Module 2: Health Promotion and Disease Prevention.

A client of Asian American descent tells the nurse he is considering using acupuncture to deal with low back pain due to strained muscles. Which question is most appropriate to ask the client? "Have you considered physical therapy first?" "Are you currently taking any anticoagulants?" "Have you thought about seeing a chiropractor?" "Can you increase your intake of rice and raw fish in your diet?"

"Are you currently taking any anticoagulants?" RATIONALE: Acupuncture involves inserting needles into tissues, therefor to prevent bleeding, it is crucial to know if the client is currently taking anticoagulants. Physical therapy and chiropractor treatments are alternative methods of treating low back pain, but the client has expressed a desire for acupuncture. The nurse should assess what the client believes is causing the illness before suggesting diet changes. TEST-TAKING STRATEGY: Use Maslow's Hierarchy of Needs Theory to support selecting the option that prevents client harm from bleeding. Eliminate the comparable or alike options that recommend another treatment the client may not desire.

A nurse is gathering subjective data from an adult client about the client's daily food intake. Which question should the nurse ask the client first? "Do you do your own shopping?" "Have you ever heard of MyPlate?" "Can you tell me what you ate and drank over the last 24 hours?" "Do you have adequate income to purchase the foods you need?"

"Can you tell me what you ate and drank over the last 24 hours?" RATIONALE: The first question the nurse should ask the client would provide data about the client's typical daily intake. Once this has been determined, the nurse would collect data regarding who shops and prepares the food and whether the client has adequate income to purchase healthy food. The nurse might ask the client about MyPlate before teaching the client about healthy eating habits; however, the nurse would use it as a guide for teaching nutrition regardless of whether the client has heard of it.

The clinic nurse, performing a physical examination of an adult client, is gathering subjective data about the client's lifestyle. When asked about alcohol, the client tells the nurse that he does drink on a daily basis. Based on this finding, which question should the nurse ask next? "What type of alcohol do you drink?" "Have you ever passed out after drinking alcohol?" "Does your drinking affect your work or home life?" "How frequently do you drink, and how much alcohol do you consume?"

"How frequently do you drink, and how much alcohol do you consume?" RATIONALE: Once it has been determined that the client uses alcohol, the nurse should next determine how frequently the client drinks and how much alcohol is consumed. This information will assist the nurse in determining whether the client has a substance abuse problem and provide a baseline for asking the client additional sensitive questions. Asking the client the type of alcohol he drinks, whether he has ever passed out as a result of drinking alcohol or whether his drinking affects his home life may all be appropriate questions, but the nurse would first ask about frequency and amount of alcohol consumed.

A nurse provides information to a client about measures to prevent infection with West Nile virus. Which statement by the client indicates a need for further information? "I need to avoid wooded or swampy areas when I'm outdoors." "I don't need to use insect repellent if my clothes are covering my skin." "I should wear clothing that covers all of my skin, and I should wear a hat." "I should stay indoors at dusk and dawn, when mosquitoes are most active."

"I don't need to use insect repellent if my clothes are covering my skin." RATIONALE: West Nile virus is associated with mosquito bites. The nurse should instruct the client to wear a hat and clothing that covers as much skin as possible when outdoors and to spray insect repellant containing DEET (N, N-diethyl-m-toluamide) on clothes that cover the skin. Mosquitoes are most prevalent in wooded and swampy areas and are most active at dusk and dawn.

36. A nurse is preparing to check the breath sounds of a client. Over which anatomic area does the nurse place the stethoscope when auscultating for bronchial breath sounds?

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The nurse prepares to listen to Sara's breath sounds. In which area should the nurse place the diaphragm endpiece of the stethoscope to assess bronchial breath sounds?

1 RATIONALE: Bronchial (tracheal) sounds are high-pitched, harsh, hollow, tubular sounds, normally heard over the trachea and larynx. Bronchovesicular sounds are moderately pitched and heard over the major bronchi. Vesicular sounds are low-pitched, with a rustling quality, and heard over the peripheral lung fields.

A nurse performing a skin assessment of a client with heart failure notes that the client's ankles are swollen. To assess the severity of the edema, the nurse presses the skin at the ankle. Moderate pitting is present, but the indentation subsides rapidly. How should the nurse document this finding? 1+ edema 2+ edema 3+ edema 4+ edema

2+ edema RATIONALE: Edema is the accumulation of fluid in the intercellular spaces. To check for edema, the nurse presses the thumbs firmly against the ankle malleolus. If the pressure leaves a dent in the skin, pitting edema is present. Edema is graded on a 4-point scale: 1+ indicates mild pitting with a slight indentation, 2+ is moderate pitting in which the indentation subsides rapidly, 3+ represents deep pitting in which the indentation remains for a short time and the ankle is swollen, and 4+ denotes very deep pitting in which the indentation remains for a long time and the ankle is very swollen. TEST-TAKING STRATEGY: Focus on the subject of the question, which is assessment for edema. Noting the words "indentation subsides rapidly" and knowing the grading scale used to assess edema will direct you to the correct option. Review: the grading scale used to assess edema.

A nurse is using a Snellen chart to assess a client's visual acuity. The client stands 20 feet from the chart, and each eye is tested separately. The client is able to read the line comprising the letters P, E, C, F, and D with each eye. The nurse encourages the client to read the next smallest line with each eye, but the client is unable to do so. How does the nurse document the client's vision? 20/40 40/20 20/30 60/20

20/40 RATIONALE: The Snellen chart is placed in a well-lit spot and the client stands 20 feet away, with the chart at eye level. Each eye is tested separately (one eye is covered), and the client is asked to read through the chart to the smallest line of letters possible. The client is also encouraged to read the next smallest line also. Findings are recorded as a comparison between what the client can read at 20 feet and the distance at which a person with normal vision can read the same line. A reading of 20/40 means that the client is able to see at 20 feet from the chart what a healthy eye can see at 40 feet. Normal visual acuity is 20/20. TEST-TAKING STRATEGY: First recall that normal visual acuity is 20/20. Next focus on the subject - the letters the client can read and note the measurement of this line. This will help direct you to the correct option. Review: Snellen chart.

The nurse is preparing to listen to Sara's apical heartbeat. In which area should the nurse place the diaphragm's endpiece to auscultate the area of the mitral valve?

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. A nurse reviewing the medical record of a client with the diagnosis of heart failure notes documentation indicating that the client has deep pitting edema, that the indentation remains for a short time, and that the leg looks swollen. How should the nurse document this finding? 1+ edema 2+ edema 3+ edema 4+ edema

3+ edema

A nurse is performing a peripheral vascular assessment. In which anatomic area should the nurse place the fingertips to assess the dorsalis pedis pulse?

4 RATIONALE: The dorsalis pedis pulse is located just lateral and parallel to the extensor tendon of the great toe (the top of the foot). The femoral artery is located in the groin. It extends down the thigh and branches to other arteries. The popliteal artery is located behind the knee. The anterior tibial artery is located on the front of the lower leg and extends from the knee to the ankle area. TEST-TAKING STRATEGY: Focus on the subject - the anatomic location of the dorsalis pedis pulse. Noting the word "pedis" in the question will assist you in determining that the pulse is in the foot. Review: anatomic locations of peripheral pulses.

The nurse has educated Shannon about BSE. The nurse realizes the education was effective if Shannon states that she will perform this examination how frequently? The first day of each month 7 days after the start of menstruation 14 days after the start of menstruation The 10th day of each month

7 days after the start of menstruation RATIONALE: Breast self-examination (BSE) should be performed monthly at a regular time when the breasts are not tender. In premenopausal women, the best time is 7 days after the start of menstruation. At this time, hormonal stimulation of the breasts is at its lowest point. Postmenopausal clients and clients who have undergone hysterectomy should select a specific day of the month and perform BSE each month on that day. First day of each month, 14 days after the start of menstruation, and the 10th day of each month are incorrect times to perform BSE.

A nurse is reviewing the findings of a physical examination that have been documented in a client's record. Which piece of information does the nurse recognize as objective data? The client is allergic to strawberries. The last menstrual period was 30 days ago. The client takes acetaminophen for headaches. A 1 × 2-inch (5 cm) scar is present on the lower right portion of the abdomen.

A 1 × 2-inch (5 cm) scar is present on the lower right portion of the abdomen.

28. A client complains that he feels as though his ear is blocked and tells the nurse that he has a history of cerumen impaction in the external ear. What should the nurse check for when inspecting the ears for cerumen impaction? Redness and swelling of the tympanic membrane An external auditory canal that is longer than normal The presence of edema in the external auditory canal A yellowish or brownish waxy material in the external auditory canal

A yellowish or brownish waxy material in the external auditory canal

What objective assessment would determine that the tympanic membrane finding is normal? A red membrane A white membrane A yellow-amber membrane A shiny, translucent membrane

A shiny, translucent membrane RATIONALE: The normal tympanic membrane is translucent, shiny, and pearly gray. It is free of tears and breaks. A bulging pink or red membrane indicates inflammation. A white membrane denotes the presence of pus behind the membrane. A yellow-amber color indicates serous otitis media.

35. A nurse listening to a client's chest to determine the quality of vocal resonance asks the client to repeat the word "ninety-nine" as the nurse listens through the stethoscope. As the client says the word, the nurse is able to hear the word clearly. The nurse documents this assessment finding in which way? Normal egophony Abnormal vesicular breath sounds Abnormal bronchophony Normal whispered pectoriloquy

Abnormal bronchophony

22. A nurse assessing a client's eyes notes that the pupils get larger when the client looks at an object in the distance and become smaller when the client looks at a nearby object. How does the nurse document this finding? Myopia Hyperopia Photophobia Accommodation

Accommodation

A nurse is preparing to administer the diphtheria/tetanus/acellular pertussis vaccine (DTaP) to a 6-month-old infant. Which action should the nurse take to minimize the potential for a local reaction to the vaccine? Using a 1.5-inch (3.8 cm) needle for injection Administering the injection in the deltoid muscle Administering the injection in the vastus lateralis muscle Changing the needle on the syringe after drawing up the vaccine

Administering the injection in the vastus lateralis muscle RATIONALE: To minimize the potential for a local reaction to a vaccine, the nurse selects a needle of adequate length to deposit the vaccine deep into the muscle mass. The vaccine is injected into the vastus lateralis muscle or ventrogluteal muscle (the deltoid may be used in children 18 months of age or older). Changing the needle on the syringe after drawing up the vaccine and before injecting will not decrease the possibility of a local reaction.

5. A client is brought to the emergency department after a motor vehicle accident. The client is alert and cooperative but has sustained multiple fractures of the legs. How should the nurse proceed with data collection? Collect health history information first, then perform the physical examination Ask health history questions while performing the examination and initiating emergency measures Collect all information requested on the history form, including social support, strengths, and coping patterns Perform emergency measures and not ask any health history questions until the client's fractures have been treated in the operating room

Ask health history questions while performing the examination and initiating emergency measures

A clinic nurse is performing a mental status examination of a client. Which action should the nurse take to test the client's remote memory? Asking about the client's first job Asking what time the client left home to come to the clinic Asking what method of transportation the client used to get to the clinic Reciting four unrelated words and asking the client to repeat them at various points later in the assessment

Asking about the client's first job

A nurse is preparing an ambulatory male client for a rectal examination. After the examination has been explained to the client, into what position should the nurse assist the client? Sims Supine Left lateral Bending forward resting upper body on exam table

Bending forward resting upper body on exam table RATIONALE: In a rectal examination, the male client is asked to bend forward, with his hips flexed and his upper body resting on the examination table. The lithotomy position may be used for this examination in a woman after examination of the genitalia is complete. A nonambulatory client may be examined while in the left lateral (Sims) position. A rectal examination could not be performed if the client were in the supine position.

31. A nurse is preparing to test cranial nerve I. Which item does the nurse obtain to test this nerve? Coffee A tuning fork A wisp of cotton An ophthalmoscope

Coffee

An adult client tells the clinic nurse that he is susceptible to middle ear infections. About which risk factor related to infection of the ears does the nurse question this client? Loud music Use of power tools Occupational noise Exposure to cigarette smoke

Exposure to cigarette smoke

6. A client who was given a diagnosis of hypertension 3 months ago is at the clinic for a checkup. Which type of database does the nurse use in performing an assessment? Emergency Follow-up Complete (total) Problem-centered

Follow-up

A nurse is making an initial home visit to a client with chronic obstructive pulmonary disease who was recently discharged from the hospital. Which type of database does the nurse use to obtain information from the client? Episodic Follow-up Emergency Complete

Follow-up

A nurse is performing a throat assessment on an assigned client. On asking the client to stick his tongue out, the nurse notes that it protrudes in the midline. Which of the following cranial nerves is the nurse testing? Cranial nerve X Cranial nerve V Cranial nerve IX Cranial nerve XII

Cranial nerve XII

A nurse inspecting a client's throat touches the posterior wall with a tongue blade and elicits the gag reflex. The nurse documents normal function of which nerve? Cranial nerve V Cranial nerve XII Cranial nerves I and II Cranial nerves IX and X

Cranial nerves IX and X

7. A Mexican-American client with epilepsy is being seen at the clinic for an initial examination. What is the primary purpose of including cultural information in the health assessment? Confirm the medical diagnosis Make accurate nursing diagnoses Identify any hereditary traits related to the epilepsy Determine what the client believes has caused the epilepsy

Determine what the client believes has caused the epilepsy

The nurse is performing an assessment of a client who is African American. Which question should the nurse ask to elicit information on a health risk associated with this cultural group? Does anyone in your family have arthritis? Does anyone in your family have thalassemia? Does anyone in your family have tuberculosis? Does anyone in your family have hypertension?

Does anyone in your family have hypertension? RATIONALE: The incidence of hypertension varies significantly among races and cultural groups. Hypertension is more prevalent among African Americans than among European Americans. Arthritis, thalassemia and tuberculosis are not health risks specific for the client who is African American

The nurse, obtaining subjective data, asks Dianne about her perception of her health. Dianne again tells the nurse that the stress of her job is the reason for her not being able to take good care of herself. After gathering additional information about Dianne's stressful life, what action should the nurse take next? Suggesting that Dianne find another job Telling Dianne to ignore the stress at work Encouraging Dianne to participate in a stress-management program Telling Dianne how important it is for her to forget about her work once the workday is over

Encouraging Dianne to participate in a stress-management program RATIONALE: Assessment of health perception is focused on the client's perceived level of health and well-being and on personal practices for maintaining health. Because Dianne has said that stress is the cause of her health problems, the nurse would suggest and encourage participation in a stress-management program. Finding another job is an unrealistic expectation and could cause even more stress. Although trying to forget about her work at the end of the workday and ignoring stress at work are strategies for alleviating stress, both are easier said than done. This client needs to learn methods for managing the stress.

14. A clinic nurse about to meet a new client and plans to gather subjective data regarding the client's health history. Which actions should the nurse take to help ensure the success of the interview? Select all that apply. Ensuring that the room is private Seeing that distracting objects are removed from the room Having the client sit across a desk or table to give the client some personal space Maintaining a distance of 2 feet (60 cm) or closer between the nurse and client. Switching on a dim light that will make the room cozier and help the client relax

Ensuring that the room is private Seeing that distracting objects are removed from the room

The nurse helps the health care provider perform a Pap test on Shannon. When should the nurse instruct Shannon to receive follow-up testing? Yearly Every 3 years Every 5 years Every 6 months

Every 3 years The American Cancer Society (ACS) recommends that all women begin cervical cancer screening at 21 years of age; screening should be performed every 3 years until age 29. Beginning at age 30, women who have had three normal Pap results in a row may be screened every 5 years along with a human papillomavirus (HPV) test. Women 65 years or older who have had no abnormal Pap results in the preceding 10 years and no pre-cancers such as CIN2 or CIN3 may choose to stop having Pap tests

13. A client complains that her skin is redder than normal. The nurse assesses the client's skin, documents hyperemia, and explains to the client that this condition is caused by which? Contraction of the underlying blood vessels A reduced amount of bilirubin in the blood Diminished perfusion of the surrounding tissues Excess blood in the dilated superficial capillaries

Excess blood in the dilated superficial capillaries

A nurse is preparing to listen to the apical heart rate in the area of the mitral valve in an adult client. The nurse should place the stethoscope at which location on the client's chest? Second left interspace Second right interspace Left lower sternal border Fifth left interspace at the midclavicular line

Fifth left interspace at the midclavicular line

29. A nurse is palpating a client's sinus areas. Which sensation does the nurse expect the client to indicate that he or she is feeling during palpation if the sinuses are normal? Firm pressure Pain behind the eyes Pain during palpation Pressure producing an acute headache

Firm pressure

A nurse at a health fair is conducting teaching sessions on dietary measures to help prevent cancer. Which foods should the nurse encourage clients attending the teaching sessions to eat as a means of preventing cancer? Select all that apply. Fruits Red meats Vegetables Foods low in fiber High-nitrate foods

Fruits Vegetables RATIONALE: Dietary factors related to the development of cancer include foods that are high in fat and low in fiber, foods that are high in animal fat, high-nitrate foods, and those that contain preservatives, contaminants, and additives. Therefore, of the options provided, fruits and vegetables are the food items whose consumption should be encouraged as a means of preventing cancer.

The health care provider recommends that Dianne undergo a physical examination, including laboratory studies, before she starts exercising. Which tests are appropriate for assessment of Dianne's nutritional status? Select all that apply. Hemoglobin Serum creatinine Serum transferrin Serum triglycerides Total thyroxine (T4) Serum glucose level (fasting)

Hemoglobin Serum transferrin Serum triglycerides Serum glucose level (fasting)

39. A nurse is assessing a client for the major risk factors associated with coronary artery disease (CAD). Which modifiable risk factor does the nurse obtain data on from the client? Age Ethnicity Hypertension Genetic inheritance

Hypertension

The nurse is participating in a planning session for public health services that promote primary prevention. The nurse should guide the group into selecting to focus on which aspects? Select all that apply. Immunizations Pollution control An exercise regimen Cardiac rehabilitation Self-examination practices Diabetes mellitus management

Immunizations Pollution control An exercise regimen Primary prevention activities are those that prevent disease or dysfunction, including health-education programs and wellness activities that maintain or improve health. Examples of primary prevention include immunizations, pollution control, nutrition, and exercise. Secondary prevention activities are focused on clients who are experiencing health problems, on activities such as screening techniques (self-examination practices, mammography, blood pressure screening), and on treatment of disease at an early stage to limit disability. Tertiary prevention is focused on rehabilitation to minimize the effects of a long-term disease and to assist clients in achieving the highest possible level of function. Examples include cardiac rehabilitation and diabetes mellitus management.

A client with peripheral artery disease tells the nurse that pain develops in his left calf when he is walking and subsides with rest. The nurse determines the client is likely experiencing which disorder? Venous insufficiency Intermittent claudication Sore muscles from overexertion Muscle cramps related to musculoskeletal problems

Intermittent claudication

The nurse begins the physical examination by taking Sara's vital signs and her height and weight; on noting that these measurements are within the normal ranges, she proceeds with the physical examination. The nurse assesses Sara's vision and prepares to perform the confrontation test. Sara asks the nurse about the purpose of this test. What should the nurse tell Sara about the test? It is used to assess near vision. It is used to assess color vision. It is used to assess distant vision. It is used to assess peripheral vision.

It is used to assess peripheral vision. RATIONALE: The confrontation test is a measure of peripheral vision in which the client's peripheral vision is compared with the nurse's under the assumption that the nurse's peripheral vision is normal. The client covers one eye and looks straight ahead, and the nurse (positioned 2 feet away) covers his or her own eye opposite the client's covered eye. The nurse advances a finger or another small object in from the periphery from several directions; the client should see the object at the same time the nurse does. Near vision is tested with the use of a hand-held vision screener or by asking the client to read from a magazine or newspaper. The Ishihara chart is a tool used to assess color vision. It reveals the client's ability to distinguish a pattern of color (a number) in a series of color plates. Distant vision is measured with the use of the Snellen eye chart. TEST-TAKING STRATEGY: Focus on the subject - confrontation test. Recall the test that is performed for each vision issue in each option. To answer correctly it is essential to know that the confrontation test assesses peripheral vision. Review: visual testing. QUESTION CATEGORIES:

A nurse performing a musculoskeletal assessment is inspecting the posterior aspect of the client's posture as the client stands. After noting an exaggeration of the posterior curvature of the client's thoracic spine, how does the nurse document this finding? Lordosis Scoliosis Kyphosis Osteoporosis

Kyphosis RATIONALE: Kyphosis, or hunchback, is an exaggeration of the posterior curvature of the thoracic spine. Lordosis, or swayback, is an increased lumbar curvature. A lateral spinal curvature is called scoliosis. Loss of height is frequently an early sign of osteoporosis.

The nurse is observing a new nurse employee assess a client's dorsalis pedis pulse. The nurse realizes the new nurse is using correct technique if the nurse places the fingertips on which part of the client's body? Behind the knee Lateral to the extensor tendon of the big toe In the groove between the malleolus and the Achilles tendon Below the inguinal ligament, halfway between the pubis and the anterior superior iliac spines

Lateral to the extensor tendon of the big toe

34. A nurse is preparing to auscultate the breath sounds of a client. The nurse should use which technique? Ask the client to lie prone Ask the client to breathe in and out through the nose Hold the bell of the stethoscope lightly against the chest Listen for at least one full respiration in each location on the chest

Listen for at least one full respiration in each location on the chest

A nurse is preparing a client for a Papanicolaou test. Into which position does the nurse assist the client for this examination? Sims Supine Lateral Lithotomy

Lithotomy RATIONALE: A Papanicolaou test (a.k.a. "Pap smear") is performed during the speculum examination of the internal genitalia. In this test, a smear of tissue is obtained and then tested for cervical or vaginal cancer. The client is placed in the lithotomy position for this examination. The positions in the other options would not allow the examiner to perform the speculum examination, which is necessary for the smear to be obtained.

The nurse is planning care for an assigned client. The nurse should include information in the plan of care about prevention of human immunodeficiency virus (HIV) for which individuals specifically at risk? Lesbian persons Men who have sex with men Women who have sex with women Female to male transgender persons

Men who have sex with men RATIONALE: Men who have sex with men are at a higher risk for HIV and Acquired Immunodeficiency Syndrome (AIDS). Although anyone who is sexually active should be counseled on prevention of sexually transmitted infections, the other populations mentioned are not at increased risk for HIV/AIDS. TEST-TAKING STRATEGY: Eliminate comparable or alike options that mention women, because men who have sex with men are the most likely to contract HIV/AIDS.

20. A nurse notes that a client's physical examination record states that the client's eyes moved normally through the six cardinal fields of gaze. How should the nurse interpret this data? Normal near vision Normal central vision Normal peripheral vision Normal ocular movements

Normal ocular movements

A nurse performing an examination of a male client's genitalia notes the presence of a foul-smelling white discharge from the urethral meatus. Which action is the most appropriate response to this finding? Obtaining a culture of the discharge Informing the client that the discharge is normal Asking the client about the possibility of the presence of an STI Informing the client that his sexual partners will need examinations

Obtaining a culture of the discharge RATIONALE: When a discharge is noted during examination of the male genitalia, a culture of the discharge is obtained. A foul-smelling white discharge from the urethral meatus is not a normal finding. Informing the client that his sexual partners will need an examination is premature; however, if an STI is diagnosed, this will be an important intervention. Asking the client about the possibility of an STI is a component of obtaining subjective data, so this information should have been obtained before objective data were collected. TEST-TAKING STRATEGY: First note the strategic words "most appropriate". Also consider the words "foul-smelling discharge". Realizing that this is not a normal finding should direct you to select the most appropriate action to carry out first. Review: examination of the male genitalia.

A nurse is preparing to perform a Rinne test on a client who complains of hearing loss. In which area does the nurse first place an activated tuning fork? On the client's teeth On the client's forehead On the client's mastoid bone On the midline of the client's skull

On the client's mastoid bone

A client is experiencing a change in vision. The nurse performing an eye examination uses an ophthalmoscope to best visualize which area? Iris Cornea Optic disc Conjunctiva

Optic disc

SEQUENCING Arrange the sequence options in the correct order by assigning each option a number. Order Sequencing Option Palpate Percuss Auscultate Inspect

Order Sequencing Option Inspect Auscultate Palpate Percuss

A nurse is performing an abdominal assessment of a client who complains of right upper quadrant pain. Which technique should the nurse use to palpate the abdomen? Palpating tender or painful areas last Tapping the client's skin with short, sharp strokes Using both hands and knead deeply into the abdomen Starting with deep palpation, then performing light palpation

Palpating tender or painful areas last RATIONALE: In palpation of the abdomen, the nurse starts with light palpation to detect surface characteristics and accustom the client to being touched. The nurse then performs deeper palpation, first asking the client about any tender areas so that these areas may be palpated last. The nurse uses one hand to palpate except when certain organs (e.g., kidneys, uterus, adnexa) are being palpated. The nurse avoids any situation in which deep palpation might cause internal injury or pain. Percussion is the act of tapping the client's skin with the use of short, sharp strokes to assess underlying structures. TEST-TAKING STRATEGY: Focus on the subject, palpation. Eliminate the option that describes percussion, not palpation. Next, eliminate the comparable or alike options that address deep palpation. Review: the procedure for palpating the abdomen.

HEALTH AND WELLNESS Health Screening

Personal History Subjective and objective data on past and current health status are obtained from the client to aid identification of risk factors. Heart disease, hypertension, stroke, diabetes mellitus, blood disorders, cancer, arthritis, allergies, obesity, alcoholism, seizure disorders, kidney disease, tuberculosis, and mental health disorders are all important findings in a health history. The nurse should also obtain data on childhood diseases and immunizations, accidents and injuries, serious or chronic illnesses, hospitalizations and surgeries, obstetric history, allergies, last examination date, current lifestyle practices, and medications, including herbal products, being taken.

A nurse is preparing to test the function of cranial nerve XI. Which action does the nurse take to test this nerve? Asking the client to stick out his or her tongue and watching the client for tremors Touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex Depressing the client's tongue with a tongue blade and noting pharyngeal function as the client says "ah." Placing his or her hands on the client's shoulders and asking the client to shrug the shoulders against resistance from the nurse's hands

Placing his or her hands on the client's shoulders and asking the client to shrug the shoulders against resistance from the nurse's hands

A nurse is using an otoscope to inspect the ears of an adult client. Which action does the nurse take before inserting the otoscope? Pulling the pinna up and back Pulling the pinna down and forward Tipping the client's head down and toward the examiner Tipping the client's head down and away from the examiner

Pulling the pinna up and back

44. A nurse conducting a peripheral vascular assessment performs the Allen test. The nurse understands that this test is used to determine the patency of which structures? Capillaries Pedal pulses Femoral arteries Radial and ulnar arteries

Radial and ulnar arteries

The nurse percusses Sara's posterior chest. Which sound does the nurse expect to note over lung tissue in this area if the tissue is normal? Tympany Resonance A dull sound Hyperresonance

Resonance RATIONALE: For percussion of the posterior chest, the client should sit leaning forward with the arms folded. Percussion of the posterior chest should yield resonance (a low-pitched sound) over lung tissue to the level of the diaphragm. Tympany — a drumlike, loud, empty quality — is heard over a gas-filled stomach or intestine and in cases of pneumothorax. A dull sound is heard over areas of abnormal density, as in pneumonia, pleural effusion, atelectasis, or tumor. Hyperresonance is a loud sound, lower-pitched than normal resonance, that is heard over hyperinflated lungs, such as in chronic obstructive pulmonary disease. TEST-T

37. A nurse is auscultating for vesicular breath sounds in a client. Of which quality would the nurse expect these normal breath sounds to be? Harsh Hollow Tubular Rustling

Rustling

16. A nurse is preparing to screen a client's vision with the use of a Snellen chart. Which action should the nurse take? Tests the right eye, then tests the left eye, and finally tests both eyes together Assesses both eyes together, then assesses the right and left eyes separately Asks the client to stand 40 feet (12 metres) from the chart and read the largest line on the chart. Asks the client to stand 40 feet (12 metres) from the chart and read the line that can be read 200 feet (60 metres) away by someone with unimpaired vision.

Tests the right eye, then tests the left eye, and finally tests both eyes together

A nurse reviewing a client's record notes that the result of the client's latest Snellen chart vision test was 20/80. How should the nurse interpret this data? The client is legally blind The client has normal vision The client can read at a distance of 20 feet (6 meters) what a client with normal vision can read at 80 feet (24 meters). The client can read at a distance of 80 feet (24 meters) what a client with normal vision can read at 20 feet (6 meters)

The client can read at a distance of 20 feet (6 meters) what a client with normal vision can read at 80 feet (24 meters).

A nurse preparing to perform a respiratory assessment of an adult client is reading the client's medical record. The nurse sees that the health care provider noted resonance on percussion of the client's posterior chest. What interpretation does the nurse make of this finding? The client has normal, healthy lungs. The client may have a pneumothorax. The client most likely has a lung tumor. An excessive amount of air is present in the lungs.

The client has normal, healthy lungs. RATIONALE: Resonance on percussion predominates in healthy adult lung tissue. Hyperresonance is noted when too much air is present such as in the case of emphysema where it is trapped in the alveoli and pneumothorax where it is trapped in the pleural space leading to lung collapse. A dull note on percussion indicates an abnormal density in the lungs, such as that noted in pneumonia, pleural effusion, or atelectasis or in the presence of a tumor. TEST-TAKING STRATEGY: Use the process of elimination. Eliminate comparable or alike options. Excessive air in the lungs will produce hyperresonance while pneumothorax will also produce the same tone as excess air is trapped in the pleural space. To select from the remaining options, recall that dullness would be noted in the presence of an abnormal density such a lung tumor. Review: normal and abnormal percussion tones.

A nurse performing a physical assessment of a client is checking the client's mouth and throat. As part of the assessment, the nurse plans to assess the function of cranial nerve XII. Which of the following best indicates adequate functioning of this nerve? The client is able to frown. The client is able to show the teeth. The client is able to stick out the tongue. The client is able to say "ah" as the tongue is depressed with a tongue blade

The client is able to stick out RATIONALE: To assess the function of cranial nerve XII (the hypoglossal nerve), the nurse asks the client to stick out the tongue. The nurse then notes the forward thrust in the midline as the client protrudes the tongue. The nurse also asks the client to verbalize certain words and then listen for clear, distinct speech. The motor function of cranial nerves IX (the glossopharyngeal nerve) and X (the vagus nerve) is tested by depressing the client's tongue with a tongue blade and noting pharyngeal movement as the client says "ah." To test cranial nerve VII (the facial nerve), the nurse asks the client to frown or show his teeth. TEST-TAKING STRATEGY: Focus on the subject of the question, which is assessment of cranial nerves. Eliminate comparable or alike options that both test the facial nerve. To select from the remaining options, recalling that cranial nerve XII is the hypoglossal nerve will direct you to the correct option. Review: the procedure for testing cranial nerve XII.

1. A nurse performing a physical assessment of a client gathers both subjective and objective data. Which finding would the nurse document as subjective data? The client appears anxious. Blood pressure is 170/80 mm Hg. The client states that he has a rash. The client has diminished reflexes in the legs.

The client states that he has a rash.

A nurse has taught a young adult male client about testicular self-examination. Which statement indicates to the nurse that the teaching was effective? The client states he will perform the self-examination at least every 2 weeks. The client indicates the need to use both hands and palpate both testes at the same time. The client states that it is important to contact the health care provider immediately if any lumps are felt. The client states that he should always perform the self-examination just before getting into the shower.

The client states that it is important to contact the health care provider immediately if any lumps are felt. RATIONALE: Testicular self-examination should be performed monthly, starting during puberty. Because men are at greatest risk for testicular cancer between the ages of 18 and 38 years, teaching should be targeted to this age group. Men should be taught to hold the scrotum in one hand and examine each testicle and spermatic cord separately by gently rolling the testicle between the thumb and fingers of the other hand. The client is taught to perform the examination on the same day of each month. Examination is performed after a warm bath or shower, when the testicles are relaxed, descended, and easier to palpate.

A nurse performing a skin assessment uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. What does the nurse determine? The client has a fever The skin temperature is normal The client needs to drink additional fluids The client needs to have the blanket removed

The skin temperature is normal

The nurse completes Sara's physical examination and plans to assist the health care provider in performing a vaginal examination and obtaining a regular Papanicolaou test. The nurse explains the vaginal examination to Sara, informs her that all of the examination findings have been normal, and says that the health care provider will call her when the results of the Pap test are returned. Sara tells the nurse that she has never had this test and asks how frequently the Pap test must be performed. How should the nurse respond? The test should be performed yearly. The test should be performed every 6 months. The test does not need to be performed again if the results are normal. The test may be performed every 5 years because Sara has no family history of cervical cancer.

The test should be performed yearly. RATIONALE: The Papanicolaou (Pap) smear is a painless screening test for cervical cancer. The test is simple, with no side effects. All women should begin cervical cancer screening about 3 years after they begin having vaginal intercourse but no later than 21 years of age; screening should be performed every year with the regular Pap test or every 2 years if the newer liquid-based test is being used. Beginning at age 30, women who have had three normal Pap results in a row may be screened every 2 to 3 years. Women older than 30 may also be screened every 3 years with the use of either the conventional or liquid-based Pap test, plus the human papillomavirus (HPV) test.

A nurse sees documentation in the client's record indicating that the nurse on a previous shift has noted the presence of adventitious breath sounds. The nurse interprets this information in which manner? These sounds are normally heard in the lungs Hollow sounds heard over the trachea and larynx indicate pneumonia Rustling sounds heard over the peripheral lung fields are associated with bronchitis These are abnormal sounds that should not be heard in the lungs of a healthy client

These are abnormal sounds that should not be heard in the lungs of a healthy client

A nurse is administering the hepatitis B vaccine to a newborn. Which anatomic site should the nurse select for the injection? Deltoid Dorsogluteal Rectus femoris Vastus lateralis

Vastus lateralis RATIONALE: Vaccines administered intramuscularly are given in the vastus lateralis muscle in newborns and in the deltoid for older infants and children. The dorsogluteal area is avoided because the site has been associated with low antibody seroconversion rates, indicating a reduced immune response. Also, it is generally recommended that the dorsogluteal site be avoided until a child has been walking for at least 1 year. The rectus femoris is not an acceptable site for injections.

A nurse is performing a voice test. To carry out this procedure correctly, the nurse asks the client to repeat which kind of words? Spoken in a soft tone of voice by the nurse about 5 feet (1.5 meters) in front of the client Whispered by the nurse from the client's side at a distance of 1 to 2 feet (30 to 60 cm) from the ear being tested Spoken by the nurse from the client's side in a normal tone of voice about 10 feet (3 meters) from the ear being tested Whispered at a distance of 20 feet (6 meters) by the nurse while he or she is standing in front of the client.

Whispered by the nurse from the client's side at a distance of 1 to 2 feet from the ear being tested

9. A nurse performing a skin assessment notes that the client's skin is very dry. How should the nurse document this finding? Xerosis Pruritus Seborrhea Actinic keratoses

Xerosis

Which type of data base is the most appropriate for the nurse to utilize when collecting information from Sara? Focused Complete Follow-up Emergency

complete RATIONALE: A complete database consists of a complete health history, including physical examination findings. It describes the client's current and past health status and serves as a baseline against which all future changes may be measured. A focused database is constructed to address a limited or short-term problem (e.g., one problem or body system). A follow-up database is focused on evaluating a client's progress. An emergency database comprises a rapid collection of information that is often obtained during lifesaving measures. Because Sara has not been examined by a health care provider in 10 years and this is her first visit to the clinic, the nurse would collect a complete database. TEST-TAKING STRATEGY: Note the use of the strategic words "most appropriate". Recall the information in the case study. Knowing that Sara has not been examined by a health care provider in 10 year should direct you to the correct option, a complete databa

Family History

Family history includes age and health or age and cause of death of blood relatives such as parents, grandparents, and siblings. A genogram (see image above) or family tree may be constructed to chart family health history clearly; this assists the nurse to identify risk factors for illness. The screener should also inquire about the health of close family members such as the client's spouse and children.

The nurse is admitting a client to the hospital. Which should be included in a discussion of the client's personal history? Select all that apply. Recent hospitalizations Cause of parents' death Health of the client's siblings Previous history of bipolar disorder Hypersensitivity reactions to medications

Recent hospitalizations Previous history of bipolar disorder Hypersensitivity reactions to medications RATIONALE: The nurse should include recent hospitalizations, previous history of diseases, and hypersensitivity or allergic reactions in a review of the client's personal history. The cause of the client's parents' death and the health of the client's siblings should be included in the client's family history.

Shannon tells the nurse that she has never had a mammogram and asks whether she needs one. On the basis of American Cancer Society (ACS) recommendations, which instruction should the nurse provide to Shannon? She will need to start having a yearly mammogram at age 40 Her health care provider will recommend that she have a mammogram done now She will have a baseline mammogram now and another one every 3 years thereafter She will have a baseline mammogram now and then will have one every year thereafter

She will need to start having a yearly mammogram at age 40 RATIONALE: According to ACS recommendations, yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health. Therefore the other options are incorrect.

18. The nurse is observing a new nurse employee who is examining the peripheral vision of a client using the confrontation test. The nurse determines the new nurse is using correct technique if the nurse performs which action? Asks the client to discriminate numbers on a chart composed of colored dots Darkens the room and asks the client to identify colored blocks and shapes that appear in the visual field Has both the client and nurse cover the right eye, stare at each other's uncovered eye, and bring a small object into the visual field, then repeat the test with the left eye Sits at eye level with the client, covers one eye, and has the client cover the eye directly opposite the nurse's, after which each stares at the other's uncovered eye and the nurse brings a small object into the visual field

Sits at eye level with the client, covers one eye, and has the client cover the eye directly opposite the nurse's, after which each stares at the other's uncovered eye and the nurse brings a small object into the visual field

15. A nurse conducting an interview with a client collects subjective data. During the interview, which action should the nurse take? Takes minimal notes to avoid impeding observation of the client's nonverbal behaviors Takes a great deal of notes to allow the client to continue at his or her own pace as the nurse records what he or she is saying Takes notes because this allows the nurse to break eye contact with the client, which may increase the client's level of comfort Takes notes to allow the nurse to shift attention away from the client, which may make the nurse more comfortable

Takes minimal notes to avoid impeding observation of the client's nonverbal behaviors

A nurse has collected subjective and objective data from an African-American client who is at risk for cardiovascular disease. The client tells the nurse that he is a cigarette smoker, drinks "a beer or two" every day, and enjoys sitting around watching sports on television. Which piece of data does the nurse identify as an unmodifiable risk factor? The client is African-American. The client is a cigarette smoker. The client drinks beer every day. The client sits around watching television.

The client is African-American. Modifiable risk factors are those that can be modified or eliminated to prevent the development of disease. In the case of cardiovascular disease, these include hypertension, obesity, diabetes mellitus, increased serum lipid concentrations, tobacco use, and physical inactivity. Unmodifiable risk factors, those that cannot be modified or eliminated, include age, sex, and heredity

11. A nurse performing an assessment of a client with kidney failure notes that the client has the appearance of generalized edema over the entire body. How should the nurse document this finding? Anasarca Ecchymosis Unilateral edema Increased vascularity of the skin tissue

Anasarca

A nurse has provided information to a client about measures to prevent cardiovascular disease. Which statement by the client indicates a need for further information? "I need to reduce my salt intake." "I need to cut down on my smoking." "I need to start a regular exercise program." "I need to watch my weight and cut down on my saturated fat."

"I need to cut down on my smoking." RATIONALE: Risk factors associated with cardiovascular disease include increasing age, sex, excessive alcohol intake, cigarette smoking, diabetes mellitus, increased serum lipid concentrations, excessive dietary sodium, obesity, sedentary lifestyle, and stress. Reduction of salt intake, reducing calorie intake, exercise, and cutting down on fat intake are appropriate preventive measures. The risk of cardiovascular disease and resultant death is higher in smokers than in nonsmokers. The client needs to stop smoking, not "cut down" on the smoking.

During her clinic visit, Dianne is instructed to follow the DASH (Dietary Approaches to Stop Hypertension) eating plan and to reduce her intake of sodium and fat. Which of these statements by Dianne indicate a need for further instruction? Select all that apply. "I should avoid milk and milk products." "I'll rinse canned vegetables with water before cooking them." "A packaged food product is safe to eat if it doesn't taste salty." "I don't need to worry about condiments such as ketchup or mustard." "I will try to eat more fresh fruits and vegetables every day." "It doesn't matter whether I choose red meat or poultry, as long as it's lean."

"I should avoid milk and milk products." "A packaged food product is safe to eat if it doesn't taste salty." "I don't need to worry about condiments such as ketchup or mustard." "It doesn't matter whether I choose red meat or poultry, as long as it's lean."

The nurse teaches Shannon about measures to help prevent skin cancer. Which statements by Shannon leads the nurse to conclude that she understands these measures correctly? Select all that apply. "I won't need to wear protective clothing if I wear sunscreen." "I'll examine my body monthly for any changes in my moles." "I'll try to avoid being out in the sun between 9 a.m. and 2 p.m." "I will ask my husband to help me examine the moles on my back." "If I find any changes in my moles, I'll tell the doctor the next time I have an appointment."

"I'll examine my body monthly for any changes in my moles." "I will ask my husband to help me examine the moles on my back." RATIONALE: The most effective means of preventing skin cancer is reducing exposure of the skin to sunlight. Secondary prevention through early detection is also essential. Avoiding sun exposure between the hours of 11 a.m. and 3 p.m., using sunscreen, and wearing protective clothing are all important measures for preventing sunburn. It is important to be aware of one's skin markings and to examine spots, scars, and lesions, including moles, monthly. Assistance with skin inspection should be obtained as needed. Any changes should be reported to the health care provider right away.

A nurse is conducting an interview with a client who has come to the clinic after finding a lump in her right breast during breast self-examination. The client says, "I am so worried. I know that this must be breast cancer. What am I going to do?" Which response should the nurse give the client? "Tell me what worries you." "Most lumps found in the breast aren't cancer." "Let's talk again after the doctor examines you." "You shouldn't be so worried. After all, if it is cancer, you found it at an early stage."

"Tell me what worries you." RATIONALE: The nurse should always focus on the client's feelings and concerns and respond so that the client is provided an opportunity to discuss feelings. "Tell me what worries you" is the only option that gives the client this opportunity. The other options are nontherapeutic and place the client's feelings on hold. TEST-TAKING STRATEGY: Recall therapeutic communication techniques to answer the question. Remembering that the nurse should always focus on the client's feelings will direct you to the correct option. Review: therapeutic communication techniques.

The nurse is counseling the parents of a 5 year-old about environmental hazards. Which statement by the parent indicates the need for further information to prevent injury? "We have our water heater's temperature set at 140°F (60° C)." "We always place our child in a safety car seat when we ride in the car." "We frequently check the smoke detectors in our home to be sure that they work." "I've taught my child about the importance of wearing a helmet when riding a bicycle."

"We have our water heater's temperature set at 140°F (60° C)." RATIONALE: A primary nursing responsibility is to teach the parents about environmental hazards and measures to reduce the risk of injury and illness. These measures include using window and stair guards, using car safety seats, wearing helmets and other protective garb when participating in activities that could result in injury, ensuring that smoke detectors are working properly, and maintaining water heater temperature below 120° F to prevent burns.

Dianne tells the nurse that several of her coworkers have lost weight on a fad diet. How should the nurse respond? "Try one of these fad diets if it will help to take off the weight." "You should try a strict vegetarian diet. That will help you lose weight quickly." "You need to eat foods from all food groups and limit fats, oils, and sweets." "Do whatever you can to get the weight off, because your weight is the cause of the high blood pressure and cholesterol."

"You need to eat foods from all food groups and limit fats, oils, and sweets." RATIONALE: The USDA's MyPlate is a guide to daily food choices and portion sizes. The dieting client should be instructed to eat foods from all food groups, especially fruits, vegetables, and whole grains, and to limit consumption of fats, oils, and sweets, as well as salt. Although weight loss on this program may be slower than that with a fad diet, it is a healthier method of weight loss, and the weight loss with such a program is more likely to be permanent. Fad diets are discouraged because they may be harmful to a person's health. It is not necessary to go on a strict vegetarian diet to lose weight, and this type of diet must be well planned to avoid problems resulting from protein deficiency. TEST-TAKING STRATEGY: Eliminate the comparable or alike options that do not include foods from all food groups. Also, note the words "all food groups" in the correct option. Review: appropriate weight-loss diets.

At the end of the breast examination, Shannon tells the nurse that she has several moles and is worried about skin cancer. She states that her father has had "several skin cancers" removed. Which of these lesions would need to be examined more closely for skin cancer? Select all that apply. A scar that has an overgrowth of skin An irregularly shaped, pigmented papule A firm, nodular lesion that is topped with dry, scaly skin A firm, movable flesh-colored nodule that contains liquid A mole that was previously flat but now, the client states, is "larger and bumpy"

A firm, nodular lesion that is topped with dry, scaly skin A mole that was previously flat but now, the client states, is "larger and bumpy" RATIONALE: The ABCD guide can be used to assess a skin lesion for characteristics associated with cancer. In this guide, A stands for asymmetry shape, B represents border irregularity, C stands for color variation within one lesion, and D denotes diameter greater than 6 mm. Every suspicious skin lesion should be examined carefully, and a person who has a lesion with one or more of the ABCD characteristics should be evaluated by a surgeon or dermatologist. An overgrowth of skin over a scar is a keloid, which is benign. Skin lesions that are irregularly shaped or have changed in color, elevation, or size may be cancerous or precancerous. A firm, nodular lesion that is covered with a dry or rough scale may be actinic keratosis, which is a premalignant lesion. A firm, movable flesh-colored nodule that contains liquid is a cyst, which is benign.

A nurse performing a breast examination is preparing to palpate the client's breasts. Into which position should the nurse assist the client to perform palpation? A standing position, with the client holding both arms above her head A standing position, with the client holding her hands firmly on her hips A supine position, with the arm on the side being examined positioned across the chest A supine position, with the arm on the side being examined positioned behind the head and a small pillow placed under the shoulder on the same side

A supine position, with the arm on the side being examined positioned behind the head and a small pillow placed under the shoulder on the same side RATIONALE: To palpate the breasts, the nurse assists the client into a supine position and positions the client's arm on the side being examined behind the head. A small pillow is placed under the shoulder on the same side. The nurse uses the pads of the first three fingers to gently compress the breast tissue against the chest wall and notes tissue consistency. Palpation is performed systematically, with care taken to ensure that the entire breast and tail are palpated. The other options are not positions that would allow effective palpation of the breast tissue. TEST-TAKING STRATEGY: Eliminate comparable or alike options (standing) are the position for inspection of the breasts. To select from the remaining two options visualize each and select the one that allows for optimal palpation of the breast. Review: clinical breast examination.

The nurse teaches Shannon how to perform BSE. What is the best way for the nurse to confirm that Shannon understands how to perform the BSE? Asks Shannon to verbalize how to perform the examination Asking Shannon to perform BSE and observing her performance Asking Shannon to read the pamphlet on performing BSE and to write down any questions she might have Asking Shannon to view a computer tutorial on performing BSE and to write down any questions she might have

Asking Shannon to perform BSE and observing her performance RATIONALE: To best determine Shannon's learning and understanding of how to perform a procedure, the nurse would ask her to perform the procedure and observe her performance. Verbalizing how to perform the examination, reading pamphlets and viewing computer tutorials are not the best ways of ensuring that the client knows how to perform BSE.

The nurse has demonstrated the technique for a surgical wound dressing change to the wife of a client who will be discharged after hip replacement surgery. Which action should the nurse take to best confirm that the wife understands the procedure? Asking the wife to perform the dressing change Asking the wife whether she has any questions about the procedure Asking the wife whether she feels comfortable performing the procedure Asking the wife whether she understands what items need to be obtained from the surgical supply store

Asking the wife to perform the dressing change RATIONALE: The nurse would best evaluate the wife's learning by observing the wife's performance of the activity. Although asking the wife whether she has any questions, feels comfortable, or understands the procedure may be appropriate, these questions do not best reveal the wife's ability to perform the dressing change.

The nurse is performing an assessment on a 64-year old client admitted with chest pain who has a history of coronary artery disease, type 2 diabetes mellitus, hypertension, and smoking 1 pack per day for 40 years. The nurse notes the following clinical findings on assessment. MULTIPLE SELECT Select the correct answers. Which actions should the nurse take? Select all that apply. Assess for focal neurological deficits Administer an as needed antihypertensive medication Assess for a history of light-headedness, dizziness, and syncope Discuss with the primary health care provider performing serial troponin levels Initiate a referral for the diabetes nurse educator and outpatient endocrinology follow-up Collaborate with the primary health care provider on prescribing a bilateral carotid ultrasound

Assess for focal neurological deficits Assess for a history of light-headedness, dizziness, and syncope Discuss with the primary health care provider performing serial troponin levels Initiate a referral for the diabetes nurse educator and outpatient endocrinology follow-up Collaborate with the primary health care provider on prescribing a bilateral carotid ultrasound RATIONALE: The carotid arteries are located in the groove between the trachea and sternocleidomastoid muscle, medial to and alongside the muscle. On auscultation, the nurse listens for the presence of a bruit (a blowing, swishing sound), which indicates blood flow turbulence. Normally a bruit is not present, so this finding, whooshing noted over the right carotid artery, necessitates the need for follow-up. Assessing for focal neurological deficits and a history of light-headedness, dizziness, and syncope are important to determine if blood flow to the brain has been compromised as a result of carotid stenosis. A carotid ultrasound should be done due to the detection of a bruit on physical assessment, as well as the risk factors of hypertension, type 2 diabetes mellitus, coronary artery disease, and smoking. Serial troponin levels should be prescribed because of the elevation noted with the first level, as well as consultation with cardiology for further testing to determine if the client experienced a myocardial infarction. The client's serum glucose level and HbA1C indicate poor diabetes control; therefore, the nurse should initiate a referral to the diabetes nurse educator and outpatient endocrinology follow-up. An as needed antihypertensive should not be administered at this time because the blood pressure, although elevated beyond normal levels, is not elevated to the point of requiring additional blood pressure management. TEST-TAKING STRATEGY: Focus on the data in the question and determine if an abnormality exists. Use of clinical judgment is necessary in making the decision regarding blood pressure management. Given the context of other clinical findings, as well as the current blood pressure reading, the safest option would be to hold off on administering as needed blood pressure medication.

The nurse is developing the plan of care for a family of seven who are recently arrived refugees from Central America. The nurse should prioritize the plan of care to take which action immediately? Provide immediate vaccinations for the entire family Assess the three year old child who has a rash, a cough and a high fever Advise the mother with a seven month old child to continue breastfeeding Obtain stool samples to determine if the family has a gastrointestinal illness

Assess the three year old child who has a rash, a cough and a high fever RATIONALE: The nurse should prioritize the assessment of the three year old child who has a rash, a cough and a fever. These could be the symptoms of a communicable disease. Providing vaccinations is important, but the child's current symptoms take priority. Obtaining stool samples may not be necessary as there is no indication of gastrointestinal symptoms. It is important to continue breastfeeding the seven month old child, but this is not as high a priority as the symptoms of rash, a cough and a fever. TEST-TAKING STRATEGY: Utilize knowledge of Maslow's Hierarchy of Needs Theory to answer this question. Actual needs, such as the child with symptoms of rash, a cough and fever, take precedence over potential needs. Vaccinations, breastfeeding instructions and obtaining stool samples are all comparable or alike options which address potential, rather than actual needs.

On a follow-up visit to the clinic, Dianne tells the nurse she has been attending a stress-management program and that it has been extremely helpful in helping her manage stress. Dianne says she feels less fatigued at the end of the workday and that she would like to begin an exercise program. The nurse should tell Dianne that which exercise would best facilitate weight loss? Ask the instructor of the stress-management program Begin walking 20 to 30 minutes at least three times a week Avoid exercise until she loses some weight to avoid stressing her heart Obtain a membership at a health club and hire a personal trainer to help get started in an exercise program

Begin walking 20 to 30 minutes at least three times a week RATIONALE: Regular exercise such as walking or other aerobic movement results in improved circulation, increased release of endorphins, and an enhanced sense of well-being. Exercise is also an effective stress-management technique. Telling Dianne to ask the instructor of the stress-management program places Dianne's question on hold and is a nontherapeutic response. Obtaining a membership at a health club is unnecessary; additionally, Dianne may not have the financial resources to hire a personal trainer. Telling Dianne to avoid exercise until she loses weight is incorrect. Exercise should be combined with dieting for overall effectiveness of weight loss TEST-TAKING STRATEGY: Focus on the strategic word, "best." First eliminate the option that places Dianne's question on hold (asking the instructor). Next eliminate the option that will require money for participation (joining a health club); there is no information in the question regarding Dianne's financial status, and this option may increase Dianne's stress if Dianne is on a limited budget. To choose between the remaining options, recall the importance of combining diet with exercise for weight loss. Review: exercise/diet and stress management

The nurse is providing preoperative instructions for day surgery scheduled in a week to a client who speaks Spanish only. Which action is the best way for the nurse to ensure that the client understands the instructions? Calling for a hospital-designated interpreter to communicate with the client Asking a family member who speaks English and Spanish to translate for the client Relying on the use of hand signals and demonstrations to teach the client about the preoperative procedures Writing the instructions on a piece of paper so that an English and Spanish speaking neighbor will be able to translate them for the client

Calling for a hospital-designated interpreter to communicate with the client RATIONALE: Arranging for a hospital designated interpreter is the best practice for communication with a client who speaks a different language. This action will ensure that the client clearly understands the preoperative instructions. Asking a family member or a neighbor is not an appropriate action, because the nurse cannot be sure that the client will receive the correct information. Also, asking a family member or neighbor to translate violates the client's privacy. Likewise, the use of hand signals and demonstrations will not ensure that the client understands the instructions. TEST-TAKING STRATEGY: Note the strategic word "best" in the question. Eliminate the comparable or alike options that violate the client's right to privacy by asking the family member or neighbor to translate. Next remember that a hospital designated translator will be familiar with medical terminology and will be able to explain the instruction accurately in lay terms. Review: the best communication techniques for a client who speaks a different language.

The nurse is volunteering with an outreach program to provide basic health care for people experiencing homelessness. Which finding, if noted, should be addressed first? Blood pressure 154/72 mmHg Visual acuity of 20/200 in both eyes Random blood glucose level of 206 mg/dL (11.77 mmol/L) Complaints of pain associated with numbness and tingling in both feet

Complaints of pain associated with numbness and tingling in both feet RATIONALE: The nurse should address the complaints of pain and numbness and tingling in both feet first with this population. If the client perceives value to the service provided, they will be more likely to return for follow up care. While the blood pressure, blood glucose and vision results are concerning, the client's stated concern should be addressed first. TEST-TAKING STRATEGY: Note the subject, the finding to be addressed, and focus on the strategic word, first. Recalling that adherence is a problem for this population will direct you to the correct option. Also note, the correct option is the only subjective finding.

A nurse conducting a physical assessment is observing the client's balance and performing tests to determine the client's sense of equilibrium. Which cranial nerve is the nurse assessing? Cranial nerve II Cranial nerve IX Cranial nerve VII Cranial nerve VIII

Cranial nerve VIII RATIONALE: Cranial nerve VIII is the acoustic nerve. Hearing tests are performed to assess the cochlear portion of this nerve. Tests to assess equilibrium, such as observation of the client's balance when the client is walking or standing, involve the vestibular portion. The function of cranial nerve II (the optic nerve) is tested by assessing the client's visual acuity. Swallowing ability and taste perception of the posterior portion of the tongue are controlled by cranial nerve IX (the glossopharyngeal nerve). Taste perception on the anterior portion of the tongue and the ability to perform facial and eye movements (e.g., closing the eyes) are controlled by cranial nerve VII (the facial nerve). TEST-TAKING STRATEGY: Focus on the subject - the cranial nerve associated with balance and equilibrium. Recalling that cranial nerve VIII is the acoustic nerve should direct you to this option. Review: functions of cranial nerves.

10. A nurse is preparing to perform a skin examination with the use of a Wood light. Which action should the nurse perform to prepare for this diagnostic test? Darken the room Obtain informed consent from the client Obtain a scalpel and a slide for diagnostic evaluation Obtain medication to anesthetize the skin area before proceeding with the examination

Darken the room

A nurse is examining a 25-year-old client who was seen in the clinic 2 weeks ago for symptoms of a cold and is now complaining of chest congestion and cough. The nurse should proceed with the examination by collecting which? Data related to follow-up care A complete (total health) database Data related to the respiratory system Data related to the treatment for the cold

Data related to the respiratory system

The nurse is developing a plan of care for a client who has a severe intellectual disability. The client has recently begun to suck on her right hand, which is becoming red and raw. She is also refusing to eat some of her favorite foods. Which intervention has the highest priority? Wrapping her hand in gauze Determining if the client has a new mouth sore Frequently reminding her it is unsanitary to suck on her hands Giving her a small reward when she does not suck on her hand during meals

Determining if the client has a new mouth sore RATIONALE: The nurse should be aware that altered behavior may be caused by illness. The highest priority should be to investigate any illness that could cause altered behavior. Wrapping her hand in gauze is not a priority if there is an underlying cause of the new behavior. Reminding her it is unsanitary to suck on her hands may not be effective if the individual has a severe intellectual disability. Providing her with a small reward for not sucking on her hands would not be effective if the cause of the behavior is a sore mouth. TEST-TAKING STRATEGY: Eliminate the comparable or alike options that focus on aspects other than addressing an underlying illness. Wrapping the hand in gauze, giving reminders and rewards do not focus on the underlying illness.

The nurse examines Sara's breasts and informs her that no masses were felt. The nurse provides teaching on self-breast examination and recommendations of the American Cancer Society (ACS) for early detection of breast cancer. What should the nurse include in the teaching? Have a yearly mammogram starting at the age of 40 Have had a baseline mammogram performed at the age of 20 Have a yearly breast examination by a health care provider beginning at the age of 40 Perform a monthly breast self-examination and have a baseline mammogram when she reaches the age of 50

Have a yearly mammogram starting at the age of 40 RATIONALE: According to the ACS, yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health. Clinical breast exams (CBEs) are recommended about every 3 years for women in their twenties and thirties and every year for women 40 and older. Breast self-exams (BSEs) should be performed monthly (starting at the age of 20 is an option), and women should know how their breasts normally look and feel and promptly report any changes to a health care provider. The ACS also recommends that some women, because of their family history, a genetic tendency, or certain other factors, be screened with the use of magnetic resonance imaging (MRI) in addition to mammography.

A nurse is preparing to perform the Weber test in a client who reports loss of hearing in one ear. In which anatomic area should the nurse place the tuning fork for this test to be performed accurately? In front of the ear In the midline of the skull On the mastoid process At the temporal lobe on the side with hearing loss

In the midline of the skull RATIONALE: In the Weber test, the stem of the vibrating tuning fork is placed in the midline of the client's skull. Normally the client should hear the tone, by way of bone conduction through the skull, equally in the two ears. In the Rinne test, the stem of a vibrating tuning fork is placed on the client's mastoid process. When the client no longer hears the sound, the tuning fork is quickly inverted and placed near the ear canal; the client should again hear the sound. Normally the sound is heard twice as long by way of air conduction (near the ear canal) than by way of bone conduction (at the mastoid process). Placing the tuning fork at the temporal lobe on the side with hearing loss is not a component of a tuning fork test. TEST-TAKING STRATEGY: Focus on the subject - the Weber test. Try to visualize both the Weber and Rinne tests to answer correctly. Remember that in the Weber test the stem of the vibrating tuning fork is placed in the midline of the client's skull. Review: the tuning fork tests.

The nurse, now performing the abdominal assessment, is listening to Sara's bowel sounds. Which descriptor does the nurse document in the health record after hearing these sounds? Select to listen to the audio clip. Borborygmus Normal sounds Hypoactive sounds Hyperactive sounds

Normal sounds RATIONALE: Normal bowel sounds are high-pitched, gurgling sounds that occur irregularly between 5 and 30 times a minute. Borborygmus, a type of hyperactive bowel sound, indicates hyperperistalsis. Hypoactive, or infrequent, bowel sounds are most often noted after abdominal surgery or with inflammation of the peritoneum. Hyperactive sounds are loud, high-pitched, rushing, tinkling sounds that indicate increased motility

After assessing clients and discussing their religious dietary practices, the nurse confers with the dietician to plan meals. The nurse demonstrates understanding of appropriate food plans if which meal recommendations are made? Select all that apply Ensuring no caffeine or alcohol is served to a client who is Buddhist On Fridays during Lent, providing a client who is Catholic a main dish with macaroni and cheese Serving a high protein meal containing hamburger patties with melted cheese to a client who is an Orthodox Jew Ensuring a client who attends the Church of the Latter Day Saints is not served meat on the first Sunday of the month During Ramadan, serving an evening meal after sunset and a morning meal before dawn to a client who practices Islam

On Fridays during Lent, providing a client who is Catholic a main dish with macaroni and cheese During Ramadan, serving an evening meal after sunset and a morning meal before dawn to a client who practices Islam RATIONALE: On Fridays during Lent, a client who is Catholic may be abstaining from meat; macaroni and cheese do not contain meat. During the month of Ramadan, clients who practice Islam may not eat until after sunset and before dawn. Alcohol and caffeine are generally avoided by clients who practice the faith of the Church of Jesus Christ of Latter Day Saints. Buddhists do not have this prohibition. A client who practices the Orthodox Jewish faith does not mix meat and milk at the same meal; a hamburger patty with cheese would not be an acceptable meal. Clients who practice the faith of the Church of Jesus Christ of Latter Day Saints may wish to fast (not just abstain from meat) on the first Sunday of the month. TEST-TAKING STRATEGY: Use knowledge of the subject, religious dietary practices, is helpful to answer this question. Recognize that many clients who are Catholic abstain from meat during Lent. Clients who practice Islam fast from sunup to sun down. Eliminate the comparable or alike options that do not follow common religious dietary practices of various groups.

A nurse performing a neurological assessment of a client who has sustained a stroke (brain attack) is preparing to check for stereognosis. Which action should the nurse take to perform this assessment? Placing an object in the client's hand and asking the client to identify it Tracing a number on the client's hand and asking the client to identify it Moving the client's finger up and down and asking the client which way it is being moved Making two simultaneous pinpricks on the skin and asking the client to distinguish them

Placing an object in the client's hand and asking the client to identify it RATIONALE: Stereognosis is the client's ability to recognize objects placed in his or her hand. Graphesthesia is the client's ability to identify a number traced on the client's hand. Position sense (kinesthesia) is tested by moving the client's finger or toe up or down and asking the client which way it is being moved. Two-point discrimination is the client's ability to discriminate two simultaneous pinpricks on the skin. TEST-TAKING STRATEGY: Focus on the subject - assessment of stereognosis. Then focus on the description of each option. It is necessary to recall that stereognosis is the client's ability to recognize objects placed in his or her hand to answer the question. Review: stereognosis

The nurse reviews the data from Sara's physical examination (refer "Chart" below). The nurse concludes that which findings are abnormal? Select all that apply. Vital SignsTemperature: 98.9° F (oral)Pulse: 94 beats/min, regular rhythmRespiratory rate: 18 breaths/min, laboredBlood pressure: 122/78 mm Hg Breath SoundsBronchial breath sounds heard over the tracheaBilateral vesicular breath sounds heard over the periphery of the lungsBronchovesicular breath sounds heard posteriorly between the scapulae NeurologicPatellar tendon reflexes: 1+ bilaterallyBabinski reflex: negativeRomberg test: positiveNo muscle weaknessRange of motion: equal bilaterally Positive result on Romberg test Temperature 98.9° F (37.2°C) (oral) Patellar tendon reflexes 1+ bilaterally Respiratory rate of 18 breaths/min, labored Bronchial breath sounds heard over the trachea

Positive result on Romberg test Patellar tendon reflexes 1+ bilaterally Respiratory rate of 18 breaths/min, labored

The nurse is observing a new nurse employee who is performing an abdominal assessment of a client and preparing to auscultate for bowel sounds. The nurse determines the new nurse employee is using correct technique if which part of the abdomen is auscultated first? Left upper quadrant Left lower quadrant Right upper quadrant Right lower quadrant

Right lower quadrant RATIONALE: To auscultate for bowel sounds, the nurse places the diaphragm endpiece of the stethoscope lightly against the skin, then begins to auscultate in the right lower abdominal quadrant, in the area of the ileocecal valve, because bowel sounds are always present there normally. After auscultating the right lower quadrant, the nurse proceeds with the examination by auscultating the remaining three quadrants.

The nurse prepares to listen to Sara's heart sounds. What heart sound is audible? Select to listen to the audio clip. S1 and S2 Split S2 sound S1 and S2 with a systolic murmur Physiologic S3 4. S1 and S2 with a systolic murmur

S1 and S2 RATIONALE: The pair of heart sounds that are close together ("lub-dup"), the S1 and S2 sounds, are considered normal heart sounds. A split S2 sound, a normal variation, occurs near the end of expiration ("lub-T-DUP"). A physiologic S3, which occurs after the S2 sound, is a dull, soft, low-pitched sound. A murmur is a blowing or swishing heart sound that may be considered "innocent" or may reflect a serious defect of blood flow in the heart. A systolic murmur may occur in a normal heart or accompany heart disease.

A nurse collects subjective and objective data from a client who underwent surgery after sustaining a leg fracture in a motor vehicle accident and is now in skeletal traction. The nurse identifies which findings as objective data? Select all that apply. Temperature is 99.9° F (37.2°C). The client complains of leg pain. Blood pressure is 128/86 mm Hg. Pin sites are red but without drainage. The client tells the nurse that he feels warm.

Temperature is 99.9° F (37.2°C). Blood pressure is 128/86 mm Hg. Pin sites are red but without drainage. RATIONALE: Subjective data are the things the client says about himself or herself or what a family member or significant other says about the client during history-taking. Objective data are the findings collected by the nurse while inspecting, percussing, palpating, and auscultating. Objective data also include information from the client's health record and the results of laboratory and diagnostic studies. The client's temperature and blood pressure readings are objective data, as is the nurse's observation of the pin sites. The other options constitute subjective data.

A nurse performing a neck assessment of a client is testing the status of cranial nerve XI. Which of the following best indicates that the client has adequate function of this nerve? The client can smile. The client can lift the eyebrows. The client can stick out the tongue. The client can shrug the shoulders against resistance.

The client can shrug the shoulders against resistance. RATIONALE: Cranial nerve XI (spinal accessory nerve) is tested by asking the client to shrug the shoulders against the resistance of the nurse's hand and to turn the head to each side as the nurse tries to resist the client's movement. Cranial nerve VII (the facial nerve) is tested by asking the client to smile, frown, close the eyes tightly against the resistance of the nurse, lift the eyebrows, show the teeth, and puff the cheeks. Cranial nerve XII (the hypoglossal nerve) is tested by inspecting the tongue as the client sticks out the tongue. TEST-TAKING STRATEGY: Focus on the subject of the question, which is assessment of cranial nerves. Eliminate the comparable or alike options that are tests of the facial nerve. To select from the remaining options, recalling that cranial nerve XI is the spinal accessory nerve will direct you to the correct option. Review: the procedure for testing cranial nerve XI. QUESTION CATEGORIES:

A nurse conducting a physical examination of a Chinese-American client is gathering subjective data about the client's health care practices. What is the nurse's primary reason for asking the client about the use of herbal products and dietary supplements? To determine whether these are acceptable forms of treatment To determine whether the client's health care provider approves of their use To determine whether they have been approved by the U.S. Food and Drug Administration To determine whether they will interact adversely with medications being prescribed for the client

To determine whether they will interact adversely with medications being prescribed for the client RATIONALE: Regardless of their cultural origins, many people use cultural remedies such as herbal products and dietary supplements in addition to prescription medications to treat their medical illnesses. Problems may arise when prescription medications interact with these substances. Therefore, it is most important for the nurse to ask the client about the use of any other substances. The nurse must be culturally sensitive to the needs and beliefs of the client, and if the client uses an alternative remedy to treat a problem, this remedy needs to be a component of the plan of care if possible. Although the other options may be considerations for the plan of care, the primary reason for asking the client about the use of herbal products and dietary supplements is to determine whether any might interact adversely with medications being prescribed for the client. TEST-TAKING STRATEGY: The nurse note the strategic word "primary" in the query of the question. Recalling that herbal products and dietary supplements may have side effects or interact adversely with prescription medications will direct you to the correct option. Also use Maslow's Hierarchy of Needs theory. The correct option relates to physiological integrity. Review: adverse effects of herbal products.