Author: Anonymous

A client states that “I can hear crunching or a grating sound when I kneel and stand up.” She further states “it is very difficult to get out of bed in the morning because of this stiffness in my joints.” The nurse suspects the sound heard is:

A 78-year-old patient tells the nurse he is having trouble hearing high-frequency sounds- particularly in large groups. He cannot always tell where the sound is coming from, words often sound “mixed up”. What might the nurse suspect as the cause for this change?

The nurse elicits a positive Romberg’s sign on a patient with suspected alcohol intoxication. The nurse makes this determination based upon inspection of?

During a hospital assessment of an 80-year-old male, the nurse notes the patient’s hands have a slight tremor and his head occasionally nods. There is no associated rigidity or limitation of movement as the patient reaches for his coffee cup.  Which of the following statements is most accurate?

Upon examination of a patient’s left knee, a nurse notices significant “swelling in the joint” after the patient fell while ambulating to the bathroom. The nurse knows to chart __________ is present in the electronic medical record? Fill in the blank

A client tells the nurse that she “notices one of her nevi moles has started to burn and bleed”. In physical assessment of the skin, the nurse would pay special attention to the danger signs for pigmented lesions. What findings would be of a concern? Choose all that apply?

During an initial skin assessment the nurse notices that a patient’s skin looks yellowish-brown in color. As the nurse presses the patient’s forehead and chin with a finger, the skin circle blanches pink. The patient’s palate is pink. The patient’s sclera is white. From these physical exam findings the nurse could eliminate the possibility of which condition?

When assessing a client’s muscle strength, the nurse observes the patient has complete range of motion (ROM) with full resistance against opposing force. What grade of muscle strength should the nurse record in the electronic medical record using a 0-5 point scale?

A 50-year-old male is at the provider’s office due to “difficulty using the bathroom”. During the health history the client states, “I just “cannot start my urine stream”. I have to urinate so frequently but I never feel like I completely empty my bladder.” The client reports increasing pain in his lower back and pelvis. Given this subjective history, what might the nurse expect the provider to “find” during the physical examination of his rectum?

In performing a breast examination using palpation, the nurse knows that it is important to examine the upper outer quadrant of each breast and the “Tail of Spence” because?