H. Assessment prepu

As part of the mental status examination, a nurse assesses the cognitive abilities of a client. Which question should the nurse ask to assess the judgment ability in the client?

"What do you do if you have pain?"

To calculate the ideal body weight for a woman, the nurse allows

100 pounds for 5 feet of height.

A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on a ventilator for 3 weeks. The nurse is completing an initial assessment and evaluating the client's skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter with damage to the subcutaneous tissue. The underlying muscle is not affected. What is the stage of this pressure ulcer?

3

A client with scabies visits the health care facility for a follow-up appointment. Which preparation by the nurse is of greatest priority for the physical examination of this client?

Adequate lighting

In what life stage, defined by Erikson, is group identity important?

Adolescence

When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles?

Attempting to roll the structure up and down and side to side

What can the nurse assess using percussion?

Borders of the heart

Which assessment is most likely performed when a client is admitted to the hospital?

Comprehensive

When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics?

Consistency, delineation, mobility, tenderness (how the move&how they feel)

The nurse asks the client to draw the face of a clock with numbers and hands and to make it read 3 o'clock. What is tested by the completion of this task?

Constructional ability

The nurse reviews growth and development theories in preparation for completing an assessment with an adolescent client. What should the nurse recall about Sigmund Freud's theory when conducting this assessment?

Developed the first formal theory of personality

Which of the following is not released during the stress response?

Dopamine Explanation: The stress response causes the release of epinephrine, norepinephrine, and cortisol.

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?

Ensuring that contact with the skin is maintained

hat factors contribute to the patient's individual makeup? (Select all that apply.)

Ethnicity of patient Nutrition Genetic composition Geographic location Cultural norms

A nurse works at a dermatologist's office and is assessing a client for skin conditions. Which of the following forms should the nurse use?

Focused

A client presents to the health care clinic with reports of a stiff neck for the past 3 days. What objective information can the nurse obtain during the health history using inspection?

Head position

What structure is found midline in the tracheal area just beneath the mandible?

Hyoid bone

Beliefs of health care providers can serve as barriers to an accurate assessment of a client's pain. Which of the following beliefs will not be likely to impair the assessment of pain?

Infants can feel pain and may respond with crying or agitation.

A nurse is describing the importance of fats to the diet to a client. Which of the following functions of fat in the body should the nurse mention? Select all that apply.

Insulating skin and nerve fibers Protecting internal organs Lubricating skin to slow water loss

During general inspection, the examiner:

Integrates visual, auditory, and olfactory data

Examples of objective data include all the following except:

Itchy skin

A nurse must examine the rectum of a woman who has complained of bleeding from the anus and pain on defecating. Which of the following positions would be most appropriate for the client?

Knee-chest

A client feels "like a failure" at work because of the inability to get a promotion. According to Freud, what should the client balance to achieve success and happiness? Select all that apply.

Love Work

You should use the bell of the stethoscope when auscultating what type of sounds?

Low-frequency sounds

What risk factors should the nurse include in a discussion on the occurrence of neck cancer? (Select all that apply.)

Male gender Tobacco use Age older than 50 years

The nurse understands that the best plans for referral or intervention will develop from what part of the nurse-patient interaction?

Ongoing dialogue

problem-oriented medical record (POMR)

Organized around a patient's problems rather than around sources of information. ADVANTAGES are the entire health care team works together identifying a master list of PTs problems and contributes collaboratively to the care plan -Progress notes focus on PT -includes defined database, problem list, care plans, progress notes

A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?

Pulse is felt with difficulty and disappears with slight pressure.

When testing the near reaction, an expected finding includes which of the following?

Pupillary constriction on near gaze; dilation on distant gaze Explanation: During accommodation, pupils constrict with near gaze and dilate with far gaze.

You are educating your patient on taking blood pressure at home. What would be important to include in your patient education?

Routine recalibration of the device

Which of the following statements most accurately conveys an aspect of the gate-control theory?

Specialized cells can decrease pain transmission by exciting inhibitory neurons.

The ulnar edge of the hand is highly receptive to which of the following sensations?

Temperature and vibrations

A nurse is performing indirect percussion of the lungs on a young woman with pneumonia. Which of the following is the correct hand placement for this technique?

The middle finger of one hand is placed on the body surface and the other middle finger strikes.

Which illustrates the nurse using the technique of inspection?

The nurse detects a fruity odor of the patient's breath.

During a general survey, the nurse asks if the patient is feeling cold. What did the nurse most likely observe in the patient?

The patient is wearing clothing that is inconsistent with warm weather.

What outcome should the nurse prioritize when addressing a patient's social, cultural, and spiritual issues?

The patient will express meaning and purpose in life. Explanation: An outcome related to social, cultural, and spiritual issues includes the patient will express meaning and purpose in life

The Joint Commission mandates that nurses assess and reassess a client's pain level. A nurse's healthcare facility mandates pain reassessment at 30 minutes for any drug given intravenously. This mandate is based on what?

The time it takes a pain medication to decrease pain intensity

A clinical instructor is discussing with students the care provided to a client. The instructor asks the student why it is important to make timely entries into the medical record. What would be the student's best answer?

To have up-to-date information on which to base clinical decisions

What is the element of pain transmission that causes nociceptors to perceive a nerve impulse?

Transduction

During this stage of Erikson, the nurse will find the client to be suspicious and fearful.

Trust vs. basic mistrust

A nurse has just discussed with a client the quality, severity, and location of the client's back pain. Which of the following is an appropriate guideline for the nurse to follow when documenting these findings?

Use phrases instead of sentences to record data.

The nurse is assessing a client with a history of drug addiction. What will be helpful in determining interventions that will be most beneficial for providing adequate pain relief to this client?

Using in-depth questions to collect significant data about the client's pain

Upon examination of the head and neck of a client, a nurse notes that the submandibular nodes are tender and enlarged. The nurse should assess the client for further findings related to what condition?

acute infection

The meibomian glands secrete

an oily substance to lubricate the eyes

When the nurse places one hand flat on the body surface and uses the fist of the other hand to strike the back of the hand flat on the body surface, the nurse is using

blunt percussion.

While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's

bone

A client's blood pressure is affected by

cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity.

clinical pathways

case management tools used to communicate the standardized, interdisciplinary plan of care for a particular group of patients; care guidelines and outcomes are specified for each day of the patient's stay; an abbreviated summary of key information taken from the more detailed case management plan.

What is the primary purpose of the patient record?

communication

An elderly client is seen by the nurse in the neighborhood clinic. The nurse observes that the client is dressed in several layers of clothing, although the temperature is warm outside. The nurse suspects that the client's cold intolerance is a result of

decreased body metabolism.

Body temperature is not impacted by which of the following factors?

diet

The apocrine glands are stimulated by what?

emotional stress

A new graduate is caring for a patient of Mexican descent and is overheard telling a coworker that she does not like caring for that particular patient because she is so different. She further states that the patient believes "crazy" things, eats "weird" things and dresses "funny." The nurse is exhibiting which of the following?

ethnocentrism

A client is wearing a hospital gown and sitting on the examination table. What area should the nurse include when completing the general survey?

facial expression

The nurse is preparing to assess a client's thyroid gland using the posterior approach. What direction should the nurse provide regarding the client's head?

flex the neck forward Explanation: When assessing the thyroid gland from the posterior approach the client should flex the neck forward to relax the neck muscles. Tilting the head back would be used if assessing the thyroid gland using the anterior approach. Turning the head to the right or left shoulder would be done later in order to further assess the individual thyroid gland lobes.

A nurse needs to assess a client who is experiencing chronic headache to determine how it is affecting her activities of daily living. Which of the following interventions should the nurse implement?

headache impact test

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

The most commonly used method of percussion is

indirect percussion

Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV.

intact, firm skin with redness ulceration involving the dermis full-thickness skin loss necrosis with damage to underlying muscle

A nurse is using the FLACC (Face, Legs, Activity, Cry, Consolability) scale for pediatric pain assessment to assess for pain in a 6-month-old client. Which of the following findings on this assessment tool would indicate the strongest pain in the client?

kicking

As the density of tissue decreases, the percussion note becomes:

lower

A patient complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent

macular degeneration

Which of the following best describes neuropathic pain?

may be labeled as central pain

A 38-year-old accountant comes to the clinic for evaluation of a headache. The throbbing sensation is located in the right temporal region, and is an 8 on a pain scale of 1 to 10. It started a few hours ago, and she has noted nausea with sensitivity to light; she has had headaches like this in the past, usually less than one per week, but not as severe. She does not know of any inciting factors. There has been no change in the frequency of her headaches. She usually takes an over-the-counter analgesic, which results in resolution of the headache. Based on this description, what is the most likely diagnosis of the type of headache?

migraine

A construction worker in his mid-40s suffered a severe laceration on his leg while on the job site. Soon after he arrives at the emergency room, a nurse assesses his pain. The client states that pain, although severe, has lessened since the accident first occurred. The nurse knows that the pain message likely has been inhibited by release of endorphins and other neurotransmitters. Which physiological process does this represent?

modulation

Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse?

open the mouth

The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess first

preauricular Explanation: The lymph nodes in front of the ear, or preauricular, are usually palpated first. The submental nodes are under the chin. The supraclavicular nodes are located near the clavicle and sternocleidomastoid muscle. The superficial cervical nodes are located superficial to the sternocleidomastoid muscle.

The nurse is discussing weight loss with a client who has risk factors for heart disease. The client states, "I've tried everything already; I'm not willing to try anything else right now." In which stage of change is this client?

precontemplation Explanation: The client is in the precontemplation stage of the change model. The client is not even considering a change at this time. Clients with obesity may have tried several times to lose weight with limited or no success, and they may have given up. In the contemplation stage, clients are ambivalent about change. The client may be willing to assess both benefits and challenges of the change. In the preparation stage of this model, the client would be preparing to embark on the change process. In the maintenance and relapse prevention stage of the model, the client is incorporating the new behavior over the long term.

A nursing student is learning how to use critical thinking in formulating a plan of care. The student understands which of the following to be things needed to demonstrate that the process of thinking critically has begun? (Select all that apply.)

reserves a final opinion until further collecting data explores other alternatives before making a decision uses past knowledge and experience to analyze data

The nurse should ask about or assess which associated factors when a patient complains of cluster headaches? Select all that apply.

rhinorrhea ptosis miosis lacrimation

A nurse is using calipers to assess a client. Which of the following measurements is the nurse taking?

skin fold measurement

The nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that

squamous cell carcinomas are most common on body sites with heavy sun exposure.

The nurse is admitting a 79-year-old man for outpatient surgery. The patient has bruises in various stages of healing all over his body. Why is it important for the nurse to promptly document and report these findings?

the PT may have been abused

A nurse is caring for a client whose injured cells are releasing chemicals such as substance P, prostaglandins, bradykinin, histamine, and glutamate. Which phase of pain is the client experiencing?

transduction

Short, pale, and fine hair that is present over much of the body is termed

vellus.

A nurse assesses a 105-pound adult client who is 5 feet 8 inches tall. What is the estimated body mass index (BMI) for this client?

16 Explanation: The BMI is calculated by dividing weight in pounds by height in inches squared and then multiplying by 703. The body mass index calculated by the nurse should be 16 for a client who is 5 feet 8 inches tall and 105 pounds.

A nurse assesses a 114-pound adult client who is 5 feet 5 inches tall. What is the estimated body mass index (BMI) for this client?

19 BMI Explanation: The BMI is calculated by dividing weight in pounds and height in inches multiplied by 703. The body mass index calculated by the nurse should be 19 for a client who is 5 feet 5 inches tall. Assuming the same height and different weight, such as 120 pounds, the BMI would be 20, whereas for 126 pounds the BMI would be 21, while for 132 pounds the BMI would be 22. The nurse should obtain the client's weight and height to determine his or her body mass index, which can be calculated regardless of the client's gender.

During a comprehensive assessment of an adult client, the nurse can best hear high-pitched sounds by using a stethoscope with a

1½-inch diaphragm.

Which of the following assessment findings suggests a problem with the client's cranial nerves?

A client's extraocular movements are asymmetrical and she complains of diplopia. Explanation: Deficits in cranial nerves III, IV, and VI can manifest as impaired extraocular movements or diplopia. Flashes of light are associated with retinal detachment, while intraocular bleeding and cataracts do not have a neurological etiology.

You are assessing visual fields on a patient newly admitted for eye surgery. The patient's left eye repeatedly does not see your fingers until they have crossed the line of gaze. You would document that the patient has what?

A left temporal hemianopsia Explanation: When the patient's left eye repeatedly does not see your fingers until they have crossed the line of gaze, a left temporal hemianopsia is present.

What data collected during an integumentary assessment should cause the nurse to be concerned that a patient is at risk for the development of skin cancer? (Select all that apply.)

Age 55 years Light-colored hair Actinic keratosis on face Explanation: Risk factors for the development of skin cancer include age over 50, light-colored hair, and actinic keratosis on sun-exposed areas of the body. Poor skin turgor is not a risk factor for the development of skin cancer. Yellow palms of the hands are carotenemia, which is caused by a diet high in carrots and other yellow vegetables and fruits.

A client in a long term care facility has lost 5 lbs of body weight in the past month. Which of the following actions should the nurse take to determine the cause of the weight loss?

Analyze the client's intake record. Explanation: For the client who is in a long-term care facility and is experiencing weight loss, the nurse can utilize the client's intake record to determine daily oral intake. An assessment of caloric and nutritional deficits can be made with this information. Conducting a complete nutritional history would be an inefficient use of time and inappropriate if the client is established at the long term care facility. Asking the client to complete a 24-hour or 2-day food diary would be appropriate only if the client lived at home.

Before assessing vital signs, the nurse knows that it is important to assess what?

Any medication that the patient may be taking

The nurse is caring for a patient who is experiencing visceral pain. What is this patient's most likely diagnosis?

Appendicitis

The nurse is inspecting the cornea and lens of an elderly client and notices a white arc around the limbus of the client's eye. The nurse recognizes this condition, common in older adults, as which of the following?

Arcus senilis Explanation: Arcus senilis, a normal condition in older clients, appears as a white arc around the limbus. The condition has no effect on vision. Presbyopia, which is impaired near vision, is caused by decreased accommodation and is a common condition in clients over 45 years of age. Ectropion is when the lower eyelids evert, causing exposure and drying of the conjunctiva. This is a normal finding in the older client. Myopia is impaired far vision.

A 82 year old female presents with neck pain, decreased strength and sensation of the upper extremities. The nurse identifies that this could be related to what?

Arthritic changes of the cervical spine

The nurse is palpating a client's cervical vertebrae. Which vertebra can be easily palpated when the neck is flexed and should help the nurse locate the other vertebrae?

C7

A nurse is working with a client with a chronic disease that has contributed to the client developing cachexia, a type of malnutrition. As a result, the client demonstrates abnormal metabolic rate, anorexia, muscle wasting, severe weight loss, and general decline in condition. Which chronic disease, strongly associated with cachexia, does the client most likely have?

Cancer Explanation: A population that is particularly at risk for developing malnutrition is the client with cancer. Wasting syndrome, known as cachexia or cancerous or malignant cachexia, can develop. This type of malnutrition is characterized by an abnormal metabolic rate, anorexia, muscle wasting, severe weight loss, and general decline in condition. Cachexia is not associated with cardiovascular disease, diabetes, or osteoporosis.

The nurse is performing an admission assessment on a patient with a diagnosis of pancreatic cancer. The nurse asks the patient about religious preference. The patient states, "Leave me alone about religion. I don't want to talk about it with you!" What is the best intervention by the nurse?

Collaborate with the hospital clergy. If a patient responds negatively to any aspect of the discussion of religion or spirituality, the nurse may collaborate with the hospital clergy or pastoral care department to further assess the situation and patient responses.

While the nurse examines a patient's pupillary response to light in the right eye, the pupil in the left eye is constricted. What does this finding suggest to the nurse?

Consensual reaction Explanation: The consensual reaction is when the pupil constricts in the opposite eye. Myopia is impaired far vision. Presbyopia is impaired near vision often seen in middle-aged and older patients. The direct reaction is when the pupil constricts in the same eye.

A light is pointed at a client's pupil, which then contracts. It is also noted that the other pupil contracts as well, though it is not exposed to bright light. Which of the following terms describes this latter phenomenon?

Consensual reaction Explanation: The constriction of the contralateral pupil is called the consensual reaction. The response of the ipsilateral eye is the direct response. The dilation of the pupil when focusing on a close object is the near reaction. Accommodation is the changing of the shape of the lens to sharply focus on an object.

A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition?

Corrective lenses Explanation: Astigmatism is corrected with a cylindrical lens that has more focusing power in one access than the other. These corrective lenses can and should be worn while driving at night. Eye drops and surgery are not usual treatments for this condition.

A patient asks a nurse if any foods promote eye health. What food would the nurse include as a response?

Deep-water fish Explanation: Foods that promote eye health include deep-water fish, fruits, and vegetables (e.g., carrots, spinach).

The nurse is beginning the examination of the skin of a 25-year-old teacher. She previously visited the office for evaluation of fatigue, weight gain, and hair loss. The previous clinician had a strong suspicion that the client has hypothyroidism. What is the expected moisture and texture of the skin of a client with hypothyroidism?

Dry and rough

An anatomy and physiology instructor is discussing the lymphatic system of the head and neck. Why would the instructor emphasize the importance of the drainage pattern of the lymph?

Enlargement of a node may be a sign of pathology that is distant from that node. Explanation: It is important to understand the drainage patterns of the lymphatics because enlargement of a node may be a sign of pathology that is not directly adjacent to that node.

A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider?

Fixed to underlying tissue Explanation: Normally lymph nodes are round and soft, less than 1 cm in size, mobile from side to side, soft in consistency, and nontender. A fixed lymph node may be seen in metastatic disease.

A nurse needs to examine a client's thyroid as part of the head and neck assessment. How should the nurse instruct the client to position his head to best facilitate this exam?

Flex the head toward the side being examined Explanation: To correctly examine the thyroid, the nurse should stand behind the client and ask him to lower the chin and turn the head toward the side being examined. This action helps to relax the client's neck muscles.

When performing a spiritual assessment, what may help the nurse to identify related nursing diagnoses, needed interventions, and improve patient care?

Gaining relevant information about the patient's spirituality.

The nurse completes her interview of a 39-year-old female client who seems happily married with four healthy children who are doing very well in school and who works part time as a college professor. The nurse would be able to conclude that this client is in which of the following psychosocial developmental stages?

Generativity.

The nurse is reviewing a client's lab data and notes the A1c is 11%. What would the nurse do next?

Give the client 10 units of regular insulin. Explanation: A Hemoglobin A1c of 11% is associated with diabetes mellitus. The health care provider needs to be notified for diagnosis and to determine a treatment plan as 11% is high. The need for insulin, education, and referrals will be determined based on the client's diagnosis.

A nurse is preparing to perform intubation on a client. Which pieces of equipment are needed to prevent the transmission of infectious agents during this procedure? Select all that apply.

Gloves Gown Face shield

A six-month old male infant is brought to the emergency department by his parents for inconsolable crying and pulling at his right ear. When assessing this infant the nurse is aware that the tympanic membrane should be what color in a healthy ear?

Gray Explanation: The healthy tympanic membrane appears pearly gray and is positioned obliquely at the base of the ear canal. This makes options A, B and D incorrect.

An older adult client with COPD has come to the clinic for a routine follow-up visit. The nurse escorts the client to an examination room and measures vital signs. The nurse would expect the patient's vital signs to be what?

Higher than normal Explanation: Many variables can lead to increased vital signs, including pain, stress, anxiety, activity, and chronic disease processes. It is imperative that nurses measure vital signs correctly and accurately, understand the data, and communicate the findings appropriately. COPD is often a result of smoking and likely result in an increase in vital signs. The client's vital signs would be assessed at each clinic visit.

A mother brings her child to the health care clinic and reports that her son has a four-day history of intense itching to his legs. On inspection of the child's legs, the nurse notes a honey-colored exudate coming from a vesicular rash bilaterally. The nurse recognizes this finding as what skin condition?

Impetigo Explanation: Honey colored exudate in a vesicular rash is indicative of impetigo. Most often, a child scratches a bug bite or other lesion that becomes infected with bacteria. These bacteria then produce the characteristic honey colored exudate. Psoriasis does not produce exudate; is not a vesicular rash. It is produced from desquamation of dead epithelial cells. Herpes zoster can produce exudate but it is usually confined to one area of the body (dermatome) and not a diffuse rash. A viral exanthum is a macular or papular rash that is present along with a viral infection.

The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes?

In the midline, a few centimeters behind the tip of the mandible Explanation: The submental lymph nodes are located near the midline, a few centimeters behind the tip of the mandible. Superficial cervical lymph nodes are located superficial to the sternomastoid. The preauricular lymph nodes are located in front of the ear. The tonsillar lymph nodes are located near the mandible.

A patient is diagnosed with an obstruction of the canal of Schlemm affecting the left eye. What assessment data concerning the left noted in the patient's medical record supports this diagnosis?

Increased intraocular pressure Explanation: Aqueous humor is produced by the ciliary body, circulates from the posterior chamber through the pupil into the anterior chamber, and drains out through the canal of Schlemm. This system controls the pressure within the eye. If there is an obstruction of the canal of Schlemm, aqueous humor will not drain, increasing pressure within the eye. An obstruction of the canal of Schlemm will not displace the optic nerve because the optic nerve is located within the posterior portion of the eye. An opaque lens is a cataract, which is not caused by an obstruction of the canal of Schlemm. Pupil reaction is a neurological function not affected by intraocular pressure.

During a comprehensive assessment, the primary technique used by the nurse throughout the examination is

Inspection

A nurse admits a client to the health care facility. The nurse gathers data about the client's social history and wants to make this information ailable to the social worker. Which initial assessment documentation form is best for the nurse to use?

Integrated Cued Checklist

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?

Isolated systolic hypertension

A student nurse learns that especially in the very young and very old pain can be inadequately treated. What else would the student learn about inadequate pain treatment in the very young?

It can lead to neurodevelopmental problems

A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye?

Lacrimal apparatus Explanation: The lacrimal apparatus (which consists of the lacrimal gland, punctum, lacrimal sac, and nasolacrimal duct) protects and lubricates the cornea and conjunctiva by producing and draining tears.

A nurse obtains a client's blood pressure (BP) on admission in both arms: right arm BP is 130/75 mm Hg and left arm BP is 140/80 mm Hg. Which arm should the nurse use for subsequent blood pressure reading?

Left arm Explanation: Blood pressure should be taken in the dominant arm first (right arm for most people). When assessing for the first time, BP should be measured in both arms. Subsequent readings should be taken in the arm with the highest measurement.

A nurse is caring for a patient admitted with neck pain. The patient is febrile. What is the most likely medical diagnosis for this patient?

Meningitis Explanation: Neck pain associated with fever and headache may signify serious illness such as meningitis and should be carefully evaluated.

A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms?

Migraine headache

Which statement about weight should a nurse keep in mind when evaluating a client's nutritional status?

Muscle, bone, fat, and fluid can account for excessive weight

When formulating a nursing diagnosis, the format that is most useful to clearly document the client's problem is

NANDA label (for problem) + related to + etiology + AMB (as manifested by) + defining characteristics.

When providing information to a client concerning the client's osteoarthritic, nociceptive pain, the nurse should include which statements about this type of pain? Select all that apply.

Neurotransmitters like endorphins and histamines regulate this pain. The pain is associated with the inflammatory process. This form of pain can be either chronic or acute in nature.

An older adult presents at the clinic with reports of a painful neck. On palpation, the nurse notes a hard, nonmovable mass, approximately 20 mm, that is painful to touch. The area seems to have several nodes matted together. How would the nurse chart this last finding?

Nodes are delimited on palpation Explanation: Usually, no lymph nodes are palpable in the adult. If a node is palpable, it is important to describe the following characteristics: location—which lymphatic chain and where along that chain is the node; size—in mm or cm; consistency—how hard or soft is the node; mobility—it should be freely movable; delimitation—there should not be any matting together of lymph nodes. The other options are distracters for the question since none demonstrate accurate documentation..

The nurse palpates a client's auricles and notes an elarged lymph node on one ear. No redness is observed, and the client denies pain or tenderness. What is the nurse's best action?

Notify the healthcare provider about the finding. Explanation: Lymph tissue should not be palpable on the ears. Enlarges lymph nodes indicate pathology or inflammation; and the healthcare provider should be notified. Ear drops are not indicated since the node is on the auricle, not in the canal. An audiogram is indicated for hearing loss.

Identify the steps in nociception. (Number 1 is the first step and number 4 is the last step.) You Selected:

Noxious stimuli cause a nerve impulse perceived by free nerve endings. The neuronal signal moves from the periphery to the spinal cord and up to the brain. The impulses being transmitted to the higher areas of the brain are identified as pain. Inhibitory and facilitating input from the brain influences the sensory transmission at the level

When assessing a client's terminal hair distribution, the nurse inspects all the following areas except:

Palmar surfaces Explanation: The palms are one of the few areas not covered with hair, while the limbs, vertex, and eyebrows all have terminal hair present.

The admitting nurse has just met a new patient. As the nurse introduces himself, he begins the process of inspection on this patient. What does the admitting nurse know it is important to do while observing during the process of inspection?

Pay attention to the details while observing

A nursing instructor is discussing nutrition screening and assessment with a clinical group. What would this instructor identify for the students as parts of a complete nutrition screening assessment? Select all that apply.

Physical examination Focused history of common symptoms Serial laboratory values Explanation: Parameters for a complete nutrition screening assessment include a risk assessment, focused history of common symptoms, comprehensive nutritional history, physical examination, calculated measurements, and serial laboratory values (especially during times of high metabolic demand, such as fever, pain, or infection or during limited nutritional intake). Generally speaking, a complete nutrition screening assessment does not include a dietary log or calorie count.

Which precaution should a nurse take to ensure the safety of a client when performing the Romberg test?

Place arms around the client without touching Explanation: During the Romberg test, the nurse should put his or her arms around the client without touching to prevent the client from falling. The eyes are closed to assess the client's ability to maintain equilibrium without looking or holding onto something. The client should not be instructed to hold on to a chair during the test as it may interfere with the assessment of equilibrium. The nurse should not hold the client's arm as it would give support to the client and affect the result.

A nurse in a dermatology clinic cares for an adolescent patient with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this patient?

Pustular acne Explanation: Acne presents as an inflammatory and non-inflammatory skin disorder characterized by one or a combination of the following lesions: comedo, papule, pustule, or cyst. Distribution of acne is frequently on the face, neck, torso, upper arms, and legs, although lesions may occur in other areas.

A nurse is assessing a client for pain who was in a car accident. Which Joint Commission standards should the nurse follow in this case? Select all that apply.

Recognize the right of patients to appropriate assessment and management of pain Screen for the existence of pain Assess the nature and intensity of pain in the client

Since the nurse is unable to obtain an average-sized cuff to assess an adult patient with a large arm, the nurse uses an oversized cuff. What blood pressure reading will the nurse most likely obtain for this patient?

Rrading will be high

When teaching the students about becoming effective diagnosticians, the nursing instructor includes the following common errors made by novice nurses. (Select all the apply.)

See things as either right or wrong. Focus only on the details.

A novice nurse is preparing for a physical examination of a client with neurological issues. The nurse takes a copy of the practice's standard assessment form and heads to the examination room, where the client is already waiting. A senior nurse notes the novice nurse's actions and says, "Here, use this form instead; it's an assessment form specifically for the neurological system." This second form is an example of which type of form?

Specialty area assessment form

A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved?

Sternocleidomastoid

A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis?

Tension

As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test?

The client and the examiner see the examiner's finger at the same time. Explanation: The observation that the client and examiner see the examiner's finger at the same time indicates normal peripheral vision. The client not seeing the examiner's finger or a delay in seeing it indicates reduced peripheral vision. Client's consensual pupils constricting in response to indirect light as well as direct light shown into the client's pupils resulting in constriction are observed when testing the pupils for reaction to light. Eyes converging on an object as it is moved towards the nose is a normal result for accommodation.

An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse?

The client has chronic hypoxia

In her assessment of a client, a nurse finds that the client has soft, spongy, and bleeding gums. The nurse recognizes that this client most likely has a deficiency in which of the following?

Vitamin C Explanation: Soft, spongy, and bleeding gums are a sign of vitamin C deficiency. Iron deficiency is associated with spoon-shaped, brittle, or rigid nails. Vitamin B12 deficiency is associated with a beefy, red tongue. Protein deficiency is associated with thinning, dry hair, edema, and ascites.

The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the following drawbacks?

Vulnerability to legal liability since the nurse's safe, routine care is not recorded.

A female client with a diagnosis of hypothyroidism asks the nurse why she has begun to gain body weight. Which is the best explanation the nurse can provide?

Your metabolism is slowing down." Explanation: The pituitary gland is responsible for the release of thyroid stimulating hormone (TSH). Due to the decreased production of TSH in hypothyroidism, the metabolism slows down resulting in weight gain. Weight gain associated from hypothyroidism is not as a result of fluid retention, though this can be a secondary cause for additional weight gain. Although making healthy food choices and encouraging exercise are important to discuss with any client, these responses do not sufficiently explain this phenomenon.

While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had

a recent illness.

While conducting a physical examination, the nurse notices the client's mucous membranes are pale in color. Which nutritional deficiency is most likely for this client?

anemia Explanation: Pale mucous membranes are common in anemia due to decreased blood flow and/or red blood cells in the body. Vitamin A deficiencies are most likely if the signs and symptoms include petechiae, ecchymoses, or poorly healing sores. A protein deficiency is most likely if there is the presence of edema, abdominal distension, or muscle wasting. A vitamin C deficiency is most likely if the client reports muscle and joint pain, bleeding gums, or poorly healing wounds.

A teenaged client is seen by the nurse for report of excessive thirst and weight loss despite high food intake. Which health condition is most likely responsible for these symptoms?

diabetes mellitus Explanation: Diabetes mellitus, juvenile onset, is characterized by symptoms of excessive thirst (polydipsia) and weight loss despite hunger and high food intake as a result of metabolic changes associated with this condition. Symptoms associated with hypothyroidism include decreased appetite, lethargy, and weight gain. Symptoms associated with protein deficiency often include problems related to quality of skin, hair, and nails. The primary characteristic of anorexia is intentional food restriction.

The nurse has tested an adult client's visual fields and determined that the temporal field is 90 degrees in both eyes. The nurse should

document the findings in the client's records. Explanation: Validate the eye assessment data that you have collected. This is necessary to verify that the data are reliable and accurate. Document the assessment data following the health care facility or agency policy.

A nurse is administering prescribed medicine to a client who experienced acute pain in the lower back after a motor vehicle accident. The client tells the nurse that compared to the previous week, his pain had reduced considerably. Which phase of pain is the client experiencing?

modulation

The nursing student demonstrates understanding of the different types of patient problems when he identifies which of the following to be a collaborative problem?

risk for complication: pneumothorax

Charting by exception (CBE)

shorthand method for documenting patient data that is based on well-defined standards of practice; only exceptions to these standards are documented in narrative notes ADVANTAGES less time needed for charting, greater emphasis on significant data, easy retrieval of significant data, better tracking of PT's response, less money. -limited usefulness when trying to prove that high-quality safe care was given if negligence claim is made against a nurse

While assessing the head and neck of an adult client, the client tells the nurse that she has been experiencing sharp shooting facial pains that last from 10 to 20 seconds but are occurring more frequently. The nurse should refer the client for possible

trigeminal neuralgia.

A nurse is interviewing a client as part of a routine examination of his ears and hearing. The nurse notes that this client has high blood pressure. Which of the following questions regarding his hearing should the nurse ask that is associated with his high blood pressure?

"Do you experience any ringing, roaring, or crackling in your ears?" Explanation: Ringing in the ears (tinnitus) may be associated with excessive ear wax buildup, high blood pressure, or certain ototoxic medications. None of the other questions pertains to conditions related to high blood pressure. Ear pain is associated with ear infections, cerumen blockage, sinus infections, teeth and gum problems, and swimmer's ear. Drainage usually indicates infection. Hearing loss may be related to any number of causes but is not associated with high blood pressure.

Which of the following examples of documentation best exemplifies sound clinical documentation practices?

"Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter."