2024NURSNGNHESIMed-SurgExamQuestionsand
AnswersGradedA+latestupdate2024A+
Whichassessmentismostimportantforthenursetoperformonaclient
whoishospitalizedforGuillain-Barresyndromethatisrapidly
progressing?
•Respiratoryeffort.
•Unsteadygait.
•Intensityofpain.
•Abilitytoeat.
Guillain-Barresyndromecausesparalysisorweaknessthattypicallystarts
atthefeetandprogressesupwards.Astheconditionprogresses,thenurse
mustensurethattheclientisabletobreatheeffectively.
Heuther,UnderstandingPathophysiology,6thed.p.412
Amaleclientcomesintotheclinicwithahistoryofpeniledischarge
withpainful,burningurination.Whichactionshouldthenurse
implement?
•Collectacultureofthepeniledischarge.
•Palpatetheinguinallymphnodesgently. •Observeforscrotalswellingandredness.
•Expressthedischargetodeterminecolor. Peniledischargewithpainfulurinationiscommonlyassociatedwith
gonorrhea.Thenurseshouldcollectacultureofthepeniledischargeto
determinethecauseofthesesymptoms.Thecausemustbedeterminedor
confirmedthroughculturetoidentifytheorganismandensureeffective
treatment.
JarvisPhysicalExaminationandHealthAssessment,
6thedition3
Aclientwithhistoryofatrialfibrillationisadmittedtothetelemetryunit
withsudden
onsetofshortnessofbreath.Thenurseobservesanewirregularheart
rhythmandshouldperformwhichassessmentatthistime?
•Checkforapulsedeficit.
•Palpatetheapicalimpulse.
•Inspectjugularveinpulse.
•Examineforacarotidbruit.
Aclientwithapasthistoryofatrialfibrillationmayreturntothat
rhythm.Anysignsofatrialfibrillation,suchassuddenonsetshortness
ofbreath,requiresfurtherinvestigation.Thenurseshouldassessthis
clientforapulsedeficitbecausethisconditionoccurswithatrial
fibrillation. Jarvis.(2016);PhysicalExaminationandHealthAssessment,(Chap19)
7thed.,p.481
4.
Whichclientshouldbefurtherassessedforanectopicpregnancy?
•A24-year-oldwithshoulderandlowerabdominalquadrantpain.
•A33-year-oldwithintermittentlowerabdominalcramping.
•A20-year-oldwithfeverandrightlowerabdominalcolic.
•A40-year-oldwithjaundiceandrightlowerabdominalpain.
A24-year-oldwithsuddenonsetoflowerabdominalquadrantpain
shouldbeassessedforanectopicpregnancy.Thepaincanalsobe
referredtotheshoulderandmaybeassociatedwithvaginalbleeding.
HealthAssessmentforNursingPractice,Wilsonand
Giddens.p.2695.
Whichdietaryassessmentfindingismostimportantforthenurseto
addresswhen
caringforaclientwithdiabeticnephropathy?
•Drinksasixpackofbeereveryday.
•Enjoysahamburgeronceamonth.
•Eatsfortifiedbreakfastcerealdaily.
•Consumesbeansandriceeveryday.
AnswersGradedA+latestupdate2024A+
Whichassessmentismostimportantforthenursetoperformonaclient
whoishospitalizedforGuillain-Barresyndromethatisrapidly
progressing?
•Respiratoryeffort.
•Unsteadygait.
•Intensityofpain.
•Abilitytoeat.
Guillain-Barresyndromecausesparalysisorweaknessthattypicallystarts
atthefeetandprogressesupwards.Astheconditionprogresses,thenurse
mustensurethattheclientisabletobreatheeffectively.
Heuther,UnderstandingPathophysiology,6thed.p.412
Amaleclientcomesintotheclinicwithahistoryofpeniledischarge
withpainful,burningurination.Whichactionshouldthenurse
implement?
•Collectacultureofthepeniledischarge.
•Palpatetheinguinallymphnodesgently. •Observeforscrotalswellingandredness.
•Expressthedischargetodeterminecolor. Peniledischargewithpainfulurinationiscommonlyassociatedwith
gonorrhea.Thenurseshouldcollectacultureofthepeniledischargeto
determinethecauseofthesesymptoms.Thecausemustbedeterminedor
confirmedthroughculturetoidentifytheorganismandensureeffective
treatment.
JarvisPhysicalExaminationandHealthAssessment,
6thedition3
Aclientwithhistoryofatrialfibrillationisadmittedtothetelemetryunit
withsudden
onsetofshortnessofbreath.Thenurseobservesanewirregularheart
rhythmandshouldperformwhichassessmentatthistime?
•Checkforapulsedeficit.
•Palpatetheapicalimpulse.
•Inspectjugularveinpulse.
•Examineforacarotidbruit.
Aclientwithapasthistoryofatrialfibrillationmayreturntothat
rhythm.Anysignsofatrialfibrillation,suchassuddenonsetshortness
ofbreath,requiresfurtherinvestigation.Thenurseshouldassessthis
clientforapulsedeficitbecausethisconditionoccurswithatrial
fibrillation. Jarvis.(2016);PhysicalExaminationandHealthAssessment,(Chap19)
7thed.,p.481
4.
Whichclientshouldbefurtherassessedforanectopicpregnancy?
•A24-year-oldwithshoulderandlowerabdominalquadrantpain.
•A33-year-oldwithintermittentlowerabdominalcramping.
•A20-year-oldwithfeverandrightlowerabdominalcolic.
•A40-year-oldwithjaundiceandrightlowerabdominalpain.
A24-year-oldwithsuddenonsetoflowerabdominalquadrantpain
shouldbeassessedforanectopicpregnancy.Thepaincanalsobe
referredtotheshoulderandmaybeassociatedwithvaginalbleeding.
HealthAssessmentforNursingPractice,Wilsonand
Giddens.p.2695.
Whichdietaryassessmentfindingismostimportantforthenurseto
addresswhen
caringforaclientwithdiabeticnephropathy?
•Drinksasixpackofbeereveryday.
•Enjoysahamburgeronceamonth.
•Eatsfortifiedbreakfastcerealdaily.
•Consumesbeansandriceeveryday.
