304 Exam 2 Review

When assessing range of motion, what would be the most important action for the nurse to take?

• Model the movements

• Initiate passive range of motion

• Percuss each joint

• If pain occurs, continue the assessment

A client is being evaluated for carpal tunnel syndrome. How should the nurse perform Phalen’s test?

• Ask the client to flex their wrist against the nurse’s resistance

• Apply direct percussion to the median nerve at the wrist

• Touch thumb to each finger and to base of little finger

• Ask the client to hold their hands back-to-back with wrists flexed 90 degrees for 1 minute

During the nurse’s examination of the genitalia of a 70-year-old woman, a normal finding would be:

• Hypertrophy of the mons pubis.

• Increase in vaginal secretions.

• Thin and sparse pubic hair.

• Bladder prolapse.

A client with multiple bruises on her arms and face is seen in the emergency department accompanied by her partner. When asked about the injuries, the partner states, “She ran into a door.” Which of the following actions by the nurse is of highest priority?

• Take the client’s vital signs.

• Interview the client in private.

• Assess for additional bruising.

• Document the location of the bruises.

A 65-year-old woman tells you she “wets” herself a little when she sneezes or coughs. The next best response is:

• “This sounds like ‘stress incontinence’ and usually is due to some weakness in the pelvic muscles.”

• “This may be a sign of infection, so let’s test a urine sample for bacteria.”

• “This is called ‘urge incontinence’ and is usually due to an overactive bladder muscle.”

• “This is a sign of blood in the urine, and we will need to refer you to a specialist.”

A 25-year-old woman has some vaginal discharge and is worried she has a sexually transmitted infection (STI). What is your next best response?

• "Tell me more about the discharge: Color? Smell? Amount?"

• "Have you been having sex with a new partner?"

• "How about condoms? Do you use one every time you have sex?"

• "This is normal for some time within the menstrual cycle. Don’t worry."

All of the following can be included as "recognizing cues" when using clinical judgement except:

• Identify normal vs. Abnormal data

• Assess vital signs

• Administer a medication

• Recognize signs and symptoms

Which of the following assessments may indicate failure to rescue? Select all that apply.

• Respiration even and unlabored

• Capillary refill >4 seconds

• Increased Oxygen saturation

• Circumoral pallor

• Use of accessory muscles

A previously alert and oriented client is now unresponsive with shallow respirations. What is the nurse’s best action to prevent failure to rescue?

• Apply oxygen and continue to monitor

• Notify the unlicensed assisted personnel

• Obtain a blood pressure

• Call the rapid response team

All of the following are preventive measures to prevent venous thromboembolism (VTE) except:

• Administration of aspirin

• Bed rest

• Administration of heparin

• Use of sequential compression devices (SCD)