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1+ edema 2+ edema 3+ edema 4+ edema 27.While reviewing a client's health care record, a nurse notes documentation of the presence of borborygmus on abdominal assessment. Which of the following findings does the nurse expect to note when auscultating the client's bowel sounds? An absence of bowel sounds 28.A nurse performing a skin assessment uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. The nurse determines that: The client needs to have the blanket removed
29.A nurse is performing an abdominal assessment on a client. On auscultation of the abdomen the nurse hears a bruit over the abdominal aorta. Which action should the nurse take as a priority on the basis of this finding? Percuss the abdomen to check for tympany 30.A nurse is preparing to assist the physician in performing an internal gynecological examination of a client. In which of the following positions does the nurse place the client for this examination? Prone Left side–lying Sims Lithotomy 31.At a health screening clinic, a nurse is educating a young woman about breast self-examination (BSE). The nurse determines that the client demonstrates understanding when she states that: Monthly BSE includes inspection before a mirror and palpation both in the shower and while lying down 32.
A nurse listening to a client's chest to determine the quality of vocal resonance asks the client to repeat the word "ninety-nine" as the nurse listens through the stethoscope. As the client says the word, the nurse is able to hear the word clearly. The nurse documents this assessment finding as: Normal whispered pectoriloquy 33.A nurse reviewing the physical assessment findings in a client's healthcare record notes documentation that the Phalen test caused numbness and burning. Which disorder does the nurse, on the basis of this finding, conclude that the client has? Carpal tunnel syndrome 34.A nurse is performing a voice test. To carry out this procedure correctly, the nurse asks the client to repeat words that are: Spoken in a soft tone of voice by the nurse about 5 feet in front of the client Whispered by the nurse from the client's side at a distance of 1 to 2 feet from the ear being tested Spoken by the nurse from the client's side in a normal tone of voice about 10 feet from the ear being tested Whispered at a distance of 20 feet by the nurse while he or she is standing in front of the client 35.
A client with peripheral artery disease tells the nurse that pain develops in his left calf when he is