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Heart sounds are loudest for S1 at the ______ and S2 at the _.

To assess a client’s pupillary reaction to accommodation, which action should the nurse take?

The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While interviewing the client, which assessment technique should the nurse use when asking about the client’s use of illegal drugs and alcohol?

When systematically auscultating a client’s anterior breath sounds, the nurse should begin by placing the stethoscope over which location?

A nurse is caring for a 57-year-old female client in the emergency department who presents with joint pain and stiffness in her hands. The client has a history of hypertension and type 2 diabetes.

Exhibits

Nurses’ Notes (0700hrs):

• The client reports experiencing joint pain and stiffness in her hands for the past few months.
• The pain is described as aching and is worse in the morning, lasting for about an hour before improving.
• The client mentions difficulty in performing daily tasks such as buttoning clothes and opening jars.
• There is visible swelling in the small joints of both hands.
• The client denies any recent trauma or injury to the hands.
• The client reports feeling fatigued and has had occasional low-grade fevers.
• The client is currently taking medication for hypertension and diabetes.

Medical History:

• Hypertension for 10 years, managed with medication.
• Type 2 diabetes for 5 years, managed with oral hypoglycemic agents.
• No known allergies.
• Family history of autoimmune diseases.

Vital Signs (0700hrs):

• Temperature: 37.8°C (100°F)
• Blood Pressure: 140/90 mmHg
• Heart Rate: 82 bpm
• Respiratory Rate: 18 breaths per minute
• Oxygen Saturation: 98% on room air

Physical Examination Results (0700hrs):

• Swelling and tenderness in the metacarpophalangeal and proximal interphalangeal joints of both hands.
• Limited range of motion in the affected joints.
• No deformities observed.
• Skin over the joints appears slightly erythematous.
• No signs of infection or injury.

Diagnostic Results (0700hrs):

• Complete Blood Count (CBC): WBC 8,000/mm³ (4,000-11,000/mm³), Hemoglobin 13.5 g/dL (12-16 g/dL), Platelets 250,000/mm³ (150,000-450,000/mm³)
• Erythrocyte Sedimentation Rate (ESR): 40 mm/hr (0-20 mm/hr)
• C-Reactive Protein (CRP): 15 mg/L (0-10 mg/L)
• Rheumatoid Factor (RF): Positive

A nurse is analyzing the assessment findings. Which findings are indicative of rheumatoid arthritis? Select all that apply.

Which skill should the nurse have an older client demonstrate to evaluate the ability to perform activities of daily living (ADL)?

The nurse observes an older adult client walking aimlessly in the hallway and staring straight ahead with a blank expression. How should the nurse enter documentation of this finding in the client’s electronic medical record (EMR)?

In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

A client is being evaluated for environmental allergies. While examining the client’s nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis?

While interviewing a newly admitted older female client, the nurse observes that the client ignores Questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?

During assessment of a client’s abdomen, the nurse observes that the client’s umbilicus is depressed and below the surface of the abdomen. Which action should the nurse take in response to this observation?