Exam (elaborations)
NUR 216: Exam 4 Review With complete solution Updated 2024/25 RATED A+
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NUR 216: Exam 4 Review With complete solution Updated 2024/25 RATED A+
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NUR 216: Exam 4 Review With completesolution Updated 2024/25 RATED A+
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You are performing a comprehensive health assessment on a 68-year-old female.
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What normal assessment findings would the nurse expect to find in this elderly
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patient? ii
Skin tenting ii ii
Thin, fragile skin ii
Actinic keratosis ii
Solar lentigo ii ii ii ii
Nevi less than 0.6 cmii ii ii ii ii
The liver plays a key role
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· Producing bile
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· Producing clotting factors
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· Metabolizing carbohydrates, proteins, fats, and drugs
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· Detoxifying harmful chemicals
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The gallbladder and biliary system perform...
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· Transport bile to the intestine to aid in digestion
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· Concentrate bile
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· Collect and store bile ii ii ii ii ii ii
Characteristics of fecal occult blood (FOB) include...
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· It can originate from any part of the digestive tract.
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· It is not observed by the patient.
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· It may be a warning sign of colorectal cancer.
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You are doing an assessment on a patient who has diabetes and chronic kidney
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disease. What tests may the healthcare provider order to assess kidney function?
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· Creatinine
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· Glomerular filtration rate (GFR)
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· Blood urea nitrogen (BUN)
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You auscultate the abdomen. What will you auscultate for the presence of bruits?
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· Aorta ii ii ii ii ii ii ii ii ii ii ii ii ii ii
A patient reports that he has recently traveled outside the country and is feeling ill.
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Suspecting hepatitis, the nurse should ask about which of the following
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symptoms?
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· Fatigue
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· Nausea
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· Poor appetite
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· Abdominal pain ii ii ii ii ii ii ii ii ii ii ii ii ii
The nurse is auscultating bowel sounds. Which of the following steps are correct?
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· Auscultate in all four abdominal quadrants.
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· Assess intensity, pitch, and frequency of bowel sounds.
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When palpating the bladder, the nurse knows that which of the following is true?
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· The patient should void before the exam
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· A distended bladder will be palpable above the symphysis pubis
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· An empty bladder is not palpable.
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· Tenderness or pain during palpation may indicate bladder infection. ii ii ii ii ii ii ii ii ii ii
Patient education for colon cancer should include which of the following?
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· Maintaining a healthy weight
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· Routine colonoscopies begin at age 45
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The patient reports that he has not had a bowel movement in several days. You
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auscultate the abdomen for bowel sounds. What characteristics are you
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assessing?
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· Quality
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· Frequency
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· 5 minutes for absent bowel sounds
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A rise in levels of aspartate aminotransferase (AST) and alanine aminotransferase
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(ALT) can indicate? ii ii ii ii ii
Injury or damage to the liver. ii ii ii ii ii ii ii ii ii ii ii
You are assessing a patient who has chronic complaints of diarrhea alternating
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with periods of constipation. As a nurse, you know that the primary function of the
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large intestine is: ii ii
Reabsorption of water.
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A patient comes to the emergency room complaining that he has been vomiting for
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the past 24 hours with black vomitus/emesis. You know that black vomitus may
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indicate: ii ii ii ii ii
Blood acted on by gastric digestion.
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A patient reports that he has been severely vomiting for the last 24 hours. He states
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that the vomiting is very strong and he describes it as projectile. Projectile
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vomiting without nausea is a sign of: ii ii ii ii
Brain pathology or head trauma.
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The nurse assesses the patient's pain as a dull, gnawing, cramping, or burning pain
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that is poorly localized. The nurse suspects that the pain is:
Visceral. ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
You are inspecting the abdomen. Where will you stand to do a full inspection of the
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abdomen? ii ii ii ii ii ii ii ii ii ii ii
Stoop down at the patient's side and stand at the patient's feet.
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You are auscultating bowel sounds. How many clicks or gurgles per minute are
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considered normal bowel sounds?
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5 to 34. ii ii ii ii ii ii ii ii ii ii
You are auscultating arterial sounds in the abdomen. Turbulent, blowing sounds
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heard over a partially or totally obstructed artery are called:
Bruits. ii ii ii ii ii ii ii ii ii ii ii
A patient presents with complaints of feeling bloated. You percuss all four
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quadrants of the abdomen. The expected high-pitched, hollow-quality, drum-like
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sound that is heard over air-filled viscera is called:
Tympany. ii ii ii ii ii ii ii ii ii ii ii ii ii
A nurse should be able to mentally visualize the organs in the abdomen for
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abdominal mapping. In assessing the abdomen, the nurse knows organs in the
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midline are the: ii ii ii
Aorta, uterus, and bladder.
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Patients who have diarrhea, laxative use, gastroenteritis, or early intestinal
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obstruction will have: ii ii
Hyperactive bowel sounds. ii ii ii ii ii ii ii ii ii ii ii ii ii
Which of the following should be done when using light palpation to assess the
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abdomen? ii ii ii ii ii ii ii ii ii ii ii
Watch the patient's facial expression for signs of pain or abdominal guarding.
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The sequence of an abdominal assessment is different from other assessments so
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that peristalsis is not stimulated. Put the sequence for the abdominal assessment
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in order.
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1. Inspection
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2. Auscultation
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3. Indirect percussion
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4. Palpation ii ii ii ii ii ii ii ii ii ii ii ii
The patient has a history of alcoholism with liver disease. The most apparent
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clinical manifestation of liver failure is...
Jaundice ii ii ii ii ii ii ii ii ii ii ii ii
The patient is complaining of sharp lower right quadrant pain with nausea and
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vomiting that started 20 hours ago. She states that she is extremely uncomfortable
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and rates the pain a 10/10. You will perform an assessment for rebound tenderness
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at ____________________ point.
McBurney's
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A woman comes to the clinic because of spotting or bleeding in between her
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menstrual cycles. Which question is most important for the nurse to ask?
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"Does the spotting occur during or after sexual intercourse?"
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A woman with a history of dysmenorrhea comes to the clinic for a follow-up
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appointment. Which question indicates that the nurse understands the major
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symptoms associated with this condition? ii ii ii ii ii ii ii ii
"Have you missed any more work during your periods?"
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A woman comes to the clinic because of heavy menstrual bleeding each month.
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Which question is most important for the nurse to ask?
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"How many pads/tampons do you generally use in 24 hours?"
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A woman comes to the clinic because she has noticed nipple discharge from her
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left breast. Which information should the nurse communicate immediately to the
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healthcare provider? ii
Bloody discharge ii ii ii ii ii ii ii ii ii ii ii
When conducting a health history and physical examination of the breasts, which
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information is most significant? ii ii ii ii ii ii ii ii ii ii
Inspection reveals an area of dimpling or retraction around the nipple.
We have an expert-written solution to this problem!
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A 36-year-old female patient visits an outpatient clinic for a routine gynecological
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examination. When conducting a review of systems, which information would the
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nurse find as most significant? ii ii
Frequent abdominal bloating
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