NCLEX Questions - Fundamentals - Health and Physical Assessment (304)

A nurse is assessing a child who is accompanied by a parent. The parent has remarried and has another child from the second marriage. What kind of a family does this child belong to? 1 Blended family 2 Extended family 3 Alternative family 4 Single-parent family

1 Blended family

A client tells the nurse, "I am so worried about the results of the biopsy they took today." The nurse overhears the nursing assistant reply, "Don't worry. I'm sure everything will come out all right." What does the nurse conclude about the nursing assistant's answer? 1 It shows empathy. 2 It uses distraction. 3 It gives false reassurance. 4 It makes a value judgment.

3 It gives false reassurance.

What would be the behavioral characteristic of a slow-to-warm up child according to the theory related to temperament? 1 Highly active 2 Irritable and irregular in habits 3 Negative reaction to new stimuli 4 A positive mild-to-moderately intense mood

3 Negative reaction to new stimuli

A client on hospice care is receiving palliative treatment. A palliative approach involves planning measures aimed to do what? 1 Restore the client's health. 2 Promote the client's recovery. 3 Relieve the client's discomfort. 4 Support the client's significant others.

3 Relieve the client's discomfort.

What would be the respiratory rate in two-year-old child? 1 20 2 30 3 40 4 50

2 30

Which response by the nurse during a client interview is an example of back channeling? 1 "All right, go on..." 2 "What else is bothering you?" 3 "Tell me what brought you here." 4 "How would you rate your pain on a scale of 0 to 10?"

1 "All right, go on..."

A nurse in a long-term health care setting will introduce a client who has a PhD to the other clients. The client tells the nurse, "I wish to be called Doctor." How should the nurse respond? 1 "Your wish will be respected." 2 "Why do you want to be called Doctor?" 3 "Residents here call one another by their first names." 4 "Wouldn't it be better if the others do not know you are a doctor?"

1 "Your wish will be respected."

What is the most important nursing action involved in caring for a client using medications to manage disease? 1 Administering the medications 2 Teaching about the medications 3 Ensuring adherence to the medication regimen 4 Evaluating the client's ability to self-administer medications

1 Administering the medications

Which physical assessment situation is appropriate for use of alcohol-based hand sanitizer for hand hygiene? 1 Before and after palpating a pulse 2 Assessing a client with norovirus 3 If the hand brushes a seeping dressing 4 When the hands have contacted sputum

1 Before and after palpating a pulse

An older adult with a history of diabetes reports giddiness, excessive thirst, and nausea. During an assessment, the nurse notices the client's body temperature as 105° F. Which condition does the nurse suspect in the client? 1 Heat stroke 2 Heat exhaustion 3 Accidental hypothermia 4 Malignant hyperthermia

1 Heat stroke

An older adult with a history of diabetes reports giddiness, excessive thirst, and nausea. During an assessment, the nurse notices the client's body temperature as 105°F (40.6°C), orally. Which condition would the nurse suspect in the client? 1 Heat stroke 2 Heat exhaustion 3 Accidental hypothermia 4 Malignant hyperthermia

1 Heat stroke

A client with a history of hypothyroidism reports giddiness, excessive thirst, and nausea. Which parameter assessed by the nurse confirms the diagnosis as heat stroke? 1 Increased heart rate 2 Increased blood pressure 3 Decreased respiratory rate 4 Increased circulatory damage

1 Increased heart rate

A nurse notices cyanosis in a client with heart disease. Which site would the nurse assess to confirm cyanosis? 1 Lips 2 Sclera 3 Conjunctiva 4 Mucus membrane

1 Lips

The nurse notices cyanosis in a client with heart disease. Which site would the nurse assess to confirm cyanosis? 1 Lips 2 Sclera 3 Conjunctiva 4 Mucus membrane

1 Lips

Nurses care for clients in a variety of age groups. In which age group is the occurrence of chronic illness the greatest? 1 Older adults 2 Adolescents 3 Young children 4 Middle-aged adults

1 Older adults

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis? 1 Planning 2 Evaluation 3 Assessment 4 Implementation

1 Planning

Which nursing action would be considered a part of self-regulation in the decision-making process? 1 Reflecting on one's own experiences 2 Looking at all the situations objectively 3 Supporting findings and conclusions 4 Making careful assumptions about a client's information

1 Reflecting on one's own experiences

While assessing a client with chills and fever, the nurse observes that the febrile episodes are followed by normal temperatures and that the episodes are longer than 24 hours. Which fever pattern does the nurse anticipate? 1 Relapsing 2 Sustained 3 Remittent 4 Intermittent

1 Relapsing

Which approach is a comforting approach that communicates concern and support? 1 Touch 2 Listening 3 Knowing the client 4 Providing a positive presence

1 Touch

The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia? 1 Crohn disease 2 Cushing disease 3 End-stage renal disease 4 Gastroesophageal reflux disease

3 End-stage renal disease

Which statement is true about the nursing model "team nursing"? 1 The registered nurse is responsible for all aspects of client care. 2 Client care can be delegated to other healthcare team members. 3 The registered nurse works directly with the client, family members, and healthcare team members. 4 Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members.

4 Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members.

A client experiencing chills and fever is admitted to the hospital. After assessing the client's vitals and medical history, the nurse concluded that the client's fever pattern is remittent. Which assessment finding led to this conclusion? 1 The client's temperature returns to an acceptable value at least once in the past 24 hours 2 The client's fever spikes and falls without a return to normal temperature levels 3 Periods of febrile episodes and periods with acceptable temperature values occur 4 The client has a constant body temperature continuously above 38°C with minimal fluctuation

2 The client's fever spikes and falls without a return to normal temperature levels

The nurse is assessing a client who had knee replacement surgery. Which assessment finding gathered by the nurse is an example of subjective data? 1 The client weighs 151 lbs (68.5 Kg). 2 The client's pain is 7 on a scale of 1 to 10. 3 The client's fasting blood sugar is 95 mg/dL. 4 The client's blood pressure is 140/90 mm Hg

2 The client's pain is 7 on a scale of 1 to 10.

The nurse is assessing a client who had knee replacement surgery. Which assessment finding gathered by the nurse is an example of subjective data? 1 The client weighs 151 lbs (68.5 Kg). 2 The client's pain is 7 on a scale of 1 to 10. 3 The client's fasting blood sugar is 95 mg/dL. 4 The client's blood pressure is 140/90 mm/Hg.

2 The client's pain is 7 on a scale of 1 to 10.

A client who underwent a physical examination reports itching after 2 days. Which condition should the nurse suspect? 1 Eczema 2 Hypersensitivity 3 Contact dermatitis 4 Anaphylactic shock

3 Contact dermatitis

A client who underwent a physical examination reports itching after 2 days. Which condition would the nurse suspect? 1 Eczema 2 Hypersensitivity 3 Contact dermatitis 4 Anaphylactic shock

3 Contact dermatitis

Arrange the order of steps involved in the evidence-based practice process. 1. Ask a clinical question. 2. Collect the most relevant and best evidence. 3. Critically appraise the evidence you gather. 4. Integrate all evidence with one's clinical expertise and client preferences and values in making a practice decision or change. 5. Evaluate the practice decision or change. 6. Share the outcomes of evidence-based practice.

1. Ask a clinical question. 2. Collect the most relevant and best evidence. 3. Critically appraise the evidence you gather. 4. Integrate all evidence with one's clinical expertise and client preferences and values in making a practice decision or change. 5. Evaluate the practice decision or change. 6. Share the outcomes of evidence-based practice.

Which factor can elevate the oxygen saturation during an assessment? 1 Nail polishes 2 Carbon monoxide 3 Intravascular dyes 4 Skin pigmentation

2 Carbon monoxide

Which degree of edema will result in a 6-mm deep indentation upon pressure application? 1 4+ 2 3+ 3 2+ 4 1+

2 3+

Which integumentary finding is related to skin texture? 1 Elasticity 2 Vascularity 3 Fluid buildup 4 Character of the surface

4 Character of the surface

The nurse is assessing four infants. Which infant does the nurse anticipate to be of abnormal weight?

The average birth weight of a newborn is 3.2 to 3.4 kg. An infant usually doubles his or her birth weight at 4 to 5 months of age. Therefore, infant 2's weight of 8.5 kg at 5 months is abnormal. Infant 1, weighing 6.1 kg, is of a normal weight. An infant has usually tripled his or her birth weight by around 1 year. Therefore, infants 3 and 4 are experiencing normal weight gain.

The client reports difficulty in breathing. The nurse auscultates lung sounds and assesses the respiratory rate. Which is the purpose of the nurse's action? 1 Data collection 2 Data validation 3 Data clustering 4 Data interpretation

the nurse's action? 1 Data collection

A nurse in the ambulatory preoperative unit identifies that a client is more anxious than most clients. What is the nurse's best intervention? 1 Attempt to identify the client's concerns. 2 Reassure the client that the surgery is routine. 3 Report the client's anxiety to the healthcare provider. 4 Provide privacy by pulling the curtain around the client.

1 Attempt to identify the client's concerns.

Which term refers to a blowing sound created by turbulence caused by narrowing of arteries while assessing for carotid pulse? 1 Bruit 2 Ectropion 3 Entropion 4 Borborygmi

1 Bruit

The client reports difficulty in breathing. The nurse auscultates lung sounds and assesses the respiratory rate. What is the purpose of the nurse's action? 1 Data collection 2 Data validation 3 Data clustering 4 Data interpretation

1 Data collection

After assessing the muscle functionality of a client, the nurse assigns a grade of F (fair) on the Lovett scale in the client. What is the muscle functionality of the client? 1 Full range of motion with gravity 2 Full range of motion with gravity eliminated 3 Full range of motion against gravity with full resistance 4 Full range of motion against gravity with some resistance

1 Full range of motion with gravity

A client with internal bleeding is in the intensive care unit (ICU) for observation. At the change of shift an alarm sounds, indicating a decrease in blood pressure. Which is the correct nursing action? 1 Perform an assessment of the client before resuming the change-of-shift report. 2 Continue the change-of-shift report and include the decrease in blood pressure. 3 Lower the diastolic pressure limits on the monitor during the change-of-shift report. 4 Turn off the alarm temporarily and alert the oncoming nurse to the decrease in blood pressure.

1 Perform an assessment of the client before resuming the change-of-shift report.

The nurse assessed a client's pulse rate and recorded the score as 3+. What is the strength of the pulse? 1 Strong 2 Bounding 3 Expected 4 Diminished

1 Strong

Which assessment finding of the skin refers to elasticity? 1 Turgor 2 Edema 3 Texture 4 Vascularity

1 Turgor

The nurse is teaching the parent of an infant about inspecting the crib before putting an infant to sleep. Which statement made by the parent indicates a need for further education? 1 "I should remove mobiles from the infant." 2 "I should attach crib toys with hanging strings." 3 "I should check whether the crib's mattress fits snugly." 4 "I should disassemble and throw away the unsafe cribs."

2 "I should attach crib toys with hanging strings."

A nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremities, the nurse notes that the client has thin, shiny skin; decreased hair growth; and thickened toenails. What might this indicate? 1 Venous insufficiency 2 Arterial insufficiency 3 Phlebitis 4 Lymphedema

2 Arterial insufficiency

While assessing the pupils of a client, a healthcare professional notices pupillary dilatation. Which drug intake might have resulted in this condition? 1 Heroin 2 Atropine 3 Morphine 4 Pilocarpine

2 Atropine

The nurse noticed the breathing rate as regular and slow while assessing a client for respiration. What could be the condition of the client? 1 Apnea 2 Bradypnea 3 Tachypnea 4 Hyperpnea

2 Bradypnea

A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte? 1 Sodium 2 Calcium 3 Potassium 4 Phosphorus

2 Calcium

A 78-year-old client who has hypertension is beginning treatment with furosemide. Considering the client's age, what should the nurse teach the client to do? 1 Limit fluids at bedtime. 2 Change positions slowly. 3 Take the medication between meals. 4 Assess the skin for breakdown daily.

2 Change positions slowly.

The nurse is gathering a client's health history. Which information would the nurse classify as biographical information? Select all that apply. One, some, or all responses may be correct. 1 Symptoms 2 Client's age 3 Family structure 4 Type of insurance 5 Occupation status

2 Client's age 4 Type of insurance 5 Occupation status

Which professional standard does the nurse feel is most important for critical thinking? 1 Logical thinking 2 Evaluation criteria 3 Accurate knowledge 4 Relevant information

2 Evaluation criteria

While examining a client, a nurse finds a circumscribed elevation of the skin filled with serous fluid on the cheek. The lesion is 0.6 cm in diameter. What does the nurse suspect the finding to be? 1 Papule 2 Vesicle 3 Nodule 4 Pustule

2 Vesicle

A client is to receive a transfusion of packed red blood cells (PRBCs). The nurse should prepare for the transfusion by priming the blood IV tubing with which solution? 1 Lactated Ringer solution 2 5% dextrose and water 3 0.9% normal saline 4 0.45% normal saline

3 0.9% normal saline

A nurse is planning to provide self-care health information to several clients. Which client should the nurse anticipate will be most motivated to learn? 1 A 55-year-old client who had a mastectomy and is very anxious about her body image 2 An 18-year-old client who smokes cigarettes and is in denial about the dangers of smoking 3 A 56-year-old client who had a heart attack last week and is requesting information about exercise 4 A 47-year-old client who has a long-leg cast after sustaining a broken leg and is still experiencing severe pain

3 A 56-year-old client who had a heart attack last week and is requesting information about exercise

Which assessment is expected when a client is placed in the lithotomy position during physical examination? 1 Assessment of the heart 2 Assessment of the rectum 3 Assessment of the female genitalia 4 Assessment of the musculoskeletal system

3 Assessment of the female genitalia

Which clinical condition will result in changes in the integrity of the arterial walls and small blood vessels? 1 Contusion 2 Thrombosis 3 Atherosclerosis 4 Tourniquet effect

3 Atherosclerosis

A client is admitted with a suspected malignant melanoma on the arm. When performing the physical assessment, what would the nurse expect to find? 1 Large area of petechiae 2 Red birthmark that has recently become lighter in color 3 Brown or black mole with red, white, or blue areas 4 Patchy loss of skin pigmentation

3 Brown or black mole with red, white, or blue areas

A client is diagnosed with acquired immunodeficiency syndrome (AIDS). When examining the client's oral cavity, the nurse assesses white patchy plaques on the mucosa. The nurse recognizes that this finding most likely represents what opportunistic infection? 1 Cytomegalovirus 2 Histoplasmosis 3 Candida albicans 4 Human papillomavirus

3 Candida albicans

A nurse is palpating the peripheral pulse of different clients. Which client has an unacceptable heart rate? 1 Client 1 2 Client 2 3 Client 3 4 Client 4

3 Client 3

A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documented as what? 1 Vesicular 2 Bronchial 3 Crackles 4 Rhonchi

3 Crackles

A client's breath has a sweet, fruity odor. Which condition is likely affecting this client? 1 Gum disease 2 Uremic acidosis 3 Diabetic acidosis 4 Infection inside a cast

3 Diabetic acidosis

While inspecting the external eye structure of a client, a nurse finds bulging of the eyes. Which condition can be suspected in the client? 1 Eye tumors 2 Hypothyroidism 3 Hyperthyroidism 4 Neuromuscular injury

3 Hyperthyroidism

Which type of breathing pattern alteration is manifested with hypercarbia? 1 Eupnea 2 Tachypnea 3 Hypoventilation 4 Kussmaul's respiration

3 Hypoventilation

A nurse is preparing a community health program for senior citizens. The nurse teaches the group that what physical findings are typical in older adults? 1 A loss of skin elasticity and a decrease in libido 2 Impaired fat digestion and increased salivary secretions 3 Increased blood pressure and decreased hormone production 4 An increase in body warmth and some swallowing difficulties

3 Increased blood pressure and decreased hormone production

A client shows an increase in rate respirations that are abnormally deep and regular. What condition would the nurse expect? 1 Hypoventilation 2 Biot's respiration 3 Kussmaul's respiration 4 Cheyne-Stokes respiration

3 Kussmaul's respiration

The nurse is assisting with the end-of-life care of an older adult. Which activity is performed when the nurse views family as context? 1 Assess the resources available to the family 2 Meet the client's family's comfort and nutritional needs 3 Meet the client's comfort, hygiene and nutritional needs 4 Determine the family's need for rest and their stage of coping

3 Meet the client's comfort, hygiene and nutritional needs

While auscultating the heart, a healthcare provider notices S3 heart sounds in four clients. Which client is at more risk for heart failure? 1 Child client 2 Pregnant client 3 Older adult client 4 Young adult client

3 Older adult client

Which food would the nurse recommend to a client when instructing to increase potassium intake? Select all that apply. One, some, or all responses may be correct. 1 Onion 2 Celery 3 Orange 4 Cheese 5 Oatmeal

3 Orange

A nurse assesses for hypocalcemia in a postoperative client. What is one of the initial signs that might be present? 1 Headache 2 Pallor 3 Paresthesias 4 Blurred vision

3 Paresthesias

Which assessing technique involves tapping a client's skin with the fingertips to cause vibrations in the underlying tissues? 1 Palpation 2 Inspection 3 Percussion 4 Auscultation

3 Percussion

The nurse finds that the client's fever spikes and falls without a return to a normal level. Which pattern of fever is this a characteristic of? 1 Relapsing 2 Sustained 3 Remittent 4 Intermittent

3 Remittent

Which component of decision-making refers to the duties and activities an individual is employed to perform? 1 Authority 2 Autonomy 3 Responsibility 4 Accountability

3 Responsibility

The nurse is developing a nursing diagnosis for a client after surgery. The nurse documents the "related to" factor as first time surgery. Which assessment activity enabled the nurse to derive this conclusion? 1 The nurse notes nonverbal signs of discomfort. 2 The nurse observes the client's position in bed. 3 The nurse asks the client to explain the surgery. 4 The nurse asks the client to rate the severity of pain.

3 The nurse asks the client to explain the surgery.

A client with coronary artery disease has a sudden episode of cyanosis and a change in respirations. The nurse starts oxygen administration immediately. Legally, should the nurse have administered the oxygen? 1 The oxygen had not been prescribed and therefore should not have been administered. 2 The symptoms were too vague for the nurse to determine a need for administering oxygen. 3 The nurse's observations were sufficient, and therefore oxygen should have been administered. 4 The primary healthcare provider should have been called for a prescription before the nurse administered the oxygen.

3 The nurse's observations were sufficient, and therefore oxygen should have been administered.

To prevent septic shock in the hospitalized client, what should the nurse do? 1 Maintain the client in a normothermic state. 2 Administer blood products to replace fluid losses. 3 Use aseptic technique during all invasive procedures. 4 Keep the critically ill client immobilized to reduce metabolic demands.

3 Use aseptic technique during all invasive procedures.

While performing a physical assessment of a female client, the nurse positions the client in Sims' position. Which body system will be assessed in this position? Select all that apply. 1 Heart 2 Vagina 3 Rectum 4 Female genitalia 5 Musculoskeletal system

3 Rectum 4 Female genitalia 5 Musculoskeletal system

A client presents to the healthcare facility with abdominal pain. Which question should the nurse ask the client to obtain information about concomitant symptoms? 1 "Can you describe the pain?" 2 "Where exactly do you feel the pain?" 3 "Which activities make the pain worse?" 4 "What other discomfort do you experience?"

4 "What other discomfort do you experience?"

An older adult with chills arrived to hospital. The nurse assesses the client's vital signs and determined the client has a fever. What would be the client's rectal temperature? 1 36.0ºC 2 36.8ºC 3 37.2ºC 4 38.5ºC

4 38.5ºC

A nurse is assessing a client's degree of edema and finds 8 mm of depth. How does the nurse document this condition? 1 1+ 2 2+ 3 3+ 4 4+

4 4+

A nurse is assessing several clients. Which client will require parenteral nutrition? 1 A client with brain neoplasm 2 A client with anorexia nervosa 3 A client with inflammatory bowel disease 4 A client with severe malabsorption disorder

4 A client with severe malabsorption disorder

Which physical assessment technique involves listening to the sounds of the body? 1 Palpation 2 Inspection 3 Percussion 4 Auscultation

4 Auscultation

While assessing a neonate's temperature, the nurse observes a drop in the body temperature. What is the most appropriate reason for this temperature drop? 1 Increased basal metabolic rate 2 Decreased involuntary shivering 3 Increased voluntary movements 4 Decreased nonshivering thermogenesis

4 Decreased nonshivering thermogenesis

While assessing the client's skin, a nurse notices a skin condition, the pathophysiology of which involves increased visibility of oxyhemoglobin caused by an increased blood flow due to capillary dilation. Which condition is associated with this client? 1 Pallor 2 Vitiligo 3 Cyanosis 4 Erythema

4 Erythema

The nurse is performing a weight assessment for different people in a community. Which question should the nurse ask a client to determine a disease-related change in weight? 1 Do you follow a strict calorie intake? 2 Have you notices any changes in the social aspects of eating? 3 Are you taking diuretics or insulin? 4 Have you noticed any unintentional weight loss in the past six months?

4 Have you noticed any unintentional weight loss in the past six months?

An obese adult develops an abscess after abdominal surgery. The wound is healing by secondary intention and requires repacking and redressing every 4 hours. Which diet should the nurse expect the healthcare provider to prescribe to best meet this client's immediate nutritional needs? 1 Low in fat and vitamin D 2 High in calories and fiber 3 Low in residue and bland 4 High in protein and vitamin C

4 High in protein and vitamin C

A client has a history of a persistent cough, hemoptysis, unexplained weight loss, fatigue, night sweats, and fever. Which risk should be assessed? 1 Lung cancer 2 Cerebrovascular disease 3 Cardiopulmonary alterations 4 Human immunodeficiency virus (HIV) infection

4 Human immunodeficiency virus (HIV) infection

A client with a head injury underwent a physical examination. The nurse observes that the client's temperature assessments do not correspond with the client's condition. An injury to which part of the brain may be the reason for this condition? 1 Pons 2 Medulla 3 Thalamus 4 Hypothalamus

4 Hypothalamus

The nurse is aware that the nursing diagnosis should follow the North American Nursing Diagnosis Association International (NANDA-I) label. How should the nurse document the nursing diagnosis in a three-part format? 1 NANDA-I label, related factor, and etiologies 2 NANDA-I label, risk factor, and nursing interventions 3 NANDA-I label, related factor, and nursing interventions 4 NANDA-I label, related factor, and defining characteristics

4 NANDA-I label, related factor, and defining characteristics

A nurse is assessing a client's nails and finds a slight convex curve at the angle from the skin to nail base of about 160 degrees. Which condition does the nurse suspect? 1 Clubbing 2 Paronychia 3 Koilonychia 4 Normal finding

4 Normal finding

The nurse is assessing a client's nails and finds a slight convex curve at the angle from the skin to nail base of about 160 degrees. Which condition would the nurse suspect? 1 Clubbing 2 Paronychia 3 Koilonychia 4 Normal finding

4 Normal finding

The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified? 1 Primary 2 Secondary 3 Superinfection 4 Nosocomial

4 Nosocomial

A client complains of pain in the ear. While examining the client, a nurse finds swelling in front of the left ear. Which lymph node does the nurse expect to be involved? 1 Mastoid 2 Occipital 3 Submental 4 Pre-auricular

4 Pre-auricular

A client has relocated to a new city for work. The client is unable to continue the practice of walking for 30 minutes daily and exercising five days a week. Which stage of the transtheoretical model of health behavior change is the client experiencing? 1 Action 2 Preparation 3 Maintenance 4 Precontemplation

4 Precontemplation

An 82-year-old retired schoolteacher is admitted to a nursing home. During the physical assessment, the nurse may identify which ocular problem common to persons at this client's developmental level?: 1 Tropia 2 Myopia 3 Hyperopia 4 Presbyopia

4 Presbyopia

What does a nurse consider the most significant influence on many clients' perception of pain when interpreting findings from a pain assessment? 1 Age and sex 2 Physical and physiological status 3 Intelligence and economic status 4 Previous experience and cultural values

4 Previous experience and cultural values

The nurse at a community healthcare center focuses on providing primary preventive care. What is the focus of primary preventive care? 1 Rehabilitating the client 2 Treating early stages of disease 3 Preventing complications from illness 4 Promoting health in healthy individuals

4 Promoting health in healthy individuals

Which physical assessment of the skin indicates that a client is addicted to phencyclidine? 1 Burns 2 Vasculitis 3 Diaphoresis 4 Red and dry skin

4 Red and dry skin

The nurse is assessing a client who is undergoing chemotherapy. The nurse notes that the client is using a scarf to cover the head. The nurse asks the client about coping with the altered body image. Which functional pattern does the assessment include? 1 Value-belief pattern 2 Role-relationship pattern 3 Cognitive-perceptual pattern 4 Self-perception-Self-tolerance pattern

4 Self-perception-Self-tolerance pattern

The nurse recognizes that which is the mental process most sensitive to deterioration with aging? 1 Judgment 2 Intelligence 3 Creative thinking 4 Short-term memory

4 Short-term memory

Which of the following is a description of the percussion technique? 1 Listening to sounds that the body makes 2 Using the sense of touch to assess and collect data 3 Carefully looking for abnormal findings 4 Tapping the skin with the fingertips to vibrate underlying tissues

4 Tapping the skin with the fingertips to vibrate underlying tissues

While assessing a client for the dorsalis pedis pulse, a nurse documents the reading as 1+. What can be inferred from this finding? 1 There is absence of a pulse. 2 The pulse strength is normal. 3 The pulse strength is bounding. 4 The pulse strength is barely palpable.

4 The pulse strength is barely palpable.

Which statement is true for collaborative problems in a client receiving healthcare? 1 They are the identification of a disease condition. 2 They include problems treated primarily by nurses. 3 They are identified by the primary healthcare provider. 4 They are identified by the nurse during the nursing diagnosis stage.

4 They are identified by the nurse during the nursing diagnosis stage.

Which site should be monitored for a pulse to assess the status of circulation to the foot? Select all that apply. 1 Carotid artery 2 Femoral artery 3 Popliteal artery 4 Dorsalis pedis artery 5 Posterior tibial artery

4 Dorsalis pedis artery 5 Posterior tibial artery

What is the correct order of steps of the nursing diagnostic process? 1. Identify the client's needs. 2. Assess the client's health status. 3. Look for defining characteristics. 4. Cluster data. 5. Interpret the meaning of the data. 6. Formulate nursing diagnoses. 7. Validate the data with other sources.

4. Cluster data. The diagnostic reasoning process involves the use of assessment data for the client. The assessment data is obtained from the client, family, and health care resources. The nurse validates and ensures the data is accurate and uses critical thinking to interpret and analyze the data before it is classified and organized into data clusters. This organization helps the nurse identify the client's health needs. The nurse then formulates the nursing diagnoses using standard formal nursing diagnostic statements.

Arrange the sequence of events occurring during a fever secondary to pyrogens in chronological order.

A true fever results from an alteration in the hypothalamic set point. Pyrogens act as antigens that trigger the immune system response. The hypothalamus reacts by raising the set point, thereby increasing the body temperature. Once the pyrogens are removed, the third phase of a febrile episode occurs. Heat loss responses are initiated when the hypothalamus set point drops.

The nurse must understand the process of changing behaviors to be able to support difficult behavioral changes in clients. Arrange the Stages of Health Behavior Change as described by DiClemente and Prochaska (1998) in the transtheoretical model of change. 1. Action 2. Preparation 3. Contemplation 4. Maintenance stage 5. Precontemplation

- 5. Precontemplation - 3. Contemplation - 2. Preparation -1. Action -4. Maintenance stage

A nurse is teaching a client about proper hair hygiene and how to protect his or her hair from lice. Which statement made by the client indicates ineffective learning? 1 "I will soak the comb used to remove lice for 15 minutes in cold water." 2 "I will remove any detectable nits by using a metal nit comb after shampooing." 3 "I will shampoo thoroughly with pediculicide in cold water at a basin or sink." 4 "I will seal nonwashable items in plastic bags if unable to dry clean or vacuum."

1 "I will soak the comb used to remove lice for 15 minutes in cold water."

While assessing a client's vascular system, the nurse finds that pulse strength is diminished or barely palpable. Which documentation is appropriate in this situation? 1 1+ 2 2+ 3 3+ 4 4+

1 1+

Which client's need should be considered high priority? 1 A client with dysphagia who is choking while eating 2 A client who needs discharge teaching about medications 3 A client who needs a dressing change of the surgical wound 4 A client who has a knowledge deficit regarding the use of an insulin pen

1 A client with dysphagia who is choking while eating

A nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. To protect the caregivers from injury, the nurse teaches them to lift the client by first placing their arms under the client's axillae and doing what next? 1 Bending and then straightening their knees 2 Bending at the waist and then straightening the back 3 Placing one foot in front of the other and then leaning back 4 Placing pressure against the client's axillae and then raising their arms

1 Bending and then straightening their knees

The nurse is discussing discharge plans with a client who had a myocardial infarction. The client states, "I'm worried about going home." The nurse responds, "Tell me more about this." What interviewing technique did the nurse use? 1 Exploring 2 Reflecting 3 Refocusing 4 Acknowledging

1 Exploring

A client complains to the nurse manager about a coworker. The nurse manager listens to both the patient's and the coworker's side of the story. Which critical thinking quality is shown in this situation? 1 Fairness 2 Discipline 3 Risk-taking 4 Responsibility

1 Fairness

A student nurse is assessing the blood pressure of a client with the client's arm unsupported. What are the expected errors in the obtained readings? 1 False high reading 2 False low diastolic reading 3 False high systolic reading 4 False high diastolic readin

1 False high reading

After assessing the muscle functionality of a client, the nurse assigns a grade of F (fair) on the Lovett scale in the client. Which describes the muscle functionality of the client? 1 Full range of motion with gravity 2 Full range of motion with gravity eliminated 3 Full range of motion against gravity with full resistance 4 Full range of motion against gravity with some resistance

1 Full range of motion with gravity

The nurse assesses an edematous client and recalls that edema occurs in what extracellular fluid compartment? 1 Interstitial 2 Intercellular 3 Intravascular 4 Intracellular

1 Interstitial

The nurse is assessing an older adult during a regular checkup. Which finding(s) during the assessment is/are normal? Select all that apply. One, some, or all responses may be correct. 1 Loss of turgor 2 Urinary incontinence 3 Decreased night vision 4 Decreased mobility of ribs 5 Increased sensitivity to odors

1 Loss of turgor 3 Decreased night vision 4 Decreased mobility of ribs

What is the inflammation of the skin at the base of the nail called? 1 Paronychia 2 Koilonychia 3 Beau's lines 4 Splinter hemorrhage

1 Paronychia

Which nurse collaborates directly with the client to establish and implement a basic plan of care after admission? 1 Primary nurse 2 Nurse clinician 3 Nurse coordinator 4 Clinical nurse specialist

1 Primary nurse

Which feature is characteristic of a risk nursing diagnosis? 1 The diagnosis does not have related factors. 2 The diagnosis can be used in any health state. 3 The defining characteristics support the diagnostic judgment. 4 The defining characteristics are supported by a client's readiness.

1 The diagnosis does not have related factors.

In which situation does the nurse consider the family as context? 1 The nurse is caring for an individual with tonsillitis. 2 The nurse is caring for a dying client and all the family members. 3 The nurse is teaching young parents about caring for their toddler. 4 The nurse is assessing the needs of the family caregivers of a client.

1 The nurse is caring for an individual with tonsillitis.

Which intervention reflects the nurse's approach of "family as a context"? 1 Trying to meet the client's comfort 2 Evaluating the client family's coping skills 3 Evaluating the client family's energy level 4 Trying to meet the client family's nutritional needs

1 Trying to meet the client's comfort

A client has corrective surgery for a bladder laceration. What nursing intervention takes priority during this client's postoperative period? 1 Turning frequently 2 Raising side rails on the bed 3 Providing range-of-motion exercises 4 Massaging the back three times a day

1 Turning frequently

Which pulse site is used for the Allen's test? 1 Ulnar 2 Radial 3 Brachial 4 Femoral

1 Ulnar

A nurse is assessing a client who underwent abdominal surgery 10 days ago. The client complains of pain in the abdomen. What type of pain does the client experience? 1 Visceral pain 2 Somatic pain 3 Referred pain 4 Intractable pain

1 Visceral pain

The nurse is assessing a client who underwent abdominal surgery 10 days ago. The client complains of pain in the abdomen. Which type of pain would the client experience? 1 Visceral pain 2 Somatic pain 3 Referred pain 4 Intractable pain

1 Visceral pain

Which workers would the nurse consider to be at high risk of developing dermatitis? Select all that apply. 1 Dry cleaners 2 Dye workers 3 Lathe operators 4 Hospital workers 5 Agricultural workers

1 Dry cleaners 2 Dye workers

A client with a recent history of head trauma is at risk for orthostatic hypotension. Which assessment findings observed by the nurse would relate to this diagnosis? Select all that apply. 1 Fainting 2 Headache 3 Weakness 4 Lightheadedness 5 Shortness of breath

1 Fainting 3 Weakness 4 Lightheadedness

Which physiologic changes may occur during the first trimester of pregnancy? Select all that apply. 1 Fatigue 2 Increased libido 3 Morning sickness 4 Breast enlargement 5 Braxton Hicks contractions

1 Fatigue 3 Morning sickness 4 Breast enlargement

A nurse is assessing an older adult during a regular checkup. Which findings during the assessment are normal? Select all that apply. 1 Loss of turgor 2 Urinary incontinence 3 Decreased night vision 4 Decreased mobility of ribs 5 Increased sensitivity to odors

1 Loss of turgor 3 Decreased night vision 4 Decreased mobility of ribs

What are physiologic symptoms assessed in a client with sleep deprivation? Select all that apply. 1 Ptosis and blurred vision 2 Agitation and hyperactivity 3 Confusion and disorientation 4 Increased sensitivity to pain 5 Decreased auditory alertness

1 Ptosis and blurred vision 5 Decreased auditory alertness

Which sites would be safe and inexpensive for temperature measurement? Select all that apply. 1 Skin 2 Oral 3 Axilla 4 Rectal 5 Tympanic membrane

1 Skin 3 Axilla

A nurse is assessing an older adult client. Which clinical findings are expected responses to the aging process? Select all that apply. 1 Slowed neurologic responses 2 Lowered intelligence quotient 3 Long-term memory impairment 4 Forgetfulness about recent events 5 Reduced ability to maintain an erection

1 Slowed neurologic responses 4 Forgetfulness about recent events 5 Reduced ability to maintain an erection

What are the goals of care when working with families according to the family health system? Select all that apply. 1 To improve family health or well-being 2 To help the family prepare for later transitions 3 To assist in family management of illness conditions 4 To promote positive family behaviors to achieve essential tasks 5 To achieve health outcomes related to the family's areas of concern

1 To improve family health or well-being 3 To assist in family management of illness conditions 5 To achieve health outcomes related to the family's areas of concern

What is the sequence of techniques used while assessing the abdomen? 1. Inspection 2. Auscultation 3. Percussion 4. Palpation

1. Inspection 2. Auscultation 3. Percussion 4. Palpation

Arrange the hierarchy of needs in ascending order beginning with the highest priority needs as defined by Maslow. Correct 1. Physiological needs Correct 2. Safety and security Correct 3. Love and belonging needs Correct 4. Self-esteem Correct 5. Self-actualization

1. Physiological needs Correct 2. Safety and security Correct 3. Love and belonging needs Correct 4. Self-esteem Correct 5. Self-actualization

The registered nurse is teaching a nursing student about the skills to build a helping relationship with the client. Arrange the events of the helping relationship in chronological order. Correct 1. Planning enough time for the initial interaction Correct 2. Assessing the client's health status Correct 3. Providing information needed to understand and change behavior Correct 4. Achieving a smooth transition for the client to other caregivers as needed

1. Planning enough time for the initial interaction Correct 2. Assessing the client's health status Correct 3. Providing information needed to understand and change behavior Correct 4. Achieving a smooth transition for the client to other caregivers as needed

The nurse must understand the process of changing behaviors to be able to support difficult behavioral changes in clients. Arrange the Stages of Health Behavior Change as described by DiClemente and Prochaska (1998) in the transtheoretical model of change. Correct 1. Precontemplation Correct 2. Contemplation Correct 3. Preparation Correct 4. Action Correct 5. Maintenance stage

1. Precontemplation Correct 2. Contemplation Correct 3. Preparation Correct 4. Action Correct 5. Maintenance stage

What is the correct order of phases a client experiences in the event of a change in body image following an illness? Correct 1. Shock Correct 2. Withdrawal Correct 3. Acknowledgement Correct 4. Acceptance Correct 5. Rehabilitation

1. Shock Correct 2. Withdrawal Correct 3. Acknowledgement Correct 4. Acceptance Correct 5. Rehabilitation

A newly hired nurse during orientation is approached by a surveyor from the department of health. The surveyor asks the nurse about the best way to prevent the spread of infection. What is the most appropriate nursing response? 1 "Let me get my preceptor." 2 "Wash your hands before and after any client care." 3 "Clean all instruments and work surfaces with an approved disinfectant." 4 "Ensure proper disposal of all items contaminated with blood or body fluids."

2 "Wash your hands before and after any client care."

When suctioning a client with a tracheostomy, an important safety measure for the nurse is to do what? 1 Hyperventilate the client with room air before suctioning. 2 Apply suction only as the catheter is being withdrawn. 3 Insert the catheter until the cough reflex is stimulated. 4 Remove the inner cannula before inserting the suction catheter.

2 Apply suction only as the catheter is being withdrawn.

Which activity by the community nurse can be considered an illness prevention strategy? 1 Encouraging the client to exercise daily 2 Arranging an immunization program for chicken pox 3 Teaching the community about stress management 4 Teaching the client about maintaining a nutritious diet

2 Arranging an immunization program for chicken pox

When providing care for a client with a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication? 1 Skin breakdown 2 Aspiration pneumonia 3 Retention ileus 4 Profuse diarrhea

2 Aspiration pneumonia

A client complains of sudden muscle weakness during times of anger or laughter that may occur at any time during the day. Which condition should be suspected in this client? 1 Insomnia 2 Cataplexy 3 Narcolepsy 4 Sleep apnea

2 Cataplexy

While assessing the muscle tone of a client, the client demonstrates a full range of muscle motion against gravity with some resistance. What score on the Lovett scale can be given to the client? 1 Fair (F) 2 Good (G) 3 Trace (T) 4 Normal (N)

2 Good (G)

The nurse tells a client undergoing diuretic therapy to avoid working in the garden on hot summer days. What condition is the nurse trying to prevent in this client? 1 Frostbite 2 Heatstroke 3 Hypothermia 4 Hyperthermia

2 Heatstroke

Which statement best describes a diagnostic label? 1 It is a condition that responds to nursing interventions. 2 It describes the essence of the client's response to health conditions. 3 It describes the characteristics of the client's response to health conditions. 4 It is identified from the client's assessment data and associated with the diagnosis.

2 It describes the essence of the client's response to health conditions.

Which landmark is correct for a nurse to use when auscultating the mitral valve? 1 Left fifth intercostal space, midaxillary line 2 Left fifth intercostal space, midclavicular line 3 Left second intercostal space, sternal border 4 Left fifth intercostal space, sternal border

2 Left fifth intercostal space, midclavicular line

Which client assessment finding should the nurse document as subjective data? 1 Blood pressure 120/82 beats/min 2 Pain rating of 5 3 Potassium 4.0 mEq 4 Pulse oximetry reading of 96%

2 Pain rating of 5

After changing a dressing that was used to cover a draining wound on a client with vancomycin-resistant enterococci (VRE), the nurse should take which step to ensure proper disposal of the soiled dressing? 1 Place the dressing in the bedside trash can. 2 Place the dressing in a red bag/hazardous materials bag. 3 Contact Environmental Services personnel to pick up the dressing. 4 Transport the dressing to the laboratory to be placed in the incinerator.

2 Place the dressing in a red bag/hazardous materials bag.

Which stage of Piaget's theory of cognitive development does the nurse observe in a preschooler? 1 Sensorimotor 2 Preoperational 3 Formal operations 4 Concrete operations

2 Preoperational

The nurse pulls up on the client's skin and releases it to determine whether the skin returns immediately to its original position. What is the nurse assessing for? 1 Pain tolerance 2 Skin turgor 3 Ecchymosis formation 4 Tissue mass

2 Skin turgor

The nurse is gathering a client's health history. Which information does should the nurse classify as biographical information? Select all that apply. 1 Symptoms 2 Client's age 3 Family structure 4 Type of insurance 5 Occupation status

2 Client's age 4 Type of insurance 5 Occupation status

Which parts of the body assessed by the nurse would confirm a diagnosis of frostbite? Select all that apply. 1 Axilla 2 Fingers 3 Ear lobes 4 Forehead 5 Upper thorax

2 Fingers 3 Ear lobes

When should the nurse consider family members as the primary source of information? Select all that apply. 1 The client is an elderly adult. 2 The client is an infant or child. 3 The client is brought in as an emergency. 4 The client is critically ill and disoriented. 5 The client visits the outpatient department.

2 The client is an infant or child. 3 The client is brought in as an emergency. 4 The client is critically ill and disoriented.

A 50-year-old client being seen for a routine physical asks why a stool specimen for occult blood testing has been prescribed when there is no history of health problems. What is an appropriate nursing response? 1 "You will need to ask your healthcare provider; it is not part of the usual tests for people your age." 2 "There must be concern of a family history of colon cancer; that is a primary reason for an occult blood stool test." 3 "It is performed routinely starting at your age as part of an assessment for colon cancer." 4 "There must have been a positive finding after a digital rectal examination performed by your healthcare provider."

3 "It is performed routinely starting at your age as part of an assessment for colon cancer."

What is the appropriate blood pressure of a 12-year-old client? 1 95/65 mm Hg 2 105/65 mm Hg 3 110/65 mm Hg 4 119/75 mm Hg

3 110/65 mm Hg

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia? 1 Red blood cell count 2 Sputum culture 3 Arterial blood gas 4 Total hemoglobin

3 Arterial blood gas

While performing a physical assessment of a female client, a nurse notices hair on the client's upper lip, chin, and cheeks. Which condition may result in this condition? 1 Aging 2 Poor nutrition 3 Endocrine disease 4 Arterial insufficiency

3 Endocrine disease

The nurse is preparing to teach a community health program for senior citizens. Which physical findings would the nurse include that are typical in older adults? 1 Increased skin elasticity and an increase in testosterone production 2 Impaired fat digestion and an increase in pepsin production 3 Increased blood pressure and decreased cardiac output 4 An increase in body warmth and some swallowing difficulties

3 Increased blood pressure and decreased cardiac output

A nurse is caring for a client who underwent cardiac catheterization. The client's skin was found to be blanched, and there was formation of edema of 15.2 cm (1-6 inches) at the site of catheterization. Upon further assessment, the skin was found to be cool, and the client complains of tenderness. Which condition does the nurse expect? 1 Phlebitis 2 Infection 3 Infiltration 4 Circulatory overload

3 Infiltration

When meeting the unique preoperative teaching needs of an older adult, the nurse plans a teaching program based on which principle about learning? 1 It reduces general anxiety. 2 It is negatively affected by aging. 3 It requires continued reinforcement. 4 It necessitates readiness of the learner.

3 It requires continued reinforcement.

A client shows an increase in respiratory rate that is abnormally deep and regular. Which condition would the nurse expect? 1 Hypoventilation 2 Biot respiration 3 Kussmaul's respiration 4 Cheyne-Stokes respiration

3 Kussmaul's respiration

Which term refers to the exaggeration of the posterior curvature of the thoracic spine? 1 Lordosis 2 Scoliosis 3 Kyphosis 4 Osteoporosis

3 Kyphosis

Which physical skin finding indicates opioid abuse? 1 Diaphoresis 2 Red, dry skin 3 Needle marks 4 Spider angiomas

3 Needle marks

Which site is best used to assess a client for jaundice? 1 Skin 2 Palm 3 Sclera 4 Conjunctiva

3 Sclera

Which site is best used to inspect a client who is suspected to have jaundice? 1 Skin 2 Palm 3 Sclera 4 Conjunctiva

3 Sclera

Which developmental changes should be evaluated in girls around 12 years of age? 1 Motor skills 2 Visual acuity 3 Skeletal growth 4 Hormonal changes

3 Skeletal growth

When teaching about aging, the nurse explains that older adults usually have what characteristic? 1 Inflexible attitudes 2 Periods of confusion 3 Slower reaction times 4 Some senile dementia

3 Slower reaction times

A registered nurse (RN) is performing a physical examination of a client with chronic obstructive pulmonary disease. Which abnormal nail bed patterns can be expected in this client? 1 Spoon-shaped nails 2 Transverse depressions in nails 3 Softening of nail beds and flat nails 4 Red or brown linear streaks in nail bed

3 Softening of nail beds and flat nails

What should the nurse teach the parents of an infant about the use of car seats? 1 The infant should ride in a front-facing car safety seat. 2 The infant should ride in a car safety seat until one year of age. 3 The infant should be restrained properly in a federally approved car safety seat. 4 The infant should always ride in a car seat restrained to the front seat of the car.

3 The infant should be restrained properly in a federally approved car safety seat.

Which are extrinsic factors responsible for falls in older adults? Select all that apply. 1 Impaired vision 2 Cognitive impairment 3 Environmental hazards 4 Inappropriate footwear 5 Improper use of assistive devices

3 Environmental hazards 4 Inappropriate footwear 5 Improper use of assistive devices

A nurse suspects that a client has interacted with poison ivy. Assessment findings reveal vesicles on the arms and legs. Which is the description of a vesicle? 1 A lesion filled with purulent drainage 2 An erosion into the dermis 3 A solid mass of fibrous tissue 4 A lesion filled with serous fluid

4 A lesion filled with serous fluid

The nurse suspects that a client has interacted with poison ivy because assessment findings reveal vesicles on the arms and legs. Which is the description of a vesicle? 1 A lesion filled with purulent drainage 2 An erosion into the dermis 3 A solid mass of fibrous tissue 4 A lesion filled with serous fluid

4 A lesion filled with serous fluid

A nurse assesses a client with dry and brittle hair, flaky skin, a beefy-red tongue, and bleeding gums. The nurse recognizes that these clinical manifestations are most likely a result of what? 1 A food allergy 2 Noncompliance with medications 3 Side effects from medications 4 A nutritional deficiency

4 A nutritional deficiency

How does the World Health Organization (WHO) define "health"? 1 A condition when people are free of disease 2 A condition of life rather than pathological state 3 An actualization of inherent and acquired human potential 4 A state of complete physical, mental, and social well-being

4 A state of complete physical, mental, and social well-being

Which critical thinking skill does the nurse associate with the concept of maturity? 1 Eagerness to acquire knowledge 2 Being tolerant of different views 3 Trust in own reasoning processes 4 Ability to reflect on own judgments

4 Ability to reflect on own judgments

The nurse is preparing to assess the four abdominal quadrants of a client who complains of stomach pain. When determining the order of the assessment, the nurse recognizes that it is important to assess the symptomatic quadrant when? 1 First 2 Second 3 Third 4 Last

4 Last

Which positioning should be avoided while assessing a client with a history of asthma? 1 Sitting 2 Supine 3 Dorsal recumbent 4 Lateral recumbent

4 Lateral recumbent

While performing a physical assessment, the nurse notices a minute, nonpalpable change in the skin color of a client. What might be the type of skin lesion involved? 1 Wheal 2 Papule 3 Vesicle 4 Macule

4 Macule

A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution? 1 No special precautions are required. 2 Cover the infected site with a dressing. 3 Drape the client with a covering labeled biohazardous. 4 Place a surgical mask on the client.

2 Cover the infected site with a dressing.

Which skill would most likely be associated with an effective nurse leader? 1 Recognizing his or her own limitations 2 Delegating work appropriately 3 Displaying confidence in his or her knowledge base 4 Respecting the rights, beliefs, wishes, and values of clients

2 Delegating work appropriately

The nurse is providing restraint education to a group of nursing students. The nurse should include that it is inappropriate to use a restraint device to do what? 1 Prevent a client from pulling out an intravenous (IV) when there is concern that the client cannot follow instructions or is confused. 2 Prevent an adult client from getting up at night when there is insufficient staffing on the unit. 3 Maintain immobilization of a client's leg to prevent dislodging a skin graft. 4 Keep an older adult client from falling out of bed following a surgical procedure.

2 Prevent an adult client from getting up at night when there is insufficient staffing on the unit.

Arrange in order the items of personal protection equipment (PPE) removed after performing a surgical procedure.

glove, face shield, gown, mask

Which critical thinking skill refers to the use of knowledge and experience to choose effective client care strategies? 1 Evaluation 2 Explanation 3 Interpretation 4 Self-regulation

2 Explanation

Which parts of the body assessed by the nurse would confirm a diagnosis of frostbite? Select all that apply. One, some, or all responses may be correct. 1 Axilla 2 Fingers 3 Ear lobes 4 Forehead 5 Upper thorax

2 Fingers 3 Ear lobes

A nurse is caring for a client who is having diarrhea. To prevent an adverse outcome, the nurse should most closely monitor what patient data or assessment finding? 1 Skin condition 2 Fluid and electrolyte balance 3 Food intake 4 Fluid intake and output

2 Fluid and electrolyte balance

Which position is indicated to assess the musculoskeletal system and is contraindicated in clients with respiratory difficulties? 1 Sims position 2 Prone position 3 Supine position 4 Knee-chest position

2 Prone position

The nurse asks questions to an older client about past experiences and listens attentively. Which therapeutic communication strategy is involved when the older client is recalling the past? 1 Touch 2 Reminiscence 3 Reality orientation 4 Validation therapy

2 Reminiscence

The nurse is assessing a client after surgery. Which assessment finding does the nurse obtain from the primary source? 1 X-ray reports 2 Severity of pain 3 Results of blood work 4 Family caregiver interview

2 Severity of pain

The nurse is caring for an African American client with renal failure. The client states that the illness is a punishment for sins. Which cultural health belief does the client communicate? 1 Yin/Yang balance 2 Biomedical belief 3 Determinism belief 4 Magicoreligious belief

4 Magicoreligious belief

The nurse is educating a client about tips for speaking up to help the client to be more involved in his or her treatment. Which statement made by the client indicates the need for further education? 1 "I should pay attention to the care." 2 "I should make assumptions regarding the treatment." 3 "I should speak up and have questions or concerns." 4 "I should learn about medical tests that are prescribed."

2 "I should make assumptions regarding the treatment."

A client requests information about the prescribed medication regimen. What is the best response by the nurse? 1 Give a computer printout about the medication to the client. 2 Ask the client to state what is already known about the medication. 3 Advise talking to the primary healthcare provider to seek information about the medication. 4 Delegate the task of sharing information about the medication to the licensed practical nurse.

2 Ask the client to state what is already known about the medication.

The nurse is caring for a client before, during, and immediately after surgery. Which type of care is provided to the client? 1 Care that supports physical functioning 2 Care that supports homeostatic regulation 3 Care that supports psychosocial functioning 4 Care that provides immediate short-term help in physiological crises

2 Care that supports homeostatic regulation

A nurse is taking the vital signs of a client who has just been admitted to the healthcare facility. Which intervention by the nurse provides greater client satisfaction? 1 The nurse records the vital signs and leaves the room. 2 The nurse adjusts the bed and asks if the client is comfortable. 3 The nurse leaves the door of the room open while attending to the client. 4 The nurse tells the client that the primary healthcare provider will visit soon.

2 The nurse adjusts the bed and asks if the client is comfortable.

A client who is human immunodeficiency virus (HIV) positive is admitted to a surgical unit after an orthopedic procedure. The nurse should institute appropriate precautions with the awareness that HIV is highly transmissible through what means? Select all that apply. 1 Feces 2 Blood 3 Semen 4 Urine 5 Sweat 6 Tears

2 Blood 3 Semen

A nurse assesses drainage on a surgical dressing and documents the findings. Which documentation is most informative? 1 "Moderate amount of drainage." 2 "No change in drainage since yesterday." 3 "A 10-mm-diameter area of drainage at 1900 hours." 4 "Drainage is doubled in size since last dressing change."

3 "A 10-mm-diameter area of drainage at 1900 hours."

An adolescent who had an inguinal hernia repair is being prepared for discharge home. The nurse provides instructions about resumption of physical activities. Which statement by the adolescent indicates that the client understands the instructions? 1 "I can ride my bike in about a week." 2 "I don't have to go to gym class for 3 months." 3 "I can't perform any weightlifting for at least 6 weeks." 4 "I can never participate in football again."

3 "I can't perform any weightlifting for at least 6 weeks."

The registered nurse is teaching a nursing student about providing care to an older adult with dementia. Which statement made by the nursing student indicates a need for further education? 1 "I should serve food that is easy to eat." 2 "I should assist the client with eating." 3 "I should monitor weight and food intake once in a month." 4 "I should offer food supplements that are tasty and easy to swallow."

3 "I should monitor weight and food intake once in a month."

A client is admitted with a suspected malignant melanoma on the arm. When performing the physical assessment, which would the nurse expect to find? 1 Large area of petechiae 2 Red birthmark that has recently become lighter in color 3 Brown or black mole with red, white, or blue areas 4 Patchy loss of skin pigmentation

3 Brown or black mole with red, white, or blue areas

When caring for a client with venous insufficiency, the nurse would implement which nursing measure? 1 Apply abdominal girdle as needed. 2 Remove compression stockings for client ambulation. 3 Elevate the client's legs above heart level. 4 Keep the upper extremities elevated.

3 Elevate the client's legs above heart level.

The nurse is assessing a client with arthritis. Which statement made by the client indicates a precipitating factor that is an intellectual standard for critical thinking? 1 "The pain is usually present in my fingers and knees." 2 "I observed swelling and redness near the pain area." 3 "I feel the pain in each and every joint of my hands and legs." 4 "I run for 30 minutes every day; this exercise increases my pain."

4 "I run for 30 minutes every day; this exercise increases my pain."

On the third postoperative day after a below-the-knee amputation, a client is refusing to eat, talk, or perform any rehabilitative activities. What is the best initial approach that the nurse should take when interacting with this client? 1 Explain why there is a need to increase activity. 2 Emphasize that with a prosthesis, there will be a return to the previous lifestyle. 3 Appear cheerful and noncritical regardless of the client's response to attempts at intervention. 4 Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving.

4 Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving.

Refusing to follow the prescribed treatment regimen, a client plans to leave the hospital against medical advice. What is it important for the nurse to inform the client of? 1 That the client is acting irresponsibly 2 That this action violates the hospital policy 3 That the client must obtain a new primary healthcare provider for future medical needs 4 That the client must accept full responsibility for possible undesirable outcomes

4 That the client must accept full responsibility for possible undesirable outcomes

Which activity would the nurse explain can be performed by infants of aged 6 to 8 months? 1 Holding a pencil 2 Showing hand preference 3 Placing objects into containers 4 Transferring objects from hand to hand

4 Transferring objects from hand to hand

Arrange the sequence of events occurring during a fever in chronological order. 1. Pyrogens are destroyed. 2. Body temperature is increased. 3. Heat loss responses are initiated. 4. The set point of the hypothalamus is raised. 5. Immune system response is triggered.

A true fever results from an alteration in the hypothalamic set point. Pyrogens act as antigens that trigger the immune system response. The hypothalamus reacts by raising the set point, thereby increasing the body temperature. Once the pyrogens are removed, the third phase of a febrile episode occurs. Heat loss responses are initiated when the hypothalamus set point drops.

A nurse on the medical-surgical unit tells other staff members, "That client can just wait for the lorazepam; I get so annoyed when people drink too much." What does this nurse's comment reflect? 1 Demonstration of a personal bias 2 Problem solving based on assessment 3 Determination of client acuity to set priorities 4 Consideration of the complexity of client care

1 Demonstration of a personal bias

A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take? 1 Don an N95 respirator mask before entering the room. 2 Put on a permeable gown each time before entering the room. 3 Implement contact precautions and post appropriate signage. 4 After finishing with patient care, remove the gown first and then remove the gloves.

1 Don an N95 respirator mask before entering the room.

On the second day of hospitalization a client is discussing with the nurse concerns about unhealthy family relationships. During the nurse-client interaction the client begins to talk about a job problem. The nurse's response is, "Let's go back to what we were just talking about." What therapeutic communication technique did the nurse use? 1 Focusing 2 Restating 3 Exploring 4 Accepting

1 Focusing

A nurse is teaching continuing care assistants about ways to prevent the spread of infection. It would be appropriate for the nurse to emphasize that the cycle of the infectious process must be broken, which is accomplished primarily through what? 1 Hand washing before and after providing client care 2 Cleaning all equipment with an approved disinfectant after use 3 Wearing personal protective equipment (PPE) when providing client care 4 Using medical and surgical aseptic techniques at all times

1 Hand washing before and after providing client care

A client who has been battling cancer of the ovary for 7 years is admitted to the hospital in a debilitated state. The healthcare provider tells the client that she is too frail for surgery or further chemotherapy. When making rounds during the night, the nurse enters the client's room and finds her crying. Which is the most appropriate intervention by the nurse? 1 Sit down quietly next to the bed and allow her to cry. 2 Pull the curtain and leave the room to provide privacy for the client. 3 Explain to the client that her feelings are expected and they will pass with time. 4 Observe the length of time the client cries and document her difficulty accepting her impending death.

1 Sit down quietly next to the bed and allow her to cry.

When assessing a client's fluid and electrolyte status, the nurse recalls that the regulator of extracellular osmolarity is what? 1 Sodium 2 Potassium 3 Chloride 4 Calcium

1 Sodium

The nurse at the well baby clinic is assessing the gross motor skills of a five-month-old infant. Which finding is a cause for concern? 1 The baby has a head lag when pulled to sit. 2 The baby can turn from the side to the back. 3 The baby can turn from the abdomen to the back. 4 The baby supports much of his own weight when he or she is pulled to stand.

1 The baby has a head lag when pulled to sit.

The nurse pulls up on the client's skin and releases it to determine whether the skin returns immediately to its original position. Which is the nurse assessing for? 1 Pain tolerance 2 Skin turgor 3 Ecchymosis formation 4 Tissue mass

2 Skin turgor

A nurse is reviewing how a hyperglycemic client's blood glucose can be lowered. The nurse recalls that the chemical that buffers the client's excessive acetoacetic acid is what? 1 Potassium 2 Sodium bicarbonate 3 Carbon dioxide 4 Sodium chloride

2 Sodium bicarbonate

A nurse is caring for a client on bed rest. How can the nurse help prevent a pulmonary embolus? 1 Limit the client's fluid intake. 2 Teach the client how to exercise the legs. 3 Encourage use of the incentive spirometer. 4 Maintain the knee gatch position at an angle.

2 Teach the client how to exercise the legs.

To prevent thrombophlebitis in the immediate postoperative period, which action is most important for a nurse to include in the client's plan of care? 1 Increase fluid intake. 2 Restrict fluids. 3 Encourage early mobility. 4 Elevate the knee gatch of the bed.

3 Encourage early mobility.

Which finding during assessment prompts the nurse to don a protective gown? 1 Open sore 2 Abrasions of the skin 3 Excessive wound drainage 4 Productive, moist coughing

3 Excessive wound drainage

A registered nurse instructs a nursing student to use knowledge and experience to choose proper strategies to use to care for clients. Which critical-thinking skill does the registered nurse refer to? 1 Analysis 2 Evaluation 3 Explanation 4 Interpretation

3 Explanation

Nursing actions for an older adult should include health education and promotion of self-care. Which is most important when working with an older adult client? 1 Encouraging frequent naps 2 Strengthening the concept of ageism 3 Reinforcing the client's strengths and promoting reminiscing 4 Teaching the client to increase calories and focusing on a high-carbohydrate diet

3 Reinforcing the client's strengths and promoting reminiscing

The nurse is developing a nursing diagnosis for a client after surgery. The nurse documents the "related to" factor as first-time surgery. Which assessment activity enabled the nurse to derive this conclusion? 1 The nurse notes nonverbal signs of discomfort. 2 The nurse observes the client's position in bed. 3 The nurse asks the client to explain the surgery. 4 The nurse asks the client to rate the severity of pain.

3 The nurse asks the client to explain the surgery.

Which statement is true for attachment in the newborn? 1 Attachment occurs for the first 28 days. 2 Attachment begins in the first week of birth. 3 Attachment is the overlapping of soft skull bones. 4 Attachment is the interaction between parent and child.

4 Attachment is the interaction between parent and child.

Which activity would the nurse use as an example of fine motor skills of infants aged 2 to 4 months? 1 Turning from side to back 2 Sitting erect using support 3 Showing good head control 4 Bringing objects from hand to mouth

4 Bringing objects from hand to mouth

A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by doing what? 1 Promoting analgesia and circulation 2 Numbing the nerves and dilating the blood vessels 3 Promoting circulation and reducing muscle spasms 4 Causing local vasoconstriction, preventing edema and muscle spasms

4 Causing local vasoconstriction, preventing edema and muscle spasms

While caring for a client with a Hemovac portable wound drainage system, the nurse observes that the collection container is half full. The nurse empties the container. What is the next nursing intervention? 1 Encircle the drainage on the dressing. 2 Irrigate the suction tube with sterile saline. 3 Clean the drainage port with an alcohol wipe. 4 Compress the container before closing the port.

4 Compress the container before closing the port.

A nurse is reviewing a client's plan of care. What is the determining factor in the revision of the plan? 1 Time available for care 2 Validity of the problem 3 Method for providing care 4 Effectiveness of the interventions

4 Effectiveness of the interventions

A nurse in the health clinic is counseling a college student who recently was diagnosed with asthma. On what aspect of care should the nurse focus? 1 Teaching how to make a room allergy-free 2 Referring to a support group for individuals with asthma 3 Arranging with the college to ensure a speedy return to classes 4 Evaluating whether the necessary lifestyle changes are understood

4 Evaluating whether the necessary lifestyle changes are understood

Which theory proposes that older adults experience a shift from a materialistic to cosmic view of the world? 1 Activity theory 2 Continuity theory 3 Disengagement theory 4 Gerotranscendence theory

4 Gerotranscendence theory

Which nursing process involves delegation and verbal discussion with the healthcare team? 1 Planning 2 Evaluation 3 Assessment 4 Implementation

4 Implementation

The nurse is transferring a client from the bed to the chair. Which action should the nurse take during the transfer? 1 Place the client in a semi-Fowler position. 2 Stand behind the client during the transfer. 3 Turn the chair so it faces away from the bed. 4 Instruct the client to dangle the legs.

4 Instruct the client to dangle the legs.

While performing a physical assessment, the nurse notices a minute, nonpalpable change in the skin color of a client. Which would be the type of skin lesion involved? 1 Wheal 2 Papule 3 Vesicle 4 Macule

4 Macule

A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. The nurse should assign the client to which type of room? 1 Private room 2 Semiprivate room 3 Room with windows that can be opened 4 Negative-airflow room

4 Negative-airflow room

Which concept refers to respecting the rights of others? 1 Maturity 2 Systematicity 3 Inquisitiveness 4 Open-mindedness

4 Open-mindedness

The nurse receives information about a client through another nurse. The nurse then finds that information has some missing facts. Which critical thinking attitude would the nurse use to clarify the information after talking to the client directly? 1 Fairness 2 Humility 3 Discipline 4 Perseverance

4 Perseverance

Which caring intervention helps to provide comfort, dignity, respect, and peace to a client? 1 Listening 2 Spiritual caring 3 Providing presence 4 Relieving pain and suffering

4 Relieving pain and suffering

The nurse is developing a plan of care for the client who has activity intolerance. In determining the desired client outcomes, what should the nurse do? 1 Prioritize psychosocial needs over physical needs. 2 Use the Nursing Outcomes Classification (NOC) only. 3 Use nursing knowledge to plan outcomes and disregard client and family desires. 4 Set priorities and outcomes using the client's and family input.

4 Set priorities and outcomes using the client's and family input.

The home healthcare nurse visits a client who lives with her two grandchildren. The client's daughter is a single-parent who is away at work and comes home only on weekends. Which term does the nurse use to define this family form? 1 Nuclear family 2 Extended family 3 Single-parent family 4 Skip-generation family

4 Skip-generation family

A community healthcare nurse is conducting a survey about homeless children in the community. Which finding helps the nurse distinguish absolute homelessness from relative homelessness? 1 The children are under-immunized and at a risk for childhood illnesses. 2 The children are more likely to drop out of school and become unemployable. 3 The children have access to healthcare only through the emergency department. 4 The children do not have a physical shelter and may sleep outdoors or in vehicles.

4 The children do not have a physical shelter and may sleep outdoors or in vehicles.

The nurse creates a plan of care for a client with a risk of infection. Which is the most desirable expected outcome for the client? 1 All nursing functions will be completed by discharge. 2 All invasive intravenous lines will remain patent. 3 The client will remain awake, alert, and oriented at all times. 4 The client will be free of signs and symptoms of infection by discharge.

4 The client will be free of signs and symptoms of infection by discharge.

Which nursing action indicates that the nurse is actively listening to the client? 1 The nurse states his or her own opinions when the client is speaking. 2 The nurse refrains from telling his or her own story to the client. 3 The nurse reads the client's health record during the conversation. 4 The nurse interprets what the client is saying and reiterates in his or her own words.

4 The nurse interprets what the client is saying and reiterates in his or her own words.

Which theories are most relevant to development in adults? Select all that apply. 1 Piaget's theory 2 Erikson's theory 3 Kohlberg's theory 4 Stage-Crisis theory 5 Life Span approach

4 Stage-Crisis theory 5 Life Span approach

The nurse applies the nursing process while caring for clients. Which is the correct order of steps of the nursing process? 1. Diagnosis 2. Planning 3. Evaluation 4. Assessment 5. Implementation

4. Assessment 1. Diagnosis 2. Planning 5. Implementation 3. Evaluation