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A+\Western Governors University \WGU D 440
The nurse is performing a routine physical examination on an adult client.
When gather a health history, which question is included in the CAGE
questionnaire?
A. When did you have your last alcoholic drink?
B. How does alcohol usually affect you?
C. What is your favorite alcoholic drink?
D. Have you ever felt guilty about your drinking?
D. Have you ever felt guilty about your drinking?
A client has just returned from the recovery room and asks to get out of
bed to go to the bathroom. The nurse decides to obtain orthostatic vital
signs first. How will the nurse position the client to begin this
procedure?
A. Lying
B. Sitting
C. Leaning
D. Standing
A. Lying
,The nurse is assessing a client for a hip flexion contracture. Which finding
indicates a negative Thomas test when the client's right knee is brought
toward the chest?
A. The left leg internally rotates.
B. The left leg rises off the table.
C. The left leg remains on the table.
D. The left leg externally rotates.
C. The left leg remains on the table.
An adult client is in the clinic for a regular physical examination. The nurse is
assessing the client's hydration status by pinching then releasing the
client's skin. Which finding is indicative of good hydration status?
A. The skin remains tented.
B. The skin appears blanched and returns to pink.
C. The skin slowly falls back into place.
D. The skin immediately returns to normal position.
D. The skin immediately returns to normal position.
The nurse is performing a thoracic assessment on a client with chronic
asthma and hyperinflation of the lungs. Which finding should be
expected for this client?
A. Kyphosis
B. Barrel chest
C. Pectus Excavatum
D. Pectus Carinatum
B. Barrel chest
, The nurse performs a series of cranial nerve tests on a client with a head
injury. Which test should the nurse use to assess damage to the first
cranial nerve?
A. Ask the client to count down from 100 by 7s for as long as possible.
B. Occlude one nostril and have the client identify various odors.
C. Have the client follow the tip of a moving penlight with the eyes.
D. Tell the client to walk heel to toe in a straight line for nine steps
B. Occlude one nostril and have the client identify various odors.
Which tool should the nurse use when assessing the neurological status of
a client with traumatic brain injury?
A. Glasgow Coma Scale
B. Braden Scale
C. Numerical pain scale
D. Cranial nerve examination
A. Glasgow Coma Scale
A client with dark skin is reporting a painful and itching area on the lower
left leg. What should the nurse look for when assessing this client's skin for
inflammation?
A. Change in consistency
B. Change in turgor
C. Redness
D. Pallor
A. Change in consistency