H. Assessment prepu

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.

What can the nurse assess using percussion?

Borders of the heart

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.

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 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

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

During general inspection, the examiner:

Integrates visual, auditory, and olfactory data

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 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

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

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.

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.

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

Trust vs. basic mistrust

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

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.

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

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.

What is the primary purpose of the patient record?

communication

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

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

lower

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

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

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 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

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

skin fold measurement

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.

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

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

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."

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 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.

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

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

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.

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

Comprehensive

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

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

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 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

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.

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

Inspection

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

Examples of objective data include all the following except:

Itchy skin

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.

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 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.

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

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

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.

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

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

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.

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

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

Temperature and vibrations

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

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

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 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.

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.

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.

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

diet

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

Which of the following best describes neuropathic pain?

may be labeled as central pain

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.

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.