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A client has dysfunction of the cochlear division of the vestibulocochlear nerve (cranial nerve VIII). The nurse should determine that the client is adequately adapting to this problem if he or she states a plan to obtain which item?

The nurse is working with a group of clients. Which clients are at risk for developing skin cancer? Which assessment findings are at risk for skin cancer (Select all 3 that apply)?

Ms. Hartzel is a 33-year-old patient who presents to the office with complaints of enlarged lymph nodes in her neck. During your examination, which part of the hand is used to assess lymph node size?

When completing a neurological assessment, which cranial nerves are tested within the mouth?

A nurse is preparing a program on osteoporosis for a local women's group. Which of the findings does the nurse recognize as a modifiable risk factor?

A nurse is assessing a client who is 6 months pregnant.Which findings should the nurse expect? (Select all four options that apply.)

A nurse is precepting a nursing student. The nurse explains to the nursing student how you would perform the graphesthesia test on a client. What is the correct way to perform this test?

A patient with a history of duodenal ulcer is admitted to the emergency department with reports of pain. The nurse should assess for this pain by palpating in which abdominal quadrant?

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which adventitious breath sounds?

The nurse in the clinic is preparing to perform a physical assessment on a client who arrived for a routine check-up. Before beginning the assessment, which four activities should the nurse carry out? (Select all that apply.)

 A nurse in an emergency department (ED) is admitting a client.

Vital Signs 

1000:

Temperature 38.6° C (101.5° F)

Heart rate 106/min

Respiratory rate 26/min

Blood pressure 110/54 mm Hg

Oxygen saturation 94% on room air

Nurses Notes 

1000:

Client presents to ED with report of shortness of breath for 3 days, with headache, chills, fever, sore throat, and cough.

Oriented to person, place, and time. Appears lethargic, difficulty answering questioning due to shortness of breath. Follows simple commands, moves all extremities with weakness.

Client's face is flushed, sinus tachycardia, rate of 106/min, $152 heart sounds heard on auscultation. Pulses palpable.

Breath sounds with crackles to right lower lobe, tachypnea, rate of 26/min. Tactile fremitus and decreased lung expansion noted upon assessment. Frequent productive cough with thick yellow sputum. Client denies hemoptysis. Unable to lie down, states they are "more comfortable sitting up."

Bowel sounds active x 4 quadrants. Denies diarrhea, last bowel movement yesterday. States "no appetite since I've been sick."

Reports decreased urination in the past day.

Client reports they have not had a pneumococcal vaccine. States, "1 Just hate needles."

Diagnostic Results

1030:

Chest x-ray.

Areas of increased density and white infiltrates to lower right lobe.

Select 3 objective findings in the client's medical record that may be indicative of pneumonia.