Question

The nurse assesses the muscle strength of a client's lower extremities. What instruction should the nurse give to the client?

Answer 1

Correct Answers:

"Use both feet to push against my hands as hard as you can."

Rationale :

💪Assessing lower-extremity muscle strength requires the client to move against applied resistance.

🦶Having the client push both feet against the nurse’s hands evaluates plantar flexion strength.

⚖️Testing both sides simultaneously allows comparison for bilateral symmetry and weakness.

📊The nurse grades the response using the 0-to-5 muscle-strength scale based on movement against gravity and resistance.

📌Core Message:

Lower-extremity muscle strength is evaluated by having the client push both feet firmly against equal resistance.

Answer 2

Correct Answers:

"Look at the wall in the back of the room. Look at my finger now."

Rationale :

👁️The letter A in PERRLA represents accommodation.

🔭Accommodation is assessed by asking the client to shift focus from a distant object to a near object.

🔍The normal response includes pupillary constriction and convergence of the eyes when focusing on the near target.

🧠This examination evaluates the accommodation response involving cranial nerves II and III.

📌Core Message:

Accommodation is assessed by having the client shift focus from a distant object to a nearby target while observing pupillary constriction and eye convergence.

Answer 3

Correct Answers:

An ulnar drift to both hands.

Rationale :

👐Ulnar drift is a characteristic deformity associated with chronic rheumatoid arthritis.

🧬Persistent inflammation damages the synovium, ligaments, and joint structures, causing the fingers to deviate toward the ulnar side.

⚖️Rheumatoid arthritis usually affects corresponding joints in a bilateral and symmetrical pattern.

🌅Additional findings may include prolonged morning stiffness, joint swelling, tenderness, and reduced range of motion.

📌Core Message:

Chronic rheumatoid arthritis commonly causes bilateral ulnar deviation because persistent inflammation damages the hand joints and supporting structures.

Answer 4

Correct Answers:

Smoking
Anticoagulant administration
Increased abdominal pressure

Rationale :

🚬Use of a nicotine patch indicates a smoking history, and nicotine impairs tissue oxygenation and wound healing through vasoconstriction.

🩸Administration of heparin increases bleeding risk and may contribute to excessive wound drainage or hematoma formation.

🤰A body mass index of 36 and straining during defecation increase intra-abdominal pressure, placing stress on abdominal sutures.

🧵The reported popping sensation, broken sutures, and saturated dressing indicate wound dehiscence, which is associated with these risk factors.

📌Core Message:

Smoking, anticoagulant therapy, obesity, and increased abdominal pressure raise the risk of abdominal wound dehiscence and other healing complications.

Answer 5

Correct Answers:

75

Rationale :

💉The available concentration is 2 g in 50 mL, while the prescribed dose is 1.5 g.

🧮The required volume is calculated as 1.5 g × 50 mL ÷ 2 g, producing 37.5 mL.

⏱️Thirty minutes is converted to 0.5 hour for pump programming.

📟The infusion rate is calculated as 37.5 mL ÷ 0.5 hour, producing 75 mL/hr.

📌Core Message:

The prescribed 1.5-g ceftriaxone dose requires 37.5 mL, which administered over 30 minutes is programmed at 75 mL/hr.

Answer 6

Correct Answers:

At 20 feet, the client reads what someone with normal vision can read at 40 feet.

Rationale :

👓In a Snellen result, the numerator represents the client’s testing distance from the chart.

📏The denominator represents the distance at which a person with normal visual acuity can read the same line.

👁️A result of 20/40 means the client sees at 20 feet what normal vision sees at 40 feet.

📉This finding indicates reduced distance visual acuity compared with 20/20 vision.

📌Core Message:

20/40 vision means the client must be 20 feet away to see what a person with normal vision can see from 40 feet.

Answer 7

Correct Answers

Blank 1 Correct Option: Atrial fibrillation
Blank 2 Correct Option: Pulse rate deficit
Blank 3 Correct Option: Radial pulse
Blank 4 Correct Option: Mitral area

Rationale :

💓A rapid, irregular peripheral pulse is characteristic of atrial fibrillation with a rapid ventricular response.

⚡Cocaine stimulates the sympathetic nervous system and can precipitate tachyarrhythmias.

🩺A pulse-rate deficit is assessed by comparing the apical heart rate with the radial pulse rate simultaneously.

📍The apical pulse is auscultated at the mitral area, located at the fifth left intercostal space along the midclavicular line.

📌Core Message:

The client’s rapid irregular rhythm suggests atrial fibrillation, which is evaluated for a pulse deficit by comparing the apical rate at the mitral area with the radial pulse.

Answer 8

Correct Answers:

Dimpling observed in one breast.

Rationale :

🎗️Pressing the hands firmly into the hips contracts the pectoral muscles beneath the breasts.

🔍Contraction may reveal subtle skin retraction, distortion, or dimpling caused by an underlying mass.

⚠️Dimpling can result when a lesion pulls on the breast’s supporting ligaments or surrounding tissue.

🩺New dimpling should be reported for additional clinical and diagnostic evaluation.

📌Core Message:

Breast dimpling during pectoral contraction is an abnormal finding that may indicate underlying tissue retraction from a breast lesion.

Answer 9

Correct Answers:

The bases of the lungs

Rationale :

🫁Crackles are discontinuous popping sounds produced when air moves through fluid-filled airways or opens collapsed alveoli.

⬇️In pneumonia, inflammatory fluid often accumulates in dependent lung regions, making crackles common at the lung bases.

🎧The nurse should auscultate systematically and compare corresponding areas of both lung fields.

📊Crackles should be interpreted with oxygen saturation, respiratory effort, fever, cough, and other clinical findings.

📌Core Message:

Pneumonia commonly produces crackles at the lung bases where inflammatory secretions and fluid tend to accumulate.

Answer 10

Correct Answers:

Depression

Rationale :

🧠An older adult with depression may exhibit poor concentration, indecisiveness, slowed thinking, and brief responses.

🐢Psychomotor slowing can cause the client to answer accurately but with delayed verbal responses.

📅The gradual development of these symptoms over several months is consistent with a depressive disorder presenting with cognitive symptoms.

🔍The nurse should assess mood, sleep, appetite, energy, loss of interest, hopelessness, and suicide risk.

📌Core Message:

Depression in older adults can resemble cognitive decline by causing impaired concentration, indecisiveness, psychomotor slowing, and brief but accurate responses.

Lab	Reference Range	4/14	4/15	4/16	4/17
Red Blood Cells (RBC)	4.2 – 5.9 cells/L	5.1	4.8	4.9	5.2
Hemoglobin (Hgb)	12 – 17 g/dL	13	14	15	14
Hematocrit (Hct)	36 – 51 %	35	38	38	36
White Blood Cells (WBC)	4,000 – 10,000 mm3	9,400	9,000	8,430	8,800

Medication	4/14	4/15	4/15	4/16
Nicotine patch 14 mg transdermal daily	Given 0903	Given 0928	Given 0936	Given 0858
Heparin 5000 units subcutaneous BID	Given 0903 / Given 2120	Given 0928 / Given 2102	Given 0936 / Given 2134	Given 0858 / Given 2106
Ketorolac 30 mg IV q6h PRN pain	Given 1100 / Given 2300	Given 1000	Given 1800	Given 1400

1 :
The nurse assesses the muscle strength of a client's lower extremities. What instruction should the nurse give to the client?

2 :
The nurse cares for a client with an embolic stroke and assesses for PERRLA. What instruction should the nurse give to the client to assess the "A" in PERRLA?

3 :
The nurse assesses a client with chronic rheumatoid arthritis (RA). What is an expected finding?

4 :
A 47-year-old client with a BMI of 36 had abdominal surgery on 4/13.

4/14 1600:

4/15 0800:

4/16 1700:

Medications

Answer Options

5 :
The nurse receives an order to administer ceftriaxone 1.5 gram IV over 30 minutes to a client diagnosed with pneumonia. Available is ceftriaxone 2 grams/50 mL of normal saline. At what rate will the nurse program the pump? (mL/hr)

6 :
The nurse tests the vision of a client with early-stage macular degeneration via use of the Snellen alphabet chart. The client's vision is 20/40. How should the nurse explain this finding to the client?

7 :
A nurse is attending to a client

Correct Answers

8 :
In teaching the female client how to perform breast self-examination, the nurse tells the client to stand before the mirror, put the hands on the hips, and push the palms into the hips. What is an abnormal finding with this aspect of the test?

9 :
The nurse assesses a client with pneumonia. Where in the client's lung field is the nurse likely to auscultate crackles?

1 : The nurse assesses the muscle strength of a client's lower extremities. What instruction should the nurse give to the client?

2 : The nurse cares for a client with an embolic stroke and assesses for PERRLA. What instruction should the nurse give to the client to assess the "A" in PERRLA?

3 : The nurse assesses a client with chronic rheumatoid arthritis (RA). What is an expected finding?

4 : A 47-year-old client with a BMI of 36 had abdominal surgery on 4/13.

4/14 1600:

4/15 0800:

4/16 1700:

Medications

Answer Options

5 : The nurse receives an order to administer ceftriaxone 1.5 gram IV over 30 minutes to a client diagnosed with pneumonia. Available is ceftriaxone 2 grams/50 mL of normal saline. At what rate will the nurse program the pump? (mL/hr)

6 : The nurse tests the vision of a client with early-stage macular degeneration via use of the Snellen alphabet chart. The client's vision is 20/40. How should the nurse explain this finding to the client?

7 : A nurse is attending to a client

Correct Answers

8 : In teaching the female client how to perform breast self-examination, the nurse tells the client to stand before the mirror, put the hands on the hips, and push the palms into the hips. What is an abnormal finding with this aspect of the test?

9 : The nurse assesses a client with pneumonia. Where in the client's lung field is the nurse likely to auscultate crackles?

1 :
The nurse assesses the muscle strength of a client's lower extremities. What instruction should the nurse give to the client?

2 :
The nurse cares for a client with an embolic stroke and assesses for PERRLA. What instruction should the nurse give to the client to assess the "A" in PERRLA?

3 :
The nurse assesses a client with chronic rheumatoid arthritis (RA). What is an expected finding?

4 :
A 47-year-old client with a BMI of 36 had abdominal surgery on 4/13.

5 :
The nurse receives an order to administer ceftriaxone 1.5 gram IV over 30 minutes to a client diagnosed with pneumonia. Available is ceftriaxone 2 grams/50 mL of normal saline. At what rate will the nurse program the pump? (mL/hr)

6 :
The nurse tests the vision of a client with early-stage macular degeneration via use of the Snellen alphabet chart. The client's vision is 20/40. How should the nurse explain this finding to the client?

7 :
A nurse is attending to a client

8 :
In teaching the female client how to perform breast self-examination, the nurse tells the client to stand before the mirror, put the hands on the hips, and push the palms into the hips. What is an abnormal finding with this aspect of the test?

9 :
The nurse assesses a client with pneumonia. Where in the client's lung field is the nurse likely to auscultate crackles?