A nurse is caring for a 73-year-old male client in an assisted living facility. The client has a history of a left-sided stroke and is experiencing increasing weakness and a decrease in range of motion (ROM) on the right side. The nurse begins the assessment at 0700hrs.

Exhibits

Based on the exhibits provided, what type of range of motion was being assessed for each joint? Select one response per row.

A nurse is caring for a 45-year-old male client in the emergency department who sustained a fall from a ladder. The client has a closed and displaced fracture of the right ulna and radius. The nurse is monitoring the client closely for any changes in condition.

A nurse is caring for a 45-year-old male client in the emergency department with a closed and displaced fracture of the right ulna and radius. Based on the exhibits provided, what is the priority nursing action at this time?

After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high-pitched almost continuous gurgling in two quadrants.

Which action should the nurse implement first?

While obtaining a client’s health history related to smoking cigarettes, the nurse plans to determine the client’s smoking pack years.

What information should the nurse obtain for this calculation? Select all that apply.

While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time.

To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?

The nurse observes that a client is experiencing melena.Which serum laboratory test should the nurse monitor in response to this finding?

While observing a client’s face, which assessment finding requires immediate intervention by the nurse?

While auscultating a client’s abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

An adult male client informs the nurse that he came to the clinic to see if, “Maybe I have lung cancer or something,” and wants to get checked out since, “I can’t seem to get rid of this body-wracking dry cough that has been hanging around for the last six weeks.”. Which computer documentation of this client’s concerns should the nurse enter?

When family members express their concern about their father’s recent memory loss, which assessment should the nurse suggest?

The nurse should anticipate difficulty locating the point of maximal impulse (PMI) in which client?