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A nurse is assessing a client's cranial nerves. Which method should the nurse use to assess cranial nerve I?

 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.

A nurse is interpreting the ECG strip of a client who has bradycardia. Which cardiac components should the nurse identify as the role of the P wave?

The nurse is teaching a group of unlicensed assistive personnel about the stethoscope. Which statements about the stethoscope are appropriate for the nurse to include in the teaching session? (Select all that apply.)

A nurse has been assigned four patients, of which one of the patients has impaired immobility. Which complications should the nurse expect as a result of gout? (Select the four options that apply.)

A nurse is assessing a client's cranial nerves. Which method should the nurse use to assess cranial nerve I?

Which lung sounds are expected? (Select all that apply.)

A nurse is assessing a client with a history of heart failure who presents with severe edema in the lower extremities. The nurse would document the presence of +4 pitting edema after noting which finding?

The nurse reviews the arterial blood gas results of a client and notes the following:  

pH 7.45, [normal range: 7.35-7.45]  

Paco2 of 30 mm Hg (30 mmol/L), [normal range: 35-45]  

HCO3- of 20 mEq/L (20 mmol/L), [normal range: 22-26]  

Which condition would the nurse analyze these results to indicate?

A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods that should be avoided. Which food should the nurse encourage the client to avoid?

How should the nurse interpret the rhythm shown on the electrocardiogram strip shown in the diagram?