Question

A nurse is assessing a client who has hypocalcemia. Which of the following findings should the nurse expect (Select all that apply.)

Answer 1

Correct Answers:

Tingling sensation around the lips
Positive Trousseau's sign
Muscle cramps

Rationale :

Tingling sensation around the lips is a sign of paresthesia, one of the earliest indicators of hypocalcemia, due to increased neuromuscular excitability.

Positive Trousseau’s sign is elicited by inflating a blood pressure cuff and observing carpopedal spasm.
It reflects latent tetany caused by low calcium levels.

Muscle cramps occur from sustained skeletal muscle contraction due to hypocalcemia’s effect on neuromuscular transmission.

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Answer 2

Correct Order:

Order : 1 : No answer text available
Order : 2 : No answer text available
Order : 3 : No answer text available
Order : 4 : No answer text available
Order : 5 : No answer text available

Rationale :

✅Abdominal assessment must follow the standard sequence: inspection → auscultation → percussion → palpation.

✅This order ensures accurate data collection without altering bowel sounds or causing client discomfort prematurely.

Observe the contours of the abdomen using a penlight (Inspection):
This step allows the nurse to identify visible abnormalities such as distention, symmetry, scars, hernias, visible pulsations, or peristalsis.
A penlight improves detection of subtle movements or changes in contour.
Inspection must always be performed first to establish a visual baseline before any touch or sound is introduced.
Determine the presence of bowel sounds using the diaphragm of the stethoscope (Auscultation):
Auscultation comes immediately after inspection and before palpation or percussion to avoid stimulating bowel activity, which can produce falsely increased bowel sounds.
The diaphragm is used because bowel sounds are high-pitched. The nurse should auscultate all four quadrants and note frequency, pitch, and character.
Systematically percuss the abdomen:
Percussion identifies the presence of air (tympany), fluid (dullness), or solid masses. It helps assess organ size (e.g., liver or spleen borders) and detect abnormal fluid accumulation such as ascites.
Performing this before palpation maintains data reliability.
Use fingertips to lightly depress the right lower quadrant (Light palpation):
Light palpation detects tenderness, muscular resistance, or superficial masses.
Begin palpation in the non-tender area to avoid guarding and involuntary muscle tension.
The right lower quadrant is often chosen first unless contraindicated by pain.
Press deeply into the upper abdomen left of midline (Deep palpation)
Deep palpation evaluates organ size, masses, or deep tenderness. Pressing near the aorta (left of midline) allows the nurse to detect aortic pulsations and screen for abdominal aortic aneurysm (AAA).
Deep palpation should be done last and performed gently to avoid discomfort or injury.

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Answer 3

Correct Answers:

The client has a symmetrical smile.

Rationale :

Cranial nerve VII, the facial nerve, is responsible for motor function to the muscles of facial expression as well as certain sensory components (such as taste on the anterior two-thirds of the tongue).
During a focused neurologic assessment, the nurse evaluates cranial nerve VII by instructing the client to smile, frown, raise eyebrows, puff cheeks, or close the eyes tightly.
A symmetrical smile indicates that the motor branches of the facial nerve are functioning correctly on both sides of the face.
Facial asymmetry, drooping of one side of the mouth, or an inability to smile evenly are clinical signs of facial nerve dysfunction, which may be due to Bell’s palsy, stroke, or trauma.
Early identification of such asymmetry is essential for prompt neurological evaluation and intervention.

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Answer 4

Correct Answers:

Pain level
Allergies
Informed consent

Rationale :

Pain level: The client reports increasing pain (now 8/10), indicating possible worsening appendicitis or imminent rupture.
Pain should be promptly addressed prior to anesthesia or positioning for surgery, as uncontrolled pain may impact intraoperative stability.

Allergies: The client has documented allergies to shellfish, latex, and penicillin, placing them at high risk for intraoperative anaphylaxis.
This must be communicated clearly to the surgical team, especially in case contrast dye (shellfish-related), latex gloves, or penicillin-class antibiotics are anticipated.

Informed consent: Though documented, the nurse must ensure that informed consent is fully completed, valid, and understood by the client, especially since the client is expressing concern.
The nurse must assess if the client truly comprehends the risks, benefits, alternatives, and voluntary nature of the procedure.

✅These findings require follow-up to promote client safety, legal protection, and preoperative stability.

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Answer 5

Correct Answers:

"l should attend a support group each week."

Rationale :

⏺Support groups provide structured, evidence-based emotional and psychological support.

⏺ They offer a space for individuals experiencing stress or life changes to connect with others, share experiences, and develop adaptive coping mechanisms.

⏺Attending regularly helps reduce isolation, normalize emotional responses, and promote self-awareness.

⏺This action shows understanding of healthy and sustainable stress management.

⏺Unlike short-term solutions or avoidance behaviors, this reflects a preventive and supportive approach to stress reduction.

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Answer 6

Correct Answers:

"l will walk three times per week."

Rationale :

Weight-bearing exercise, like walking, stimulates osteoblast activity, promoting bone remodeling and strength maintenance.
This is essential for osteoporosis prevention, especially in older adults. Walking at least three times a week aligns with national guidelines for maintaining bone density and mobility.
It also improves postural stability, reducing fall risk. In contrast, inadequate calcium intake, lack of exercise, and avoiding sunlight can exacerbate bone loss.
This statement demonstrates the client’s understanding of a non-pharmacological, lifestyle-based preventive strategy.

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Answer 7

Correct Answers:

Allow the client to slide down their outstretched leg.

Rationale :

🟣This technique is a controlled fall maneuver, used when a client becomes unstable during ambulation.

🟣By extending one leg and guiding the client to slide down while supporting them, the nurse minimizes the risk of injury to both the client and themselves.

🟣This method avoids sudden movements that could lead to trauma.

🟣It demonstrates the use of safe body mechanics and fall-prevention protocol in clinical mobility support.

🟣Prompt and controlled assistance reflects professional standards in client-centered fall safety.

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Answer 8

Correct Answers:

"Keep the collection bag below bladder level."

Rationale :

🔹Keeping the catheter collection bag below the bladder level at all times maintains gravity-dependent drainage, preventing urinary backflow which can introduce bacteria into the bladder and cause catheter-associated urinary tract infections (CAUTIs).

🔹Proper positioning also reduces bladder pressure and ensures unobstructed urinary flow, which is essential in clients with indwelling catheters.

🔹This is a core infection prevention strategy recommended by CDC and infection control guidelines.

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Answer 9

Correct Answers:

The client drinks their thickened juice with a straw

Rationale :

▶Clients with dysphagia (difficulty swallowing) are at increased risk for aspiration, especially when using a straw.

▶Straws can cause liquids to bypass the oral preparatory phase, propelling fluid quickly to the pharynx and increasing aspiration risk.

▶Thickened fluids are specifically designed to slow the transit time and improve swallowing safety, which is undermined by straw use.

▶The nurse must intervene immediately to ensure safe oral intake techniques, such as upright positioning, chin-tuck method, and slow sips without straws.

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Answer 10

Correct Answers:

The client takes an antihypertensive medication.

Rationale :

Antihypertensive medications, especially diuretics and vasodilators, can lead to orthostatic hypotension, a major contributor to falls in older adults.
When blood pressure drops upon standing, clients may experience dizziness, weakness, or syncope.
This physiological effect increases the risk of injury during activities of daily living.
During a fall risk assessment, the nurse must identify medications that alter hemodynamic stability, particularly in the elderly population.
Recognizing this risk factor allows implementation of appropriate fall-prevention interventions.

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RN Fundamentals 2023 Exam 3

No.

1 :
A nurse is assessing a client who has hypocalcemia. Which of the following findings should the nurse expect (Select all that apply.)

2 :
A nurse is assessing a client's abdomen. In what order should the nurse complete the steps of the assessment? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Available Items

Arrange Your Answers

3 :
A nurse is assessing a client's cranial nerve VII. Which of the following responses should the nurse expect?

4 :
A nurse is caring for a client who is scheduled for an appendectomy.

Answer Options

5 :
A nurse is teaching a client about stress management techniques. Which of the following client statements indicates an understanding of the teaching?

6 :
A nurse is teaching an older adult client about reducing the risk for osteoporosis. Which of the following statements by the client indicates an understanding of the teaching?

7 :
A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take?

8 :
A charge nurse is teaching a group of nurses about decreasing the risk for catheter- associated urinary tract infections in clients. Which of the following information should the nurse include in the teaching?

9 :
A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?

10 :
A home health nurse is performing a fall risk assessment for an older adult client. Which of the following findings should the nurse identify as a potential fall risk in the home?

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RN Fundamentals 2023 Exam 3

No.

1 : A nurse is assessing a client who has hypocalcemia. Which of the following findings should the nurse expect (Select all that apply.)

2 : A nurse is assessing a client's abdomen. In what order should the nurse complete the steps of the assessment? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Available Items

Arrange Your Answers

3 : A nurse is assessing a client's cranial nerve VII. Which of the following responses should the nurse expect?

4 : A nurse is caring for a client who is scheduled for an appendectomy.

Answer Options

5 : A nurse is teaching a client about stress management techniques. Which of the following client statements indicates an understanding of the teaching?

6 : A nurse is teaching an older adult client about reducing the risk for osteoporosis. Which of the following statements by the client indicates an understanding of the teaching?

7 : A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take?

8 : A charge nurse is teaching a group of nurses about decreasing the risk for catheter- associated urinary tract infections in clients. Which of the following information should the nurse include in the teaching?

9 : A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?

10 : A home health nurse is performing a fall risk assessment for an older adult client. Which of the following findings should the nurse identify as a potential fall risk in the home?

1 :
A nurse is assessing a client who has hypocalcemia. Which of the following findings should the nurse expect (Select all that apply.)

2 :
A nurse is assessing a client's abdomen. In what order should the nurse complete the steps of the assessment? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

3 :
A nurse is assessing a client's cranial nerve VII. Which of the following responses should the nurse expect?

4 :
A nurse is caring for a client who is scheduled for an appendectomy.

5 :
A nurse is teaching a client about stress management techniques. Which of the following client statements indicates an understanding of the teaching?

6 :
A nurse is teaching an older adult client about reducing the risk for osteoporosis. Which of the following statements by the client indicates an understanding of the teaching?

7 :
A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take?

8 :
A charge nurse is teaching a group of nurses about decreasing the risk for catheter- associated urinary tract infections in clients. Which of the following information should the nurse include in the teaching?

9 :
A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?

10 :
A home health nurse is performing a fall risk assessment for an older adult client. Which of the following findings should the nurse identify as a potential fall risk in the home?