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. Assess visual acuity B. Elicit gag reflex C. Checking for pupillary response to light D. Observing for facial symmetry

Correct Answer is A

Explanation

A. Assessing visual acuity directly tests cranial nerve II (the optic nerve), which is responsible for vision.

B. Eliciting the gag reflex tests cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve II.

C. Checking for pupillary response to light primarily assesses the function of cranial nerve II but is more associated with cranial nerve III (oculomotor) since it involves the constriction of the pupil. While relevant, it is not the best standalone action for assessing cranial nerve II specifically.

D. Observing for facial symmetry is associated with cranial nerve VII (facial nerve), not cranial nerve II.

A. Audiometer B. Ophthalmoscope C. Pneumatic otoscope D. Tuning fork

Correct Answer is C

Explanation

A. An audiometer is used to assess hearing ability and is not appropriate for examining the tympanic membrane.

B. An ophthalmoscope is used to examine the interior of the eye and cannot assess tympanic membrane mobility.

C. A pneumatic otoscope is specifically designed for examining the tympanic membrane and allows for assessment of its mobility by using air pressure.

D. A tuning fork is used to evaluate hearing and vibration sense, not tympanic membrane mobility.

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Correct Answer is A

Explanation

Correct Answer is C

Explanation

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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 II?

Correct Answer is A

Explanation

To assess the tympanic membrane mobility, which instrument is most appropriate for the nurse to use?

Correct Answer is C

Explanation

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 42/min, respiratory rate 14/min, and BP 98/77 mm Hg. Which vital sign should the nurse re-measure?

While performing an abdominal assessment on a patient, the nurse notes an abdomen shape similar to the rounded abdomen only greater. This contour is anticipated in pregnancy and seen in adults with ascites and obesity. What term should the nurse use to document this finding?

Which disorder is depicted in the image below?

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 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?

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 III?

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?

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