Exam (elaborations)
NUR 216 Exam 3 With Actual Questions and answers | With complete solution | Updated 2024/25
- Course
- Institution
NUR 216 Exam 3 With Actual Questions and answers | With complete solution | Updated 2024/25
[Show more]
Content preview
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
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
indication that cranial nerve 1 is intact?
ii ii ii ii ii ii ii
A. The client can stick their tongue out
ii ii ii ii ii ii ii ii
B. The client can smile symmetrically
ii ii ii ii ii
C. The client can hear whispered words
ii ii ii ii ii ii
D. The client can identify a minty scent - D. The client can identify a minty scent
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
Rationale- Cranial nerve 1, the olfactory nerve, controls the sense of smell. To test this
ii ii ii ii ii ii ii ii ii ii ii ii ii ii
nerve's function, the nurse should ask the client to identify a nonirritating aroma, such as
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
mint or coffee
ii ii ii
A nurse is performing a respiratory assessment on a client. The nurse auscultates a wet,
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
popping sound upon inspiration of the clients breathing. The nurse should identify this
ii ii ii ii ii ii ii ii ii ii ii ii ii
observation as which of the following findings?
ii ii ii ii ii ii ii
A. Crackles ii
B. Stridor ii
C. Wheezes ii
D. Friction Rub - A. Crackles
ii ii ii ii ii ii ii
Rationale- crackles, sometimes called rales, are wet, popping sounds created by air
ii ii ii ii ii ii ii ii ii ii ii
moving through liquid or by collapsed alveoli snapping open on inspiration. They are most
ii ii ii ii ii ii ii ii ii ii ii ii ii ii
common at the end of inspiration of breathing.
ii ii ii ii ii ii ii ii
A nurse is performing a cardiovascular assessment on a client which of the following
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
findings should the nurse expect?
ii ii ii ii ii
A. A continuous sensation of vibration felt over the second and third left intercostal spaces
ii ii ii ii ii ii ii ii ii ii ii ii ii ii
B. A high-pitched, scraping sound heard in the third intercostal space to the left of the
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
sternum
ii
C. A brief thump felt near the fourth or fifth intercostal space near the left mid clavicular line
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
D. A whooshing or swishing sound over the second intercostal space along the left arsenal
ii ii ii ii ii ii ii ii ii ii ii ii ii ii
border - C. A brief thump felt near the fourth or fifth intercostal space near the left mid
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
clavicular line
ii ii
Rationale- This is where you would inspect and palpate for the point of maximal impulse.
ii ii ii ii ii ii ii ii ii ii ii ii ii ii
Also called an apical pulse station, it occurs as the Apex of the heart bumps against the
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
chest wall with each heartbeat. The apical impulse is not always visible but can be felt as a
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
brief thump. This is an expected finding and should be performed when you are preparing
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
to auscultate the apical pulse.
ii ii ii ii ii
, The nurse is preparing to perform a comprehensive physical assessment on a client.
ii ii ii ii ii ii ii ii ii ii ii ii ii ii
Which of the following actions should the nurse plan to take first?
ii ii ii ii ii ii ii ii ii ii ii ii
A. Document accurate data
ii ii ii
B. Develop a plan of care
ii ii ii ii ii
C. Validate previous data
ii ii ii
D. Evaluate outcomes of care - B. Develop a plan of care
ii ii ii ii ii ii ii ii ii ii ii ii ii
Rationale- The first action the nurse should take using the nursing process is to assess the
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
client and develop a plan of care. The nursing process follow the steps of assessment,
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
analysis, planning, implementation, and evaluation.
ii ii ii ii ii
A nurse is palpating a tender area of a clients abdomen. The nurse slowly applies
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
pressure over the area with their fingertips, then quickly releases it. The client reports
ii ii ii ii ii ii ii ii ii ii ii ii ii ii
increased pain on the release of pressure. Which of the findings should the nurse
ii ii ii ii ii ii ii ii ii ii ii ii ii ii
document?
ii
A. Borborygmi
ii
B. Rebound Tenderness
ii ii
C. Tympany
ii ii
D. Abdominal Guarding - B. Rebound Tenderness
ii ii ii ii ii ii ii ii
Rationale- The nurse should document that the client is experiencing rebound tenderness,
ii ii ii ii ii ii ii ii ii ii ii
which is an increase in pain when deep palpation over a tender area is released. Rebound
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
tenderness is in the right lower quadrant at McBurney's point (one-third the distance from
ii ii ii ii ii ii ii ii ii ii ii ii ii ii
the anterior iliac crest to the umbilicus) is an indication of acute appendicitis.
ii ii ii ii ii ii ii ii ii ii ii ii ii
A nurse is performing a physical examination of the spine for an older adult client. The
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
nurse should identify that which of the following findings is common with aging?
ii ii ii ii ii ii ii ii ii ii ii ii ii
A. Lordosis
ii
B. Kyphosis
ii ii
C. Ankylosis
ii ii
D. Scoliosis - B. Kyphosis
ii ii ii ii ii ii ii
Rationale- kyphosis, a pronounced "hunchback" curvature of the spine, is an abnormal
ii ii ii ii ii ii ii ii ii ii ii
angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. It is
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
most common in older adults and tends to increase with aging. This pronounced convexity
ii ii ii ii ii ii ii ii ii ii ii ii ii ii
of the thoracic spine is also common in older clients who have had vertebral fractures.
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
Disorders in which parts of the ear usually result in earaches?
ii ii ii ii ii ii ii ii ii ii ii ii
A. Inner and middle ear
ii ii ii ii
B. Inner and external ear
ii ii ii ii
C. Middle and external ear
ii ii ii ii
D. Travis and eardrum - B. Inner and external ear
ii ii ii ii ii ii ii ii ii ii ii
Eye discharge is usually associated with:
ii ii ii ii ii ii ii
A. Hypertension (HTN)
ii ii
B. Conjunctivitis
ii ii
C. Otitis externa
ii ii ii
D. Meibomianitis - B. Conjunctivitis
ii ii ii ii ii ii
, Which type of hearing loss results from disorders of the inner ear or of the eighth cranial
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
nerve?
ii
A. Conductive hearing loss
ii ii ii
B. Sensorineural hearing loss
ii ii ii
C. Mixed hearing loss
ii ii ii
D. Functional hearing loss - B. Sensorineural hearing loss
ii ii ii ii ii ii ii ii ii ii
Which term is used to test for corneal sensitivity?
ii ii ii ii ii ii ii ii ii ii
A. Cotton-tipped applicator
ii ii
B. Gauze pad
ii ii
C. Tissue
ii
D. Wisp of cotton - D. Wisp of cotton
ii ii ii ii ii ii ii ii ii ii
What should you palpate before inserting the otoscope into the patient's ear?
ii ii ii ii ii ii ii ii ii ii ii ii ii
A. Tragus
ii ii
B. Lymph nodes
ii ii
C. Helixii
D. Earlobe - A. Tragus
ii ii ii ii ii ii
Which symptom commonly accompanies throat pain?
ii ii ii ii ii ii ii
A. Eye pain
ii ii
B. Ear pain
ii ii
C. Headache
ii
D. Nasal congestion - B. Ear pain
ii ii ii ii ii ii ii ii
If your patient presents with severe epistaxis, what is important for you to check quickly?
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
A. Their history
ii ii
B. Their height
ii ii
C. Their weight
ii ii
D. Their vital signs - D. Their vital signs
ii ii ii ii ii ii ii ii ii ii
What is scoliosis? - A deformity caused by a lateral curvature of the thoracic spine. It is
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
typically detected in adolescence. Mild scoliosis usually has little consequence, but more
ii ii ii ii ii ii ii ii ii ii ii ii
severe curvature can restrict lung function.
ii ii ii ii ii ii
What is ankylosis? - Immobility and consolidation of a joint due to disease, injury, or
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
surgical procedures. The stiff joint is often a result of a congenital condition or scarring.
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
What is kyphosis? - a pronounced "hunchback" curvature of the spine, is an abnormal
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. It is
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
most common in older adults and tends to increase with aging. This pronounced convexity
ii ii ii ii ii ii ii ii ii ii ii ii ii ii
of the thoracic spine is also common in older clients who have had vertebral fractures.
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
A nurse is performing an abdominal assessment on a client. Over which of the following
ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii ii
areas of the client's abdomen should the nurse attempt to auscultate active bowel sounds
ii ii ii ii ii ii ii ii ii ii ii ii ii ii
first?
ii
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller STUVATE. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $11.99. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
81531 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now