Exam (elaborations) NURS 190 PA FINAL Exam

1. The nurse is caring for a client who was admitted to the medical unit. The nurse notes in the physical exam done by the physician that the client has a positive Romberg. When meeting elimination needs for this client, the nurse would perform which of the following interventions? A. obtain an order for a catheter B. limit fluid intake C. obtain a bedside commode D. allow the client to walk independently 2. The nurse observes drainage from a client’s ears after a head injury, and suspects a cerebral spinal fluid (CSF) leak. The nurse would document which of the following descriptions of the drainage? A. blood-tinged without sediment B. pink without sediment C. yellow without sediment D. clear, colorless 3. The nurse is performing a neurological assessment on a client and needs to use seterognosis. Which of the following instructions would the nurse provide for the client? A. “Identify the number being traced in your hand with your eyes closed.” B. “Identify the object in your hand with your eyes closed.” C. “Tell me if you feel one or two objects touching you with your eyes closed.” D. “Open and close your hand each time I tell you to.” 4. The nurse notes fanning of the toes when the sole of the foot is stimulated during assessment of the plantar reflex. The nurse would correctly chart which of the following? A. Brudzinski sign B. nuchal rigidity C. hyperreflexia D. Babinski response 5. The nurse is assessing a female client and notes facial hirsutism. The client asks the nurse why this has happened to her. The nurse would correctly respond with which of the following statements? A. “Your diet is not nutritionally balanced.” B. "You need to take vitamins.” C. “There is not a known cause for this condition.” D. “You may have some hormone imbalances.” 6. The nurse is assessing the patellar reflex on a client and obtains no reflective activity. The client is alert and oriented. The nurse should do which of the following in this situation? A. look at the medication records for central nervous system depressants B. retest the reflex after having the client use distraction during the exam C. notify the physician immediately D. document the findings as normal 7. The nurse is caring for a client that insists on having their food very hot and very cold at each meal. The nurse correctly recognize this as a health belief in which of the following cultural groups? A. Chinese Americans B. Native Americans C. Cuban Americans D. Jewish Americans 8. The nurse is caring for a client who is a long-time smoker and notes clubbing of the fingers. The nurse utilized which of the following techniques to validate this assessment? A. place two of the same fingers from each hand together B. place the hands out straight with the palm sides down C. place two index fingers together tip to tip D. place two thumbs touching side by side 9. A 24-year-old client reports difficulty with near vision during an interview with the nurse. The nurse realizes the finding is consistent with: A. hyperopia B. presbyopia C. astigmatism D. aging 10. The nurse is performing a neurological assessment on a client experiencing anosmia. The nurse would suspect cranial nerve involvement in which of the following? A. trigeminal, cranial nerve V B. trochlear, cranial nerve IV C. olfactory, cranial nerve I D. oculomotor, cranial nerve III 11. The nurse is assessing the visual fields of a 38-year-old female who reports recent changes in visual abilities. Which of the following statements would be appropriate for the nurse to use with this client? A. “These changes are probably related to your age.” B. "It is possible you have taken narcotics recently?” C. “The changes could be related to increased pressure within your eye.” D. “These changes require a prescription for glasses.” 12. The nusse assesses a client and finds that a grating sound is present when a joint is bent and straightened. The nurse would correctly document this finding as which of the following? A. joint noise B. grating C. crepitation D. grinding 13. The nurse is planning care for a client with hypothyroidism. Which of the folliwng would be the priority nursing diagnosis for this client? A. altered nutrition, less than body requirements B. risk for constipation related to metabolic imbalance C. risk for injury related to confusion and lethargy D. activity intolerance related to fatigue 14. The nurse is assessing the pulses of a client and palpates the area behind the client’s knee. The nurse would choose which of the following names to document this pulse? A. radial B. brachial C. popliteal D. dorsalis pedis 15. The nurse is assessing cranial nerve XI (spinal accessory). Which of the following statements would the nurse use to the client? A. “Smell these items and identify what they are.” B. “Shrug your shoulders and turn your head against my head.” C. “Stick out your tongue and move it from side to side.” D. “Taste these foods and decide which is sweet and which is sour.”