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NUR 210 final exam with complete solutions 2024_2025.
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NUR 210 final exam with complete solutions 2024_2025.
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NUR 210 final exam with completesolutions 2024/2025
infection - ANSWER-While assessing a client's abdomen, the nurse observes
involuntary reflex guarding on expiration. The nurse would interpret this as most
likely indicating what complication?
An increase in the pitch - ANSWER-Which change in auscultation of bowel
sounds should the nurse recognize as most diagnostic of an intestinal
obstruction?
Ask the client to breathe slowly and deeply - ANSWER-The nurse is performing
light palpation of the client's abdomen. How can the nurse best prevent voluntary
guarding during this phase of assessment?
ureteral stone - ANSWER-Linda is a 29-year-old who had excruciating pain that
started under her lower ribs on the right side. The pain eventually moved to her
lateral abdomen and then into her right lower quadrant. Which is most likely
given this presentation?
"I should avoid lifting heavy objects." - ANSWER-The nurse provides teaching to
a client with gastroesophageal reflux disease (GERD). Which client statement
indicates that teaching has been effective?
Renal calculi
Kidney infection
Hydronephrosis - ANSWER-A client expresses pain when the left costovertebral
angle is palpated. What should the nurse suspect is occurring with this client?
Select all that apply.
,Cullen's sign - ANSWER-A nurse suspects intra-abdominal bleeding in a client
who was recently involved in a motor vehicle accident. Which finding would most
likely lead the nurse to this suspicion?
absent - ANSWER-A young adult male who comes to the emergency department
complaining of abdominal pain for the past 3 days is suspected of having a
ruptured appendix. What bowel sound would the nurse expect to assess in this
client?
Question the order as a barium enema is contraindicated in acute appendicitis -
ANSWER-The client with a acute appendicitis has been ordered a barium enema.
What should the nurse do first?
Ovarian tumor
Impacted colon
Uterine enlargement
Full bladder - ANSWER-A nurse observes the abdomen of a client and notices it
to be distended below the umbilicus. The nurse recognizes that this can be
caused by which of these conditions? Select all that apply.
Esophageal varices - ANSWER-A 46-year-old former salesman presents to the ER
complaining of black stools for the past few weeks. His past medical history is
significant for cirrhosis. He has gained weight recently, especially around his
abdomen. He has smoked two packs of cigarettes a day for 30 years and has
drunk approximately 10 alcoholic beverages a day for 25 years. He has used IV
heroin and smoked crack in the past. He denies any recent use. He is currently
unemployed and has never been married. Examination shows a man appearing
older than his stated age. His skin has a yellowish tint and he is thin with a
prominent abdomen. Multiple "spider angiomas" are at the base of his neck.
Otherwise his heart and lung examinations are normal. On inspection he has
dilated veins around his umbilicus. Increased bowel sounds are heard during
auscultation. Palpation reveals diffuse tenderness that is more severe in the
epigastric area. His liver is small and hard to palpation and he has a positive fluid
wave. He is positive for occult blood on his rectal examination. What cause of
black stools most likely describes his symptoms and signs?
Gastroesophageal reflux - ANSWER-A client complains of abdominal pain that is
worsened when he lies on his back. The nurse should suspect which of the
following as the underlying cause?
,Ascites - ANSWER-The nurse has the client participate in the assessment
technique shown. For which health problem is the nurse assessing in this client?
Right side-lying - ANSWER-A nurse is preparing to palpate a client's spleen.
Which position should the nurse use to best facilitate palpation?
Acute pancreatitis - ANSWER-The client has epigastric pain that is poorly
localized and radiates to the back. What would be an important diagnosis to
assess for?
Stop the palpation and notify the health care provider - ANSWER-A nurse
performs light palpation of the abdomen and feels a prominent, non-tender,
pulsating mass above the umbilicus that measures approximately six (6)
centimeters. What is an appropriate action by the nurse?
Murphy's sign - ANSWER-During the abdominal examination, a nurse presses her
fingers at the client's right costal margin and tells the client to inhale. At this
point, the client holds his breath as a result of experiencing a sharp pain where
the nurse is pressing. This test is positive for which sign?
Bowel sounds normal - ANSWER-When conducting the physical examination of a
client's abdomen, the nurse auscultates 20 clicks and gurgles over 1 minute.
Which of the following statements would accurately describe this finding?
Gastric ulcer - ANSWER-A client complains of epigastric pain and tarry stools.
The nurse should suspect which of the following as the underlying cause?
Irritable bowel syndrome - ANSWER-Monique is a 33-year-old administrative
assistant who has had intermittent lower abdominal pain approximately one week
a month for the past year. It is not related to her menses. She notes relief with
defecation, and a change in form and frequency of her bowel movements with
these episodes. Which of the following is most likely?
Sickle cell anemia - ANSWER-A shift report indicates that an African American
client has symptoms of both jaundice and splenomegaly. Considering the client's
ethnicity and diagnoses, what is the likely medical diagnosis?
"Do you take painkillers like aspirin on a regular basis?" - ANSWER-A client
exhibits many of the most common signs and symptoms of peptic ulcer disease.
What interview question addresses the most plausible cause of the client's health
problem?
, Constipation related to decrease in fluid intake - ANSWER-A college student
presents to the health care clinic with reports of no bowel movement for 4 days,
bloating, and generalized abdominal discomfort. She states that she has not been
eating and drinking correctly and is stressed because she has a final exam in 2
days. A nurse assesses the abdomen and finds positive bowel sounds in all four
quadrants and tenderness in the left lower quadrant with a few small, round, firm
masses. The Rovsing's sign and Psoas sign are negative. What nursing diagnosis
can the nurse confirm for this client?
body mass index greater than 30
taking multiple medications
hiatal hernia - ANSWER-A nurse suspects that a client has gastroesophageal
reflux disease (GERD). Which risk factors must be present for the nurse to
confirm this? Select all that apply.
Right upper quadrant
Costovertebral angles
Epigastrium - ANSWER-The nurse is admitting a client who is in hypertensive
crisis. The doctor's notes indicate that bruits that are both systolic and diastolic
have been noted and renal artery stenosis is suspected as the cause of the
hypertension. Where would the nurse auscultate the client's abdomen to hear
these bruits? (Select all that apply.)
3 - ANSWER-A client is able to actively move the right arm against gravity. How
should the nurse document this finding using the muscle strength grading scale?
Flexion
Supination
Extension
Pronation - ANSWER-A client is experiencing left elbow pain. When assessing
this joint, in which direction should the nurse move the extremity? Select all that
apply.
Ask the client to move the part against gravity. - ANSWER-When testing muscle
strength, a client has difficulty moving each extremity against resistance. Which
of the following would the nurse do next?
Hyperextension of 20 degrees - ANSWER-A nurse is testing the range of motion
of the thoracic and lumbar spine. Which of the following would the nurse
document as an abnormal finding?
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