Question 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 com...
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.
A 75-year-old client with a recent history of a cerebrovascular accident (CVA) presents
with right hemiparesis. The nurse tests the deep tendon reflexes 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.
Med Surg
, Med Surg
The nurse examines a client's abdomen. Which finding indicates an abnormal 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.
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
A male client arrives at the clinic for follow-up health assessment after recent antibiotic
treatment for pneumonia without hospitalization. Which technique 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.
A client with streptococcus pharyngitis reports high fever, difficulty swallowing and a muffled
voice. Which complication should the nurse suspect?
A. Foreign body obstruction.
B. Laryngeal polyps.
C. Peritonsillar abscess.
Med Surg
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