that cranial nerve 1 is intact?
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A. The client can stick their tongue out
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B. The client can smile symmetrically
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C. The client can hear whispered words
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D. The client can identify a minty scent - D. The client can identify a minty scent
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Rationale- Cranial nerve 1, the olfactory nerve, controls the sense of smell. To test this
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nerve's function, the nurse should ask the client to identify a nonirritating aroma, such as
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mint or coffee
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A nurse is performing a respiratory assessment on a client. The nurse auscultates a wet,
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popping sound upon inspiration of the clients breathing. The nurse should identify this
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observation as which of the following findings?
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A. Crackles ii
B. Stridor ii
C. Wheezes ii
D. Friction Rub - A. Crackles
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Rationale- crackles, sometimes called rales, are wet, popping sounds created by air
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moving through liquid or by collapsed alveoli snapping open on inspiration. They are most
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common at the end of inspiration of breathing.
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A nurse is performing a cardiovascular assessment on a client which of the following
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findings should the nurse expect?
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A. A continuous sensation of vibration felt over the second and third left intercostal spaces
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B. A high-pitched, scraping sound heard in the third intercostal space to the left of the
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sternum
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C. A brief thump felt near the fourth or fifth intercostal space near the left mid clavicular line
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D. A whooshing or swishing sound over the second intercostal space along the left arsenal
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border - C. A brief thump felt near the fourth or fifth intercostal space near the left mid
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clavicular line
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Rationale- This is where you would inspect and palpate for the point of maximal impulse.
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Also called an apical pulse station, it occurs as the Apex of the heart bumps against the
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chest wall with each heartbeat. The apical impulse is not always visible but can be felt as a
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brief thump. This is an expected finding and should be performed when you are preparing
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to auscultate the apical pulse.
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, The nurse is preparing to perform a comprehensive physical assessment on a client.
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Which of the following actions should the nurse plan to take first?
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A. Document accurate data
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B. Develop a plan of care
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C. Validate previous data
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D. Evaluate outcomes of care - B. Develop a plan of care
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Rationale- The first action the nurse should take using the nursing process is to assess the
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client and develop a plan of care. The nursing process follow the steps of assessment,
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analysis, planning, implementation, and evaluation.
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A nurse is palpating a tender area of a clients abdomen. The nurse slowly applies
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pressure over the area with their fingertips, then quickly releases it. The client reports
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increased pain on the release of pressure. Which of the findings should the nurse
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document?
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A. Borborygmi
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B. Rebound Tenderness
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C. Tympany
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D. Abdominal Guarding - B. Rebound Tenderness
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Rationale- The nurse should document that the client is experiencing rebound tenderness,
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which is an increase in pain when deep palpation over a tender area is released. Rebound
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tenderness is in the right lower quadrant at McBurney's point (one-third the distance from
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the anterior iliac crest to the umbilicus) is an indication of acute appendicitis.
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A nurse is performing a physical examination of the spine for an older adult client. The
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nurse should identify that which of the following findings is common with aging?
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A. Lordosis
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B. Kyphosis
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C. Ankylosis
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D. Scoliosis - B. Kyphosis
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Rationale- kyphosis, a pronounced "hunchback" curvature of the spine, is an abnormal
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angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. It is
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most common in older adults and tends to increase with aging. This pronounced convexity
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of the thoracic spine is also common in older clients who have had vertebral fractures.
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Disorders in which parts of the ear usually result in earaches?
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A. Inner and middle ear
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B. Inner and external ear
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C. Middle and external ear
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D. Travis and eardrum - B. Inner and external ear
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Eye discharge is usually associated with:
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A. Hypertension (HTN)
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B. Conjunctivitis
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C. Otitis externa
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D. Meibomianitis - B. Conjunctivitis
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, Which type of hearing loss results from disorders of the inner ear or of the eighth cranial
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nerve?
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A. Conductive hearing loss
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B. Sensorineural hearing loss
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C. Mixed hearing loss
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D. Functional hearing loss - B. Sensorineural hearing loss
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Which term is used to test for corneal sensitivity?
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A. Cotton-tipped applicator
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B. Gauze pad
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C. Tissue
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D. Wisp of cotton - D. Wisp of cotton
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What should you palpate before inserting the otoscope into the patient's ear?
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A. Tragus
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B. Lymph nodes
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C. Helixii
D. Earlobe - A. Tragus
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Which symptom commonly accompanies throat pain?
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A. Eye pain
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B. Ear pain
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C. Headache
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D. Nasal congestion - B. Ear pain
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If your patient presents with severe epistaxis, what is important for you to check quickly?
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A. Their history
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B. Their height
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C. Their weight
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D. Their vital signs - D. Their vital signs
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What is scoliosis? - A deformity caused by a lateral curvature of the thoracic spine. It is
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typically detected in adolescence. Mild scoliosis usually has little consequence, but more
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severe curvature can restrict lung function.
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What is ankylosis? - Immobility and consolidation of a joint due to disease, injury, or
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surgical procedures. The stiff joint is often a result of a congenital condition or scarring.
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What is kyphosis? - a pronounced "hunchback" curvature of the spine, is an abnormal
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angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. It is
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most common in older adults and tends to increase with aging. This pronounced convexity
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of the thoracic spine is also common in older clients who have had vertebral fractures.
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A nurse is performing an abdominal assessment on a client. Over which of the following
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areas of the client's abdomen should the nurse attempt to auscultate active bowel sounds
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first?
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