West Coast University - NURS 190 PA FINAL Exam - Latest - Already graded A

1. The nurse is caring for a client who was admitted to the medical unit. The nurse notes in the physical exam done by the physician that the client has a positive Romberg. When meeting elimination needs for this client, the nurse would perform which of the following interventions? A. obtain an order for a catheter B. limit fluid intake C. obtain a bedside commode D. allow the client to walk independently 2. The nurse observes drainage from a client’s ears after a head injury, and suspects a cerebral spinal fluid (CSF) leak. The nurse would document which of the following descriptions of the drainage? A. blood-tinged without sediment B. pink without sediment C. yellow without sediment D. clear, colorless 3. The nurse is performing a neurological assessment on a client and needs to use seterognosis. Which of the following instructions would the nurse provide for the client? A. “Identify the number being traced in your hand with your eyes closed.” B. “Identify the object in your hand with your eyes closed.” C. “Tell me if you feel one or two objects touching you with your eyes closed.” D. “Open and close your hand each time I tell you to.” 4. The nurse notes fanning of the toes when the sole of the foot is stimulated during assessment of the plantar reflex. The nurse would correctly chart which of the following? A. Brudzinski sign B. nuchal rigidity C. hyperreflexia D. Babinski response 5. The nurse is assessing a female client and notes facial hirsutism. The client asks the nurse why this has happened to her. The nurse would correctly respond with which of the following statements? A. “Your diet is not nutritionally balanced.” B. "You need to take vitamins.” C. “There is not a known cause for this condition.” D. “You may have some hormone imbalances.” 6. The nurse is assessing the patellar reflex on a client and obtains no reflective activity. The client is alert and oriented. The nurse should do which of the following in this situation? A. look at the medication records for central nervous system depressants B. retest the reflex after having the client use distraction during the exam C. notify the physician immediately D. document the findings as normal 7. The nurse is caring for a client that insists on having their food very hot and very cold at each meal. The nurse correctly recognize this as a health belief in which of the following cultural groups? A. Chinese Americans B. Native Americans C. Cuban Americans D. Jewish Americans 8. The nurse is caring for a client who is a long-time smoker and notes clubbing of the fingers. The nurse utilized which of the following techniques to validate this assessment? A. place two of the same fingers from each hand together B. place the hands out straight with the palm sides down C. place two index fingers together tip to tip D. place two thumbs touching side by side 9. A 24-year-old client reports difficulty with near vision during an interview with the nurse. The nurse realizes the finding is consistent with: A. hyperopia B. presbyopia C. astigmatism D. aging 10. The nurse is performing a neurological assessment on a client experiencing anosmia. The nurse would suspect cranial nerve involvement in which of the following? A. trigeminal, cranial nerve V B. trochlear, cranial nerve IV C. olfactory, cranial nerve I D. oculomotor, cranial nerve III 11. The nurse is assessing the visual fields of a 38-year-old female who reports recent changes in visual abilities. Which of the following statements would be appropriate for the nurse to use with this client? A. “These changes are probably related to your age.” B. "It is possible you have taken narcotics recently?” C. “The changes could be related to increased pressure within your eye.” D. “These changes require a prescription for glasses.” 12. The nusse assesses a client and finds that a grating sound is present when a joint is bent and straightened. The nurse would correctly document this finding as which of the following? A. joint noise B. grating C. crepitation D. grinding 13. The nurse is planning care for a client with hypothyroidism. Which of the folliwng would be the priority nursing diagnosis for this client? A. altered nutrition, less than body requirements B. risk for constipation related to metabolic imbalance C. risk for injury related to confusion and lethargy D. activity intolerance related to fatigue 14. The nurse is assessing the pulses of a client and palpates the area behind the client’s knee. The nurse would choose which of the following names to document this pulse? A. radial B. brachial C. popliteal D. dorsalis pedis 15. The nurse is assessing cranial nerve XI (spinal accessory). Which of the following statements would the nurse use to the client? A. “Smell these items and identify what they are.” B. “Shrug your shoulders and turn your head against my head.” C. “Stick out your tongue and move it from side to side.” D. “Taste these foods and decide which is sweet and which is sour.” 16. The nurse is caring for a client with Hepatitis A when the client asks the nurse how the illness is contracted. The nurse would respond with which of the following? A. “You must have gotten it from your blood transfusion.” B. “Have you traveled out of the country?” C. “Why are you asking?” D. “It comes from contaminated food.” 17. When assessing the cardiac system of a healthy adult, the nurse would expect to hear which of the following heart sounds? A. S2 then S3 B. S1 then S2 C. S3 then S4 D. S2 then S1 18. The nurse notes swelling and tenderness of the olecranon process during palpation. The client’s chief complaint is pain upon movement of the forearm and wrist. The nurse would correctly suspect which of the following conditions in this situation? A. epicondylitis B. crepitus C. bursitis D. arthritis 19. The nurse is preparing a seminar on Alzheimer’s disease for a group at a Senior Action Center. The nurse would include which of the following information in this session? (Select all). A. incidence increases with age B. may be caused by a virus C. occurs more commonly in men D. causes memory loss and disorientation 20. The nurse is preparing to assess a client’s spine for abnormalities. The nurse would ask the client to do which of the following to perform this assessment? A. bend over, stand tall, and stretch arms over the head B. stand, bend back slowly, then to the right and left while the nurse looks from the back C. lie down on the abdomen so the nurse can look at the back more carefully D. sit down, then stand as the nurse looks from the front of the client 21. The nurse has assessed a client and notes diminished reflexes. The nurse would correctly document which of the following? A. 4+ B. 3+ C. 2+ D. 1+ 22. The nurse is assessing a client with complaints of back pain, possibly related to sciatic nerve involvement. Which of the following findings would support this diagnosis? A. pain with sitting B. pain with leg raises C. pain with adduction D. pain with abduction 23. The nurse instructs a client to walk heel-to-toe, then on toes, and last on heels. The nurse is assessing the function of the which of the following? A. brainstem b. cerebellum C. mid brain D. cerebrum