Exam 1 Practice Questions P1

A nurse is documenting a client's headache. Which of the following would be the best entry to include for this finding? Client has a dull, aching pain in the back of his head that began 2 weeks ago. The pain is constant and seems to be worse in the mornings. Client has severe headache, probably related to alcoholism. Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m. Client reports headache.

Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m. Explanation: As this is subjective data, the nurse should record it as the "client reports" instead of the "client has," to clarify that this is based on the client's perception. The nurse should use phrases instead of sentences for brevity. Finally, the nurse should record complete information and details for all client symptoms or experiences, not just, "Client reports headache."

A client reports a weight loss and fatigue during the review of systems. In which area should the nurse document this information? General Appetite Rest and sleep Gastrointestinal

General Explanation: Information to document under the general area includes usual weight, recent weight change, any clothes that fit more tightly or loosely than before, weakness, fatigue, or fever. Information about weight and fatigue is not documented under the gastrointestinal system. Appetite and rest and sleep are not areas within the review of systems.

The nurse is preparing for a physical examination of a client. What should the nurse do first? Hand hygiene Gather equipment Palpitation Auscultation

Hand hygiene Explanation: The nurse should perform hand hygiene before beginning the physical assessment. This includes prior to gathering equipment. Auscultation and palpitation should not occur until after hand hygiene has been performed.

The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which of the following clinical situations? When communicating a client's change in condition to the client's physician. When providing a change-of-shift report to a colleague. When documenting the care that was provided to a client whose condition recently deteriorated. When reporting to a client's family member or significant other.

When communicating a client's change in condition to the client's physician. Explanation: SBAR communication is an increasingly common tool for interdisciplinary communication. It is not typically used during change-of-shift report nor when communicating with family members. SBAR is considered a framework for communication rather than a format for documentation.

A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve? III VI VIII XII

XII - hypoglossal Explanation: Decreased tongue strength may occur with a defect of the twelfth cranial nerve. The third cranial nerve is involved with eye muscle movement. The sixth cranial nerve is involved with lateral eye movement. The eighth cranial nerve is involved with hearing and equilibrium

While recording the subjective data of an adult client who complains of pain in his lower back, the nurse should include the location of the pain and the cause of the pain. client's caregiver. client's occupation. pain relief measures.

pain relief measures. Explanation: Record complete information and details for all client symptoms or experiences. For example, do not record: "Client has pain in lower back." Instead record: "Client reports aching-burning pain in lower back for 2 weeks. Pain worsens after standing for several hours. Rest and ibuprofen used to take edge off pain. No radiation of pain. Rates pain as 7 on scale of 1 to 10."

A client has an enlarged area on the lower leg. Which technique should the nurse expect to use to assess this body area? palpation inspection percussion auscultation

palpation Explanation: Palpation is the use of touch to assess texture, temperature, moisture, size, shape, location, position, vibration, crepitus, tenderness, pain, and edema. Inspection is used to conduct the general survey, observing for body positioning, appearance, and behavior. Percussion is used to illicit sound or determine tenderness. Auscultation is used to listen to sounds.

While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 0.75 cm. The nurse documents this as a plaque. macule. papule. patch.

papule. Explanation: Papules are elevated, palpable, solid masses smaller than 1 cm. Plaques are greater than 1 cm and may be coalesced papules with a flat top.

A nurse obtains a blood pressure on an elderly client of 160/70 mm Hg. The nurse knows that the term for this condition is what? Orthostatic hypotension Stage I hypertension Normal for the elderly Isolated systolic hypertension

Isolated systolic hypertension Explanation: The elderly are prone to isolated systolic hypertension (systolic greater than 140 but diastolic under 90) due to arteriosclerosis that makes blood vessels stiff and less compliant. Orthostatic hypotension is a blood pressure that drops when a client changes positions. Stage 1 hypertension is a blood pressure reading of 140 to 159/90 to 99 mm Hg. Hypertension is not normal for any client.

The nurse is preparing to assess an adult woman's activities related to health promotion and maintenance. Which question should the nurse ask to obtain the most objective and thorough assessment data? "Do you always wear your seatbelt when driving?" "How much beer, wine, or alcohol do you drink?" "Do you use condoms with each sexual encounter?" "Could you describe how you perform self-breast exams?"

"Could you describe how you perform self-breast exams?" Explanation: Asking the client to describe self-breast examination is an open-ended question that allows the client to verbalize openly about the activity and provides the nurse with information that allows determination of correct technique. Asking about wearing a seatbelt, how much alcohol the client drinks, or using condoms with sexual activity are closed-ended questions that would provide information of one or two words.

Which of the following data entries follows the recommended guidelines for documenting data? "Patient is overwhelmed by the diagnosis of pancreatic cancer." "Patient kidneys are producing sufficient amount of measured urine." "Following oxygen administration, vital signs returned to baseline." "Patient complained about the quality of the nursing care provided on previous shift."

"Following oxygen administration, vital signs returned to baseline." Explanation: The nurse should record client findings (observations of behavior) rather than an interpretation of these findings, and avoid words such as "good," "average," "normal," or "sufficient," which may mean different things to different readers. The nurse should also avoid generalizations such as "seems comfortable today." The nurse should avoid the use of stereotypes or derogatory terms when charting, and should chart in a legally prudent manner.

A nurse is providing a verbal update to a client's primary care provider because of the client's worsening nausea. When using an SBAR format to provide a report, the nurse should complete the report with which statement? "What would you like to do to address this client's nausea?" "I think this client would benefit from an antiemetic." "This client has no recent history of any nausea or vomiting." "This client rates his nausea as seven out of ten."

"I think this client would benefit from an antiemetic." Explanation: The SBAR format culminates with a recommendation. The client's rating of nausea and recent history are part of the situation ("S") and background ("B").

The nurse is conducting a history of the present illness. Which statement represents a possible response by the client? Select all that apply. "I want to be able to sleep on my left side." "My pain is a 7 all the time." "Climbing stairs makes my pain worse." "I am able to dress myself." "I walk 2 miles every day."

"I want to be able to sleep on my left side." "My pain is a 7 all the time." "Climbing stairs makes my pain worse." Explanation: The nurse conducting a history of the present illness includes six elements of symptom analysis: location, duration, intensity, quality/description, aggravating/alleviating factors, pain goal, and functional goal. "I want to be able to sleep on my left side" is a functional goal. Intensity is reflected in the statement rating the pain as 7. The client statement about stair climbing identifies an aggravating factor. The client statements about ability to dress self and walking 2 miles every day are data cues that pose no problem for the client.

A client is being admitted to the medical unit after being seen in the emergency department. Which statement by the nurse indicates an understanding of the importance of the appropriate timing of a health assessment? "The client has been ordered a nutritional consult; I do the health assessment right after that is finished." "I'll do the health assessment when the client's family leaves so that distractions will be minimal." "I'm going to assess the client now so that I can begin formulating the care plan." "The health assessment will be more thorough if I wait until the client is pain free."

"I'm going to assess the client now so that I can begin formulating the care plan." Explanation: Each person needs a complete health assessment. Ideally this is done on admission, but extenuating circumstances may prohibit its completion in detail at this time. The sooner the health assessment is completed fully, the better the nurse knows the client, and more holistic care can be provided to ensure health promotion and quality of life. The assessment should not be postponed until after the consult. The family should be informed of the need for the assessment and asked to leave until it is completed, unless their input with the history is needed. While pain may complicate the assessment process, it is not advisable to wait until the client is pain free to complete the assessment.

A nurse at an ambulatory clinic is preparing to begin the collection of objective assessment data from a female client. After meeting the client and bringing her into the examination room, what instruction should the nurse provide? "I'll get you to lay down flat on the exam table, please." "Please have a seat on the edge of the exam table." "I'll start the assessment with you standing up and then help you onto the table." "Where would you like me to conduct your health assessment?"

"Please have a seat on the edge of the exam table." Explanation: The client should be in a comfortable sitting position in a chair, on the examination table, or on a bed in the home setting. Asking for the client's preference shows client-centered care, but the nurse should position the client in a sitting position unless there are extenuating circumstances.

The nurse assesses the amplitude of the client's radial pulse and finds it to be weak and diminished. Which of the following scores should the nurse record? 0 1+ 2+ 3+

1+ Explanation: Pulse amplitude of 0 means that it is absent, 1+ that it is weak and diminished (easy to obliterate), 2+ that it is normal (can be obliterated with moderate pressure), and 3+ that it is bounding (unable to obliterate or requires firm pressure).

A nurse is preparing to conduct an assessment on a client. In what order should the nurse conduct the following actions? Place the steps in the correct order. 1. Wash hands and don gloves. 2. Take the client's vital signs. 3. Assess eyes, ears, nose, and mouth. 4. Auscultate heart and lung sounds. 5. Assess genitalia.

1. Wash hands and don gloves. 2. Take the client's vital signs. 4. Assess eyes, ears, nose, and mouth. 5. Auscultate heart and lung sounds. 6. Assess genitalia. Explanation: In order to decrease anxiety and build rapport, the nurse should explain to the client what they are doing and why. Less intrusive procedures should be performed first, for example, vital signs; height and weight; and inspection of hair, eyes, ears, mouth, skin, posture, and so on. Assessments should be conducted in an orderly fashion, generally starting at the head and moving downward, leaving the most invasive for last, such as examining genitalia. To reduce the transmission of microorganisms, the nurse must wash hands and don gloves prior to assessing a client.

Due to a change in the client's level of consciousness, a nurse is now assessing a client's temperature by the axillary route. Previously, the client had an oral temperature of 98.4ºF. Which finding would the nurse interpret as corresponding most closely to the client's previous temperature? 97.0ºF 97.4ºF 98.9ºF 99.4ºF

97.4ºF Explanation: An axillary temperature is 1ºF lower than the oral temperature. In this case, the axillary temperature that is within the client's oral temperature range would be 97.4ºF. Rectal temperature is between 0.7ºF and 1ºF higher than the normal oral temperature.

The nurse obtains a client's blood pressure when standing and compares it to the measurement obtained while the client was sitting. The client's blood pressure when sitting was 122/72 mmHg. Which finding would suggest to the nurse that the client is experiencing orthostatic hypotension? 114/68 mmHg 110/62 mmHg 108/58 mmHg 98/52 mmHg

98/52 mmHg Explanation: A drop of 20 mmHg or more form the recorded sitting blood pressure may indicate orthostatic hypotension. Therefore, a change in blood pressure from 122/72 mmHg to 98/52 mmHg fits this criteria. The other blood pressure readings, although lower than the sitting blood pressure would not reflect orthostatic hypotension.

A nurse finds crepitus when palpating over a client's maxillary sinuses. Which of the following should the nurse most suspect in this client? Normal, air-filled sinuses A large amount of exudate in the sinuses Obstruction of the nostril by a foreign object A perforated septum

A large amount of exudate in the sinuses -crepitus: a crackling or grating sound Explanation: Frontal or maxillary sinuses are tender to palpation in clients with allergies or acute bacterial rhinosinusitis. If the client has a large amount of exudate, you may feel crepitus upon palpation over the maxillary sinuses. Normal, air-filled sinuses would not demonstrate crepitus. Obstruction of the nostril by a foreign object would prevent sniffing or blowing air through the nostrils, but would not produce crepitus. A perforated septum would also not produce crepitus.

When assessing a client, the nurse notes a brownish ridge along the gum line. This finding would be considered normal in a client from what background? African American Native American Pacific Islander Asian American

African American Explanation: In dark-skinned clients, the gums are more deeply colored; a brownish ridge is often found along the gum line.

The nurse prepares to complete a past medical history with a client. Which areas should the nurse include in this history? (Select all answer choices that apply) Location Allergies Medications Adult illnesses Exacerbating factors

Allergies Medications Adult illnesses Key elements of the past history include allergies, medications, and adult illnesses. Location and exacerbating factors are a part of the history of present illness.

A female client is admitted to the health care facility due to reports of decreased appetite, loss of sleep, feelings of being unsafe in her own home, and inability to concentrate. She appears pale; her hair is disheveled, she is not wearing makeup, and she will not make eye contact. Based on this data, which nursing diagnosis can the nurse confirm? Imbalanced nutrition: less than body requirements Anxiety Risk for self-directed violence Impaired verbal communication

Anxiety Explanation: The major defining characteristics of anxiety are present: loss of sleep, feeling unsafe, inability to concentrate, and poor eye contact. There are no major characteristics for the nursing diagnosis of imbalanced nutrition: less than body requirements, risk for self-directed violence, or impaired verbal communication.

A nurse obtains vital signs on a 22-year-old client: temperature 97.8° F (36.6° C), pulse 55 beats/min regular, blood pressure 100/70 mm Hg, and respiratory rate 12 breaths/min. Which of the following actions should the nurse take first? Perform a two-step (auscultatory method) blood pressure. Ask the client if they are having difficulty breathing. Report abnormal findings to the health care provider. Ask the client if they are experiencing any dizziness or lightheadedness.

Ask the client if they are experiencing any dizziness or lightheadedness. Explanation: The nurse should first ask the client if they are experiencing any symptoms that may be related to the slow heart rate, such as dizziness, lightheadedness, or decreased urine output. The client is young and may be a well-conditioned athlete, which would explain the heart rate of 55 beats/min (bradycardia). A two-step blood pressure is not necessary. Blood pressure of 100/70 mm Hg and respiratory rate of 12 are within normal limits for a client of this age, and there is no indication of difficulty breathing.

Which action by the nurse is appropriate to provide a clear view of the uvula for observation? Depress the tongue slightly off center Ask the client to say "aaah" Press firmly on the back of the tongue Ask the client to stick out the tongue

Ask the client to say "aaah" Explanation: Asking the client to say "aaah" and instructing him or her to open the mouth wide makes the uvula more clear for observation. The nurse should depress the client's tongue slightly off center to prevent the gag reflex during observation of the uvula. Depressing the back of the tongue would elicit the gag reflex. Having the client stick out the tongue would not provide a clear view of the uvula.

Alexandra, 28 years old, presents to the clinic. She has abdominal pain that she describes as a dull ache, located in the right upper quadrant, and that she rates as a 3 at the least and an 8 at the worst. The pain started a few weeks ago; it lasts for 2 to 3 hours at a time, comes and goes, and seems to be worse a few hours after eating. The client has noticed that the pain starts after eating greasy foods, so she has cut down on this as much as she can. Initially the pain occurred once a week, but now it happens every other day. Nothing makes it better. From this description, which of the attributes of a symptom has been omitted? Setting in which the symptom occurs Associated symptoms and signs Quality Timing

Associated symptoms and signs Explanation: The interviewer has not recorded whether nausea, vomiting, fever, chills, weight loss, and so on have accompanied the pain. Associated manifestations are additional symptoms that may accompany the initial chief complaint and that help the examiner to start refining his or her differential diagnosis.

Recommended protective measures to avoid skin cancer include which of the following? Avoiding sun exposure Knowing signs of skin cancer Performing monthly skin self-examinations Seeking biannual examination by a clinician after age 40 years

Avoiding sun exposure Explanation: While monthly self-examination and awareness of signs of skin cancer may aide in early detection, only avoiding sun will prevent and protect against skin cancer. Clinical examinations are recommended annually.

What can the nurse assess using percussion? Borders of the heart Movement of the diaphragm during expiration Strength of the pulse Rectal distension

Borders of the heart Explanation: Percussion allows the examiner to assess such normal anatomic details as the borders of the heart. Options B, C, and D are incorrect because they cannot be assessed by percussion.

While the nurse performs the initial assessment, the client states "This is my first hospitalization and I have had no previous surgeries." How would the nurse document this information? Client denies prior hospitalizations and surgeries Client has not been hospitalized before nor has he had any surgery Client answered no to previous hospitalizations or surgery Negative for past hospitalizations

Client denies prior hospitalizations and surgeries Explanation: Documentation of the nursing history, whether it is positive or negative, needs to be objective, measurable, and succinct. The statement about the client denying prior hospitalizations and surgeries meets this goal. The statement about the client not having been hospitalized nor having surgery is wordy. The statement about the client answering no to previous hospitalizations or surgery is inappropriate because it denotes how the information was obtained. The statement about negative for hospitalizations, although succinct, is too succinct and does not address the surgery aspect.

A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use? Reflex hammer Tuning fork Tongue depressor Coin or key

Coin or key Explanation: The nurse needs a coin or a key to test the client for stereognosis, which is the ability to recognize objects by touch. A reflex hammer is used to determine deep tendon reflexes. A tuning fork is used to test for vibratory sensation. A tongue depressor is used to test for the rise of the uvula and gag reflex.

Several hours into a shift, the nurse working on a medical-surgical unit observes a change in the client's mental status. Which action should the nurse take first? Perform a comprehensive head-to-toe assessment. Conduct a focused assessment. Notify the health care provider. Alert the critical assessment team.

Conduct a focused assessment. Explanation: Because a comprehensive assessment had already been conducted, the nurse would perform a focused assessment based on the observed neurological changes. The nurse would need to obtain more information before alerting the critical assessment team or contacting the health care provider; some actions would include completing the physical neurological exam, checking blood glucose, checking for changes in medications that may have contributed to the change in mental status, and reviewing the a.m. labs for abnormal sodium level.

A nurse will be assessing many clients and needs an assessment form that will promote easy and rapid documentation, while at the same time allowing the categorization of information. Which assessment form should the nurse use? Open-ended forms Cued or checklist forms Integrated cued checklist Nursing minimum data set

Cued or checklist forms Explanation: Cued or checklist forms promote easy and rapid documentation while categorizing information. Open-ended forms are the traditional forms that individualize information and allow the narrative description of problems. An integrated cued checklist combines assessment data with identified nursing diagnoses. A nursing minimum data set is usually a computerized document and is often used in long-term care facilities.

A nurse observes the presence of hirsutism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process? Iron deficiency anemia Cushing's disease Basal cell carcinoma Lupus erythematosus

Cushing's disease Explanation: Hirsutism, or facial hair, on females is a characteristic feature of Cushing's disease due to an imbalance of adrenal hormones. Iron deficiency anemia may cause loss of hair but not excessive hair. Carcinoma of the skin causes lesions but not facial hairs. Lupus erythematosus causes patchy skin loss but does not cause excessive facial hair.

The nurse is focusing an interview on a client's respiratory status. Which question should the nurse ask first to begin this interview? Do you currently have a cough? Do you have any difficulty producing sputum? Describe how you breathe for me? Do you experience any pain when you breathe?

Describe how you breathe for me? Explanation: During an interview, questions should proceed from general to specific. The question that is the most general is "describe your breathing." This provides the client with an opportunity to discuss the current breathing pattern with the nurse. The other questions are specific and will elicit a yes-no response.

A nurse is providing care to a dark-skinned client of Mediterranean descent. On assessment the nurse observes that the client's lips are bluish and freckled. What is the best action of the nurse? Document the findings as normal. Notify the health care provider. Ask the client if they are cold. Check for signs of blood loss.

Document the findings as normal. Explanation: Although pink lips are normal in light-skinned clients, bluish or freckled lips are normal in some dark-skinned clients, especially those of Mediterranean descent. The buccal mucosa and hard and soft palate will appear darker in dark-skinned clients and pink in light-skinned clients. Because these are normal findings, the nurse does not need to ask the client if they are cold or notify the client's health care provider. Cyanosis occurs with impaired perfusion due to loss of blood volume or poor ventricular pump action; there is no indication of impaired circulation.

The nurse completes documentation for a client. Which statement should be questioned? Apical heart rate 88 and regular Bowel sounds present all 4 quadrants 24/minute Client reports pain as a 4 on a scale from 1 to 10 Dressing on lower leg has some purulent drainage

Dressing on lower leg has some purulent drainage Explanation: The term "some" should be quantified. The amount of drainage on the dressing should be measured. The other statements are appropriately written for documentation.

The client presents to the clinic reporting chest pain and shortness of breath. Which type of health history would the nurse would conduct? Emergency Comprehensive Focused Review of systems

Emergency - ABCs Explanation: Reports of chest pain and shortness of breath can indicate a life-threatening situation, such as myocardial infarction. The nurse needs to quickly collect information regarding the presenting problem and act to stabilize the client. A comprehensive health history would not be appropriate at this time, because information about demographics, family history, functional and psychosocial status, and review of systems is not a priority. A focused assessment is not appropriate for the client presenting with a potential life-threatening situation.

A mother of a client complains of getting no sleep because of excessive snoring from the client every night. The nurse is reviewing with the mother what causes the snoring. Based on this information, what is the best response to the mother of the client about the cause of snoring? Enlargement of the adenoids Elevation of the soft plate Elevation of the uvula Swollen Eustachian tubes

Enlargement of the adenoids Explanation: Enlargement of the adenoids can cause snoring or obstruction of the upper airway. During the act of swallowing, the soft palate and uvula elevate to block the nasal cavity, preventing food from entering the respiratory system. The auditory (Eustachian) tubes connect the nasopharynx with the middle ear.

A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test and pelvic examination. The nurse would implement which action to help reduce the client's anxiety during the physical exam? Ensuring client's privacy by providing an examination gown Providing a comfortable, warm room temperature Arranging exam equipment on a bedside tray table Explaining why standard precautions are being used

Ensuring client's privacy by providing an examination gown Explanation: The client is usually concerned about unnecessary body exposure. Explanation and reassurance that the nurse will protect the client's privacy decreases this anxiety. Providing a comfortable, warm room temperature is appropriate to prevent chilling, but is usually less important to the client than privacy. Arranging exam equipment on a bedside tray table if within the view of the client may add to the client's anxiety. However, arranging the exam equipment would facilitate organization. Explaining why standard precautions are being used may help alleviate some anxiety, but the client probably will not understand what standard precautions are.

A nurse is examining a child who is suspected of having bronchitis and is preparing to auscultate his chest with a stethoscope. Which of the following actions would demonstrate the correct technique for this procedure? Application of firm pressure when using the bell Using the diaphragm to listen to low-pitched sounds Using the bell to detect high-pitched sounds Ensuring that contact with the skin is maintained

Ensuring that contact with the skin is maintained Explanation: While using a stethoscope to listen to air movement through the respiratory tract, the nurse should avoid listening through clothing, as it may obscure or alter the sound. However, too much pressure should not be applied when using the bell, as it would cause it to work like a diaphragm. The diaphragm is used to listen to high-pitched sounds, whereas the bell is used to listen to low-pitched sounds.

The client's demographical/biographical data comprise an important part of the health history. Components include name, address, and billing information as well as other more pertinent areas, such as (check all that apply): Environmental data about exposure to contagious diseases Travel to high-risk areas Current diet Concerns about exposure to pollution, hazards, and allergens List of current medications

Environmental data about exposure to contagious diseases Travel to high-risk areas Concerns about exposure to pollution, hazards, and allergens Explanation: Demographical/biographical data include more that just insurance information and name and address. They include important details about the client's home and work environment, previous travel, and harmful exposures. They do not include a list of medications or current diet.

Which of the following is a normal temperature in centigrade for a healthy adult? oral: 36.8°C rectal: 36.0°C axillary: 37.5°C tympanic: 34.4°C

Explanation: Normal values for temperature fall within a range. Normal values for an oral temperature are around 36.8°C, a rectal temperature around 37.1°C, an axillary temperature around 36.0°C, and a tympanic temperature around 37.0°C.

The nurse is preparing to examine a client's skin. What would the nurse do next? Ensure that the room is hot to prevent chilling. Wear gloves when preparing to inspect the skin and nails. Expose only the body part that is being examined. Have the client remove clothing from the upper body.

Expose only the body part that is being examined. Explanation: When preparing to examine a client's skin, the nurse would expose only the body part to be examined to ensure privacy. The room should be at a comfortable temperature, one that is not too warm or too cool. Gloves are needed when palpating any lesions. The client needs to remove all clothing and jewelry and put on an examination gown.

A nurse is gathering subjective data. Which of the following would the nurse be most likely to assess? Feelings of happiness Posture Mood Behavior

Feelings of happiness Explanation: Subjective data are sensations, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client. Happiness is a feeling and therefore subjective. Posture, mood, and behavior are observable and considered objective data.

When assessing pulses, the nurse would use which part of the hand for palpation? Finger pads Ulnar surface Palmar surface Dorsal surface

Finger pads Explanation: The finger pads are used for fine discrimination such as pulses, texture and size. The ulnar or palmar surface is used for vibrations, thrills and fremitus. The dorsal surface is used for temperature.

A client is having frequent blood pressure and blood glucose measurements to regulate an insulin infusion. Which type of documentation should the nurse use for this data? Checklist Flow sheet Narrative note Specialty assessment form

Flow sheet Explanation: Flow sheets streamline the documentation process and prevent needless repetition of data. A checklist would not be appropriate for this type of data. A narrative note would be too cumbersome. This type of data would not be appropriate for a specialty assessment form.

The review of systems component of the health history is best described as a: Focus on diseases of the major body systems Detailed investigation of questions about major body systems Focus on common questions and issues related to each of the different body systems Series of questions that start at the head and finish at the feet

Focus on common questions and issues related to each of the different body systems Explanation: The review of systems is a systematic method of addressing common questions, symptoms, and issues, rather than specific diseases, of the major body systems. As it is an overview, there should not be a large number or detailed investigation of questions about each system. Given the focus on identifying symptoms, it would be simplistic to describe it as simply a series of head-to-toe questions.

The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is the preceptor talking about? Functional Focused Head-to-toe Body system

Head-to-toe Explanation: A head-to-toe or comprehensive assessment is the most organized system for gathering comprehensive physical data.

The nurse is assessing the seven attributes of a client's symptom using the mnemonic OLD CART. In which section of the comprehensive health history will the nurse document this information? Initial information Review of systems Health patterns History of present illness

History of present illness Explanation: The seven attributes of each principle symptom are documented within the history of present illness within the comprehensive health history. The initial information within the comprehensive health history includes date and time of history, identifying data, and reliability. The review of systems within the comprehensive health history includes the presence or absence of common symptoms related to each major body system. The health patterns section within the comprehensive health history includes personal and social history.

Upon assessing a client who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs? Increased pulse rate Decreased pulse rate Increased temperature Decreased temperature

Increased pulse rate Explanation: When the stroke volume decreases, such as when blood volume is decreased because of hemorrhage, the heart rate increases to try to maintain the same cardiac output.

A new nurse is unfamiliar with the electronic charting system in use at the institution. What positive attribute of electronic charting could the nurse's preceptor emphasize to this new nurse? It maximizes compliance with standards of documentation. It disables the graphing of trends in vital signs or assessment data. It allows several health team members to view the client record simultaneously. It automatically corrects both spelling and grammar.

It allows several health team members to view the client record simultaneously. Explanation: Electronic medical records allow several health care team members to view the client record simultaneously.

Which of the following statements is true of the role of inspection in the physical examination? It should be performed after auscultation but before palpation and percussion. It is often the source of the most physical signs. To maximize findings, local inspection should be conducted prior to general inspection. The acuity of the client will determine whether general or local inspection should be implemented in the examination.

It is often the source of the most physical signs. Explanation: Inspection often yields the most signs during an examination. It should begin the examination, and general inspection precedes local inspection. The two are not mutually exclusive and should both be implemented in each examination.

A nurse documents a client's radial pulse as 2+, indicating which of the following? It occludes easily. It occludes with moderate pressure. It occludes with very firm pressure. It cannot be occluded.

It occludes with moderate pressur e. Explanation: The amount of pressure required to occlude the pulse is rated at a 1+ (easy to occlude) to 3+ (requires firm pressure to occlude). A radial pulse of 2+ is average (normal) and requires moderate pressure to occlude.

What physical assessment technique should a nurse use to obtain a pulse on a client? Light palpation Moderate palpation Deep palpation Bimanual palpation

Light palpation Explanation: The nurse should use the light palpation technique to check the pulse of the client. Moderate and bimanual palpation is used to note the size, consistency, and mobility of the structures that are palpated. Deep palpation enables the nurse to feel very deep organs or structures that are covered by thick muscles.

As the density of tissue decreases, the percussion note becomes: Softer Shorter Lower pitched Less musical

Lower pitched Explanation: Low density tissue tends to produce sound that is lower pitched, musical, loud, and longer in duration than in denser tissue.

An older adult client has been admitted to the hospital with failure to thrive resulting from complications of diabetes. Which of the following would the nurse implement in response to a collaborative problem? Encourage the client to increase oral fluid intake. Provide the client with a bedtime protein snack. Assist the client with personal hygiene. Measure the client's blood glucose four times daily.

Measure the client's blood glucose four times daily. Explanation: Collaborative problems, such as changes in blood glucose, are certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems by implementing both physician- and nurse-prescribed interventions to reduce further complications. Nutrition (oral fluids, bedtime snack) and hygiene are most often considered to be independent nursing concerns.

The nurse is providing care for an 83-year-old woman with a history of hypotension who has been admitted to hospital following a fall. The nurse recognizes the need to assess for orthostatic hypotension. How should the nurse perform this assessment? Alternate the scheduled blood pressure measurements between the standing and lying positions. Measure the client's heart rate and blood pressure while supine then within 3 minutes of standing. Measure the client's blood pressure and heart rate while she is standing then after 10 minutes of lying supine. Estimate systolic blood pressure by palpation while the client is lying, then measure blood pressure when the client is standing.

Measure the client's heart rate and blood pressure while supine then within 3 minutes of standing. Explanation: Orthostatic blood pressure is measured by recording blood pressure and heart rate with the client in two positions supine after the client is resting up to 10 minutes, then within 3 minutes after the client stands up. Usually, as the client rises from the horizontal to the standing position, systolic pressure drops slightly or remains unchanged, while diastolic pressure rises slightly.

When using an interpreter to facilitate an interview, where should the interpreter be positioned? Behind the examiner, so the interpreter can pick up the movements of the lips of the client and the client's nonverbal cues Next to the client, so the examiner can maintain eye contact and observe the nonverbal cues of the client Between the examiner and the client, so all parties can make the necessary observations In a corner of the room, so as to provide minimal distraction to the interview

Next to the client, so the examiner can maintain eye contact and observe the nonverbal cues of the client Explanation: A priority is for the examiner is to have a good view of the client and to avoid having to look back and forth between client and interpreter. The nurse should remember to use short simple phrases while speaking directly to the client and ask the client to repeat back what he or she understands.

A nurse must assess a client's red reflex. Which piece of equipment will the nurse need for this? Ophthalmoscope Tuning fork Otoscope Penlight

Ophthalmoscope Explanation: An ophthalmoscope is used to view the red reflex and to examine the retina of the eye. A tuning fork is used to test for bone and air conduction of sound. An otoscope is used to view the ear canal and tympanic membrane. A penlight is used to view the mouth and throat and to transilluminate the sinuses.

Having completed the general survey of a new client, the nurse will proceed with assessment. Which of the following assessments should the nurse next conduct? Blood pressure Level of consciousness Pain level Heart rate

Pain level Explanation: Because pain results in alterations in all the vital signs, it should be assessed prior to measuring blood pressure, heart rate, respiratory rate, and temperature. Level of consciousness is part of the general survey.

A nurse in the ED is assessing an adult client involved in a motor vehicle collision. What findings during the assessment would indicate that the situation is acute? Select all that apply. Pallor Ruddy cheeks Extreme anxiety Pain Change in mental status

Pallor Extreme anxiety Change in mental status Indicators of an acute situation include extreme anxiety, acute distress, pallor, cyanosis, and a change in mental status. In cases of such acute or urgent findings, the nurse begins interventions while continuing the assessment. Ruddy cheeks and pain are not indicators of an acute situation.

A nurse is palpating a client's chest for vibration as he inhales and exhales. Which part of the hand should the nurse use in this case? Fingertips Palmar surface Dorsal surface Finger pads

Palmar surface Explanation: The ulnar-or palmar-surface is the part of the hand used to palpate vibrations. The fingertips are not used to palpate. The dorsal surface is sensitive to temperature and the finger pads are used to detect fine discriminations, such as pulses, texture, size, consistency, shape, and crepitu

Assessment of the pulse amplitude is accomplished by which of the following? Palpating the flow of blood through an artery Auscultating the area of the left ventricle Palpating the area of the left ventricle Auscultating the flow of blood through an artery

Palpating the flow of blood through an artery Explanation: The pulse amplitude describes the quality of the pulse in terms of its fullness and reflects the strength of left ventricular contraction. It is assessed by the feel of the blood flowing through an artery.

For which assessment would the nurse plan to use light palpation? Papular rash Shape of abdominal mass Size of liver Pulsation of abdominal aorta

Papular rash Explanation: Light palpation is used to assess surface characteristics, such as a papular rash. Deep palpation is used to assess the size, shape, and consistency of abdominal organs.

A nurse observes the gait of an elderly client admitted for surgery. The client's gait is stiff with rigid movements. The nurse should ask this client questions about which disease? Chronic obstructive pulmonary disease (COPD) Parkinson's disease Lordosis of the cervical spine Multiple sclerosis

Parkinson's disease Explanation: A stiff, shuffling, rigid gait is seen in persons with Parkinson's disease due to the destruction of dopamine receptors in the brain that maintain balance between contraction and relaxation of the muscles. COPD clients have no problems with gait except that activity makes them short of breath. Lordosis of the spine is seen in pregnant women occurs in the lumbar area of the spine due to the weight of the developing fetus. Multiple sclerosis causes muscle weakness not rigidity.

The nurse responds to a call light for a client rating their pain "ten out of ten." The nurse's initial inspection reveals the client is watching videos and appears to be at ease physically and emotionally. How should the nurse validate the client's subjective complaint of pain? Ask the client to repeat his rating of his pain in five minutes. Observe the client for several seconds to see if his demeanor or his behavior changes. Consult the client's medication administration record to check for recent analgesic use. Perform further assessments addressing various aspects of the client's pain.

Perform further assessments addressing various aspects of the client's pain. Explanation: Additional questions and assessments would be necessary to validate the apparent inconsistency between the client's self-report and the nurse's observations. Consulting the MAR would be of little benefit, and having him repeat his statement does not provide sound validation.

When assessing a client's respirations, what is most important to include in the documentation? Numerical pain rating Position of the client Assessment of pedal pulses Presence of dyspnea

Presence of dyspnea Explanation: The presence of dyspnea is the most important of the choices listed to include in the documentation. Dyspnea can be an indicator of potential respiratory distress. The presence of pain and position of the client can impact the client's respiratory status, but are not the primary piece of information to include in the documentation. Assessment of pedal pulses is a component of a circulatory assessment.

A client with abdominal pain is admitted from the emergency department. After having a gastrointestinal consultation and numerous tests, the results have been recorded on the client's chart. The nurse knows to look at what part of the client's medical record to check the current medical diagnosis? Demographic data sheet Progress notes Admission history Medication record

Progress notes Explanation: All members of the healthcare team use the progress notes to record the client's progress and any changes. The demographic sheet contains the client's personal information. The admission history states the problems upon admission. The medication record lists all medications that the client has been and are scheduled to be given.

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions? Psoriasis, fungal infections, trauma Vitiligo, hirsutism, vitamin deficiency Eczema, melanoma, herpes zoster Alopecia, dermatitis, chemotherapy

Psoriasis, fungal infections, trauma Explanation: Additional nail problems include psoriasis, fungal infections, and trauma. Vitiligo, vitamin deficiency, eczema, melanoma, and herpes zoster are skin conditions. Hirsutism and alopecia are hair conditions. Vitamin deficiencies and chemotherapy can cause problems with many body systems.

Which characteristic of the gums should a nurse expect to assess in a client who has scurvy? Pink, moist, firm Red, bleeding Enlarged, reddened A grey-white line

Red, bleeding Explanation: Red, swollen, bleeding gums are seen in gingivitis, scurvy, and leukemia. The nurse may find enlarged, reddened gums as an adverse effect of phenytoin treatment. Pink, moist, firm gums are normal findings of the gums. A grey-white line along the gum line is seen in cases of lead poisoning.

A 34-year-old man has come to the clinic to establish care. His chief complaint is that "my skin feels sour, so sour" and he fidgets continuously during the interview. How should the clinician best respond to this statement? Initiate a focused integumentary assessment. Tell the client that the clinician has concerns regarding the client's cognition and orientation. Redirect the conversation to include components of a mental status examination. Explain to the client that his complaint is phrased in an unusual way and that the clinician wants to assess for neurological health problems.

Redirect the conversation to include components of a mental status examination. Explanation: A bizarre description of a problem may prompt suspicions of a neurological or psychiatric health problem and is best addressed by steering the interview toward a mental status assessment.

While conducting a comprehensive assessment on a new client, the client states, "I've had these mouth and tongue sores for a few weeks that do not seem to heal." The nurse assesses the client's mouth and finds thickened lumpy areas with a rough and crusty appearance. What is the best action of the nurse? Document the findings. Refer the client for further evaluation of the sores. Request medication for aphthous stomatitis (canker sores). Recommend the client use over-the-counter mouthwash twice a day.

Refer the client for further evaluation of the sores. Explanation: Lesions that last for more than 2 weeks are not normal and need to be further examined with possible referrals to a specialist. The nurse will document the findings, but nurse will also need to refer the client. Recommending the use of over-the-counter mouthwash twice a day will not be beneficial and will cause pain due to the alcohol contained in most mouthwashes. The client's symptoms symptoms do not indicate canker sores.

The nurse is percussing the area over the lungs and hears a loud, low pitched, hollow sound. The nurse documents this finding as which of the following? Flatness Resonance Tympany Dullness

Resonance Explanation: A loud, low-pitched hollow sound on percussion is termed resonance and is a typical finding over the lungs, which are part air and part solid tissue. Flatness is a soft, high flat sound typically heard over very dense tissue. Tympany is a loud, high-pitched drum like sound heart over air filled areas. Dullness is a medium, medium-pitched thud like sound heard over more solid tissue.

Jason, a 41-year-old electrician, presents to the clinic for evaluation of shortness of breath, which occurs with exertion and improves with rest. The shortness of breath has been occurring for several months. Initially, it happened only a few times a day with strenuous exertion; however, it has started to occur with minimal exertion and is happening more than 12 times a day. The shortness of breath lasts for fewer than 5 minutes at a time. The client has no cough, chest pressure, chest pain, swelling in his feet, palpitations, orthopnea, or paroxysmal nocturnal dyspnea. Which of the following symptom attributes was not addressed in this description? Severity Setting in which the symptom occurs Timing Associated symptoms and signs

Severity Explanation: The interviewer did not record the severity of the symptom, so we have no understanding as to how bad the symptom is for this client. The client could have been asked to rate his pain on a 0 to 10 scale or according to one of the other standardized pain scales available. This allows the comparison of pain intensity before and after an intervention.

For which assessment would the nurse plan to use direct percussion? Sinuses Kidneys Liver Gallbladder

Sinuses Explanation: The nurse performs direct percussion by tapping the fingers directly on the client's skin, such as for assessment of the sinuses. The nurse performs indirect percussion by using the non-dominant hand as a barrier between the nurse's dominant hand and the client to assess organs, such as the gallbladder, kidneys, and liver.

For which assessment would the nurse plan to use deep palpation? Size of liver Macular rash Texture of a mole Skin temperature

Size of liver Explanation: Deep palpation is used to assess the size, shape, and consistency of abdominal organs. Light palpation is used to assess surface characteristics, such as skin temperature, texture of a mole, and a macular rash.

A client arrives in the emergency department in diabetic ketoacidosis. What assessment finding would the nurse expect in this client? Sweet-smelling breath Hypoglycemia Bradycardia O2 saturation of less than 90%

Sweet-smelling breath Explanation: Sweet-smelling breath may indicate diabetic ketoacidosis.

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which of the following observations can be made by the nurse and athletes by measuring the blood pressure? The ability of the arteries to stretch The thickness of the circulating blood The oxygen levels in the blood The volume of air entering the lungs

The ability of the arteries to stretch Explanation: Measuring the blood pressure helps to assess the efficiency of the client's circulatory system. Blood pressure measurements reflect the ability of the arteries to stretch, the volume of circulating blood, and the amount of resistance the heart must overcome when it pumps blood. Measuring the blood pressure does not help in assessing the thickness of blood, oxygen level in the blood, or the volume of air entering the lungs.

During a general survey, the nurse asks if the client is feeling cold. What did the nurse most likely observe in the client? The client is wearing clothing that is inconsistent with warm weather. The client is bouncing both legs up and down while seated. The client has an oral temperature of 37°C (98.6°F). The client's lips are bluish in color.

The client is wearing clothing that is inconsistent with warm weather. Explanation: The question "Are you feeling cold?" would be applicable for the client who is wearing clothing that is inconsistent with warm weather. The question "Are you feeling cold?" would not be appropriate for the client who is bouncing both legs up and down while seated. This could indicate anxiety. An oral temperature of 37°C (98.6°F) is within normal limits while the bluish color of the lips is associated with cyanosis, a respiratory issue.

A nurse who provides care in a hospital setting is creating a plan of nursing care for a client who has a diagnosis of chronic renal failure. The nurse's plan specifies frequent ongoing assessments. The frequency of these nursing assessments should be primarily determined by what variable? The client's age The unit's protocols The client's acuity The nurse's potential for liability

The client's acuity Explanation: The frequency of ongoing assessment is determined by the acuity of the client. This factor is more important than the nurse's liability, the client's age, or the protocols of the unit.

A nurse is obtaining subjective data from an adult client who is new to the clinic. The nurse has asked the client, "Where do you usually turn for help in a time of crisis?" What domain is this nurse assessing? The client's family relationships The client's current level of social and relational stability The client's critical thinking and problem-solving abilities The client's stress management and coping strategies

The client's stress management and coping strategies Explanation: This assessment question helps the nurse ascertain the client's strategies for coping and for managing stress. It does not directly assess social support or family relationships, although these may become apparent from the client's response. This question does not address critical thinking or problem solving.

A nurse is preparing to perform the physical examination of an adult client who has presented to the clinic for the first time. Which statement would guide the nurse's use of a stethoscope during this phase of assessment? Auscultation can be performed through clothing. The diaphragm should be held firmly against the body part. The bell of the stethoscope can detect bowel sounds. The binaurals connect the tubing to the chest piece.

The diaphragm should be held firmly against the body part. Explanation: The diaphragm should be held firmly against the body part being examined. Auscultation should not be performed through clothing because it may obscure or alter sounds. The bell detects low-pitched sounds such as murmurs and bruits. The binaurals are the metal tubing that connects the ear pieces to the tubing.

The nurse is assessing a new client's blood pressure using a manual sphygmomanometer. Which of the following sounds constitutes the client's systolic blood pressure? The first appearance of faint but distinctive tapping sounds The last sound before there is complete and continuous silence The first sound that is audible after the auscultatory gap The transition from tapping sounds to muffled sounds

The first appearance of faint but distinctive tapping sounds Explanation: The systolic blood pressure reading occurs during phase I, which is characterized by the appearance of faint but clear tapping sounds that gradually increase in intensity.

Which of the following statements most accurately provides the underlying rationale for the use of auscultation and percussion as assessment techniques? The nature and elasticity of tissue and body structures influence sound. Pitch and duration of sound depend on each other and allow for conclusions regarding client health. High-intensity sounds indicate compromised tissue integrity, lack of tissue density, or both. Percussion and auscultation findings are more objective than inspection and palpation findings.

The nature and elasticity of tissue and body structures influence sound. Explanation: Because the nature of tissue and elasticity of body structures influence sound, listening and percussing can help examiners gain insights into these parameters. Pitch and duration do not necessarily depend on one another, and it is simplistic to conclude that high-intensity sounds indicate compromised tissue integrity or that percussion and auscultation are more objective than inspection and palpation.

The nurse is assessing a client's radial pulse. What should prompt the nurse to obtain an apical pulse reading? Select all that apply. The radial pulse is irregular. The client's condition calls for a more precise pulse rate. Checking the radial pulse on the other arm results in the same findings. The radial pulse is 90 beats per minute. The pulse is located on the first attempt.

The radial pulse is irregular. The client's condition calls for a more precise pulse rate. Explanation: The nurse should obtain an apical pulse reading if the radial pulse is irregular or if the client's condition calls for a more precise pulse rate. Identical assessment findings on both radial pulses should not prompt the nurse to obtain an apical pulse reading. The radial pulse being 90 beats per minute or being located on the first attempt are not reasons to obtain an apical pulse rate.

The nurse is taking a comprehensive health history on a new client. Why would it be essential for the nurse to obtain a complete description of the present illness? To assess if the client is a reliable historian To obtain primary data To obtain demographic data To establish an accurate diagnosis

To establish an accurate diagnosis Explanation: A complete description of the present illness is essential to an accurate diagnosis.

What is the most important focus area for the integumentary system? UV radiation exposure Chemical exposure Moles with defined borders smaller than 6 mm Washing the face and hands

UV radiation exposure Explanation: Excessive UV radiation is the most important focus area for the integumentary system, because exposure to it has been shown to cause skin cancers, particularly melanoma. Chemical exposure, moles with defined borders smaller than 6 mm, and hygiene of the face and hands are not the most important focus areas for the integumentary system.

The nurse is the primary care provider for a 21-year-old man who, as the result of a brain injury suffered in a mountain-biking accident in his teens, has the cognitive abilities of a 9-year-old. How should the nurse accommodate the client's cognition and comprehension during assessment? Rely on the client's documented history rather than the client interview. Perform objective assessments rather than eliciting subjective information. Use the client's family as a source of information. Address interview questions to the client's mother rather than the client.

Use the client's family as a source of information. Explanation: Limitations on intelligence often require the clinician to use the client's family as a source of assessment data, though it is still appropriate to direct questions to the client himself. It would be simplistic to downplay the interview and rely solely on the written history or to categorically reject subjective assessment.

The nurse is providing care to a newly admitted client with a long history of chronic obstructive pulmonary disease (COPD). According to the client's chart, the client has been taking several inhalers to manage their respiratory condition. The nurse enters the room with the prescribed inhalers to administer them. What action should the nurse take next? Leave the inhalers with the client to self-administer. Validate that the client understands how to use the inhalers. Ask the client if they need any assistance with the inhalers. Provide privacy for the client to administer the inhalers.

Validate that the client understands how to use the inhalers. Explanation: The nurse should not assume that the client knows how to administer their medications. The nurse should always validate information, for example, that the client knows how to properly administer the inhalers. If the nurse does not validate that the client knows how to properly administer medication, the treatment may be ineffective.

An inexperienced nurse has just performed percussion on a client's chest and detected hyper-resonance, which would tend to indicate emphysema. However, the client is 35 years old, appears healthy otherwise, and denies ever having smoked. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case? Repeat the percussion using the nondominant hand. Clarify the data by asking whether the client has experienced any trouble breathing lately. Verify the data by having another nurse come in to perform the percussion. Confirm that the client has truly never been a smoker by asking him.

Verify the data by having another nurse come in to perform the percussion. Explanation: The most appropriate method of validation in this case would be to have another nurse come in to perform the percussion. We know that the nurse is inexperienced, and with all of the other information supplied, it is much more likely that the discrepancy is due to improper percussion technique or faulty interpretation of the sound than it is to the client actually having emphysema. Repeating the procedure with the nondominant hand is not likely to change the results. If the client appears healthy and has not reported breathing difficulty, it is not likely that he has emphysema. If the client has already denied smoking, asking him again will likely only insult him.

The nurse is caring for the client who is receiving heparin. The nurse plans to: Wear clean gloves when administering heparin to the client Recap the needle after administering heparin to the client Perform hand hygiene with alcohol-based gel after administering the heparin Wear a mask when administering heparin to the client

Wear clean gloves when administering heparin to the client (best answer) Explanation: Heparin is an anticoagulant administered subcutaneously in the abdomen, which may expose the nurse to direct contact with the client's body fluids. The nurse wears clean gloves when administering heparin and after administering the heparin does not recap the needle and performs hand hygiene with alcohol-based gel. A mask is not required when administering heparin to the client.

When documenting assessment information in the medical record, what does the nurse know that the assessment information must accurately reflect? Select all that apply. What the nurse assessed from the client's family What the nurse overheard What the nurse heard What the nurse palpated What the nurse observed

What the nurse heard What the nurse palpated What the nurse observed Explanation: Assessment information that nurse enters into the client's record must accurately reflect what the nurse observed, heard, auscultated, palpated, percussed, or smelled. Assessment information does not include what is overheard or what the nurse assessed from the client's family.

The nurse uses the SBAR model when reporting on clients at the change of shift. This type of report incorporates what part of the nursing process? evaluation nursing diagnosis implementation assessment

assessment Explanation: One component of SBAR that is the same as the nursing process is assessment. The others, while part of the nursing process, are not used in the SBAR model. The other components of SBAR are situation, background, and recommendations.

Nurses are aware that "handoff" can significantly increase the risk for errors. Common examples of "handoffs" are as follows (check all that apply): at change of shift when a nurse leaves for lunch when a client is transferred from the PACU to the floor upon admission to the ED when a client is discharged

at change of shift when a nurse leaves for lunch when a client is transferred from the PACU to the floor Explanation: Handoff occurs whenever care of a client transfers from one health provider to another. Standardized reporting at handoffs promotes continuity of care and prevents errors. It does not occur when the client is admitted to the ED or when the client is discharged to home.

What site for taking body temperature with a glass thermometer is contraindicated in clients who are unconscious? Rectal Tympanic Oral Axillary

oral Explanation: Assessing an oral temperature with a glass thermometer is contraindicated in unconscious, irrational, or seizure-prone adults as well as in infants and young children because of the danger of breaking the thermometer in the mouth.

The nursing instructor is teaching nursing students about hand hygiene prior to performing a health assessment. The nursing instructor determines effectiveness of the teaching when the students state that hand hygiene should occur at which point? Select all that apply. before touching a client before eating before leaving a client's room when hands become visibly soiled immediately before glove removal

before touching a client before eating before leaving a client's room when hands become visibly soiled Explanation: Hand hygiene should occur immediately before touching a client, before and after eating, before leaving a client's room, immediately after (not before) glove removal, and when hands are soiled. Hands must be washed with soap and water when they become visibly soiled.

A client's blood pressure is affected by cardiac intake, elasticity of the arteries, blood flow, blood cells, and blood thickness. cardiac intake, elasticity of the veins, blood flow, blood cells, and blood thickness. cardiac output, distensibility of the veins, blood volume, blood velocity and viscosity. cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity.

cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity. Explanation: Blood pressure is the pressure exerted by blood on the walls of the arteries. It is affected by cardiac output, distensibility (elasticity) of the arteries, blood volume, blood velocity, and blood viscosity (thickness).

The nurse observes a student nurse performing a focused assessment on a client presenting with signs and symptoms of appendicitis. The nurse should intervene when the student nurse is observed performing which of the following actions on the client's abdomen? light palpation moderate palpation direct palpation deep palpation

deep palpation Explanation: Deep or bimanual palpation is contraindicated in clients presenting with signs and symptoms of appendicitis, enlarged spleen, or abdominal aortic aneurysm (AAA). Deep palpation may cause rupture of the organ or artery. Moderate palpation should be performed; the client will most likely present with rebound tenderness. Light palpation may be performed to assess rigidity and warmth. Direct percussion is performed to produce sound or elicit pain to assess underlying structures, for example, sinuses and the thorax.

During a comprehensive assessment of the lungs of an adult client with a diagnosis of emphysema, the nurse anticipates that during percussion the client will exhibit hyperresonance. tympany. dullness. flatness.

hyperresonance. Explanation: Hyper-resonance is a sound heard when percussing over the lungs of a client with emphysema.

A 38-year-old client has been admitted to the emergency department (ED) with reports of abdominal pain and vomiting for the past 6 hours. Which type of assessment will the nurse complete on this client? focused assessment comprehensive assessment emergency assessment ongoing assessment

focused assessment Explanation: A focused assessment may occur in all health care settings. It is smaller in scope than a comprehensive assessment, but more in depth related to the problem being presented. It usually involves one or two body systems. Data gathered and analyzed will determine the cause of the client's report. A comprehensive assessment includes the collection of objective data (data gathered during a step-by-step physical examination) and subjective data (the client's perception of the health of all body parts or systems, past health history, family history, lifestyle and health practices, including overall functioning). An emergency assessment is a very rapid assessment performed in life-threatening situations. In such situations (choking, cardiac arrest, drowning), an immediate assessment is needed to provide prompt treatment.

A client reports experiencing chest pain after eating. Which category within the review of systems should the nurse document this information? neurologic cardiovascular gastrointestinal musculoskeletal

gastrointestinal Explanation: Because the client reports "chest pain" after eating, this information is most appropriate for the gastrointestinal system. This pain should not be documented under neurologic or musculoskeletal system. If the chest pain was not associated with eating, then it would be appropriate to document it under cardiovascular

A nurse is caring for a 59-year-old female client admitted with suspected gastrointestinal (GI) bleeding. The nurse anticipates the following vital signs related to the loss of blood volume:

increased heart rate decreased blood pressure When there is a loss of volume in the body, whether blood loss or dehydration, blood pressure will decrease and the heart will try to maintain cardiac output by increasing the heart rate per minute. Respiratory rate will increase and oxygen saturations will decrease with a loss blood volume. Temperature may increase in dehydration states due to the loss of cooling fluid.

The nurse wants to elicit a sound from a client's abdomen. Which technique should the nurse use? direct palpation direct percussion indirect palpation indirect percussion

indirect percussion Explanation: Indirect percussion ensures that the client does not receive direct strikes to the body part being examined. Direct percussion might be painful when assessing the abdomen. Percussion is not divided into direct and indirect approaches.

Osteoporotic thinning and collapse of the vertebrae secondary to bone loss in an elderly client may result in lordosis scoliosis skeletaldosis kyphosis

kyphosis Explanation: In older adults, osteoporotic thinning and collapse of the vertebrae secondary to bone loss may result in kyphosis.

During the review of systems a client states that at times both hands feel numb. In which category should the nurse document this information? neurologic cardiovascular musculoskeletal peripheral vascular

neurologic Explanation: Because the client states numbness of the hands, this information should be included under the neurologic system. Even though the symptom affects the hands, it should not be documented under musculoskeletal. This symptom is not a cardiovascular problem. Peripheral vascular is not a category within the review of systems.

While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using inspection. palpation. Doppler magnification. percussion.

percussion. Explanation: Percussion involves tapping body parts to produce sound waves. These sound waves or vibrations enable the examiner to assess underlying structures.

The nurse is completing a health assessment with a newly admitted client. What should the nurse do after completing the health history? cluster the data document the findings determine a problem list perform a physical examination

perform a physical examination Explanation: The health assessment includes a health history and physical examination. After completing the health history, the nurse should complete the physical examination. Clustering data and determining a problem list would occur after the physical examination is complete. Documentation of the findings would occur while conducting the health history and after completing the physical examination.

The nurse assesses a bed-bound older adult client in the client's home. While assessing the client's buttocks, the nurse observes that an area of the skin is broken. The wound is shallow and dry, and there is no bruising. The nurse should document the client's pressure ulcer as stage I. stage II. stage III. stage IV.

stage II. Explanation: A stage II pressure ulcer is a partial-thickness loss of dermis presenting as either a shallow, open ulcer with a red-pink wound bed, without slough or as an intact or open/ruptured, serum-filled blister. The ulcer is shiny or dry, and there is no slough or bruising. A stage I pressure ulcer presents with intact skin with nonblanchable redness. A stage III ulcer involves full-thickness tissue loss, and subcutaneous fat may be visible. A stage IV ulcer exposes bone, tendon, or muscle.

The review of systems is to be completed next while conducting a comprehensive assessment. Which type of question should the nurse use for this review? narrative yes or no open-ended summative

yes or no Explanation: Review of system questions are usually presented as yes or no. Narrative and summative are not types of questions. Open-ended questions would not be appropriate when completing the review of systems.