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

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?

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?

 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.

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 is caring for a client in an assisted living facility who has vision problems.

Medical history 

A 68-year-old woman with complaints of having trouble reading the paper, sewing, and even seeing the faces of her grandchildren up close.

Nurse's notes

The client was noted to have some loss of nearsightedness

Complete the sentence by using the list of options.The findings noted by the health care practitioner suggest that

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

To determine the quality and intensity of a cardiac murmur, the nurse would take which action?

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.)

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 receiving a patient from the emergency room (ER) with an admitting diagnosis of hypothyroid disorder. 

Admitting diagnosis

acute hypothyroid disorder

Physician order

Synthroid 0.1 mg po daily

The receiving medical- surgical nurse would expect the patient to exhibit which signs and symptoms? Select all that apply