Solutions - Chapter 30 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

10TYK. For a client whose assessment of the musculoskeletal system is normal, which does the nurse check on the medical record? (Select all that apply.)
1.  ___Atrophied
2.  ___Contractured
3.  ___Crepitation
4.  ___Equal
5.  ___Firm
6.  ___Flaccid
7.  ___Hypertrophied
8  ___Spastic
9.  ___Symmetrical
10.  ___Tremor
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1CTC. In the hospital, it is unrealistic to expect to be able to spend an uninterrupted 30 to 60 minutes with a single client performing an admission assessment. Which three systems would have top priority for her initial assessment and why?
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1TYK. Which is a normal finding on auscultation of the lungs?
1.  Tympany over the right upper lobe
2.  Resonance over the left upper lobe
3.  Hyperresonance over the left lower lobe
4.  Dullness above the left 10th intercostal space
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2CTC. While gathering relevant history data, what should you do if the client answers with simple one-word answers or gestures?
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2TYK. The nurse positions the client sitting upright during palpation of which area?
1.  Abdomen
2.  Genitals
3.  Breast
4.  Head and neck
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3TYK. After auscultating the abdomen, the nurse should report which finding to the primary care provider?
1.  Bruit over the aorta
2.  Absence of bowel sounds for 60 seconds
3.  Continuous bowel sounds over the ileocecal valve
4.  A completely irregular pattern of bowel sounds
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4CTC. If the client is unable to provide a detailed recent history, what other sources of these data could you consider?
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4TYK. If unable to locate the client’s popliteal pulse during a routine examination, what should the nurse do next?
1.  Check for a pedal pulse.
2.  Check for a femoral pulse.
3.  Take the client’s blood pressure on that thigh.
4.  Ask another nurse to try to locate the pulse.
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5TYK. Which of the following is an expected finding during assessment of the older adult?
1.  Facial hair that becomes finer and softer
2.  Decreased peripheral, color, and night vision
3.  Increased sensitivity to odors
4.  An irregular respiratory rate and rhythm at rest
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6TYK. List five aspects of the skin that the nurse assesses during a routine examination.
1.
2.
3.
4.
5.
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7TYK. If the client reports loss of short-term memory, the nurse would assess this using which one of the following?
0  Have the client repeat a series of three numbers, increasing to eight if possible.
1  Have the client describe his or her childhood illnesses.
2  Ask the client to describe how he or she arrived at this location.
4, Ask the client to count backward from 100 subtracting seven each time.
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8TYK. Refer back to Figure 30-14. If the client can accurately read only the top three lines, what would be an appropriate nursing diagnosis?
1.   Deficient Knowledge
2.   Impaired Memory
3.   Ineffective Tissue Perfusion
4.   Risk for Injury
Reference Figure 30-14:
 
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9TYK. To palpate lymph nodes, the nurse uses which technique?
1. Use the flat of all four fingers in a vertical and then side-to-side motion.
2. Use the back of the hand and feel for temperature variation between the right and left sides.
2.  Use the pads of two fingers in a circular motion.
3.  Compress the nodes between the index fingers of both hands.
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