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. Carotid B. Radial C. Brachial D. Femoral

Correct Answer is A

Explanation

A. The carotid pulse should not be assessed bilaterally at the same time, as simultaneous palpation can lead to a decrease in heart rate or cause syncope due to stimulation of the carotid sinus.

B. The radial pulse can be assessed bilaterally without risk.

C. The brachial pulse can also be assessed bilaterally without concern.

D. The femoral pulse is typically assessed one side at a time, but there is no risk in palpating both femoral arteries simultaneously as there is with the carotid.

A. Checking pupillary response to light B. Observe for facial symmetry C. Testing for sense of smell D. Elicit gag reflex

Correct Answer is D

Explanation

A. Checking pupillary response to light assesses cranial nerve II (optic nerve).

B. Observing for facial symmetry primarily assesses cranial nerves VII (facial nerve) and possibly V (trigeminal nerve).

C. Testing for sense of smell assesses cranial nerve I (olfactory nerve).

D. Eliciting the gag reflex assesses cranial nerve IX (glossopharyngeal nerve) and also cranial nerve X (vagus nerve), making it the correct action to assess cranial nerve IX.

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Correct Answer is A

Explanation

Correct Answer is D

Explanation

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

Correct Answer is A

Explanation

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which action should the nurse take to assess cranial nerve IX?

Correct Answer is D

Explanation

A nurse is teaching about the risk factors of developing a stroke with a group of older adult clients. Which nonmodifiable risk factors should the nurse include in the teaching?

During which part of a comprehensive physical assessment would the nurse auscultate after inspecting but before percussing?

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

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?

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

A nurse is caring for a client who has contact dermatitis of the neck and upper chest. Which assessment data is an expected finding?

A nurse is caring for a postoperative client. The nurse should base the client's pain management interventions primarily on which methods of determining the intensity of the client's pain?

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