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.

decreased urine output

headache

respiratory assessment

Chest X-ray

Religion

Bowel sounds

perception of needles

Question Solution

Correct Answer : A,C,D

A. Decreased urine output: While not a direct sign of pneumonia, decreased urine output can be an objective finding indicative of dehydration, which often accompanies infections like pneumonia.

B. Headache: Although the client has a headache, it is a subjective symptom rather than an objective finding and is not a primary indicator of pneumonia.

C. Respiratory assessment: The respiratory assessment reveals shortness of breath, crackles in the right lower lobe, and tachypnea, which are commonly associated with pneumonia.

D. Chest X-ray: The chest X-ray shows areas of increased density and infiltrates in the right lower lobe, a hallmark finding that indicates pneumonia.

E. Religion: This does not relate to the clinical findings associated with pneumonia.

F. Bowel sounds: Normal bowel sounds are not indicative of pneumonia.

G. Perception of needles: This is irrelevant to the diagnosis of pneumonia.

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A. Oatmeal B. Apples C. Chocolate D. Nonfat milk

Correct Answer is C

Explanation

A. Oatmeal is generally considered a good food for individuals with GERD as it can help absorb stomach acid.

B. Apples are typically a safe fruit for GERD sufferers.

C. Chocolate can relax the lower esophageal sphincter and may worsen GERD symptoms, so it should be avoided.

D. Nonfat milk is usually tolerated better than full-fat dairy products and may help soothe the stomach.

A. Wheezes B. Crackles C. Rhonchi D. Stridor

Correct Answer is A

Explanation

A. Wheezes are continuous high-pitched sounds that occur during expiration (or sometimes inspiration) and are common in conditions like asthma due to narrowed airways.

B. Crackles are discontinuous sounds often described as popping or crackling and are not typically high-pitched.

C. Rhonchi are low-pitched, snoring-like sounds caused by the obstruction of larger airways and are not characterized as high-pitched.

D. Stridor is a high-pitched sound usually associated with upper airway obstruction and is not typically heard with asthma.

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Correct Answer is C

Explanation

Correct Answer is A

Explanation

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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?

Correct Answer is C

Explanation

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?

Correct Answer is A

Explanation

Which technique would the nurse use to perform scoliosis screening in a school-age child?

A nurse is assessing a client's circulatory system. Which pulse site should the nurse avoid assessing bilaterally at the same time?

The nurse is performing a neurological assessment on a client and is assessing the function of cranial nerves III, IV, and VI. Assessment of which aspect of function will yield the best information about these cranial nerves?

Which finding should the nurse expect when assessing a client who is cyanotic?

A nurse is performing a pain assessment for an alert client. Which measure should the nurse recognize as the most reliable indicator of pain?

When assessing the elbow, a nurse asks a client to hold the arm out and turn the palm down. When the client performs this maneuver, the nurse is testing what?

Providing a safe and comfortable environment, applying critical thinking, and identifying cues presented by the patient is

A nurse is completing a client's history and physical examination. Which information should the nurse consider subjective data?

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