NU 273 practice questions Week 1

A nurse is assessing a client who reports abdominal pain, nausea, and diarrhea. When examining the client's abdomen, which sequence should the nurse use?

Inspection, auscultation, percussion, palpation

The nurse notes several very small, round, red and purple macules on a patient's skin. The patient has a history of anticoagulant use. The nurse records this finding as which of the following

Petechiae Petechiae are small red or purple macules, usually 1 to 2 mm in size, associated with bleeding tendencies. A patient with a history of anticoagulant use would fall in this category. Ecchymoses are round or irregular macular lesions larger than petechiae. Cherry angiomas are papular, round, red or purple lesions that are normal-age related changes. Telangiectasias are spider-like or linear bluish or red lesions associated with varicosities.

Which client being treated for anorexia displays assessment values that warrant hospitalization?

A 25yo whose weir is 70% of ideal and who has a serum glucose of 58mg/dL A 25-year-old whose weight is 70% of ideal and who has a serum glucose of 58mg/dL should be hospitalized because both values are troublesome. The values of the other clients do not meet the criteria for hospitalization.

The nurse is assessing the plantar creases on the newborns for documentation on the Ballard Scale. Which documentation is interpreted as evidence of a full-term infant?

Creases covering two-thirds of the anterior foot On the Ballard Scale, an assessment and documentation of a crease covering two-thirds of the anterior foot is interpreted as characteristic of a full-term newborn. The creases are assessed on the foot, not the hand or brow. No creases are indicative of a preterm newborn.

A nurse revises the care plan for a client who has difficulty dealing with a crying neonate. Which strategy should the new care plan implement early in this mother's hospital stay?

Assessment of the mother's coping strengths and weaknesses and the presence or absence of support system Assessment of the mother's coping strengths and weaknesses and the presence or absence of support systems is an important aspect in the implementation process. Assessment will also help the nurse identify situations that the mother perceives as stressors. Educating the client about alternative ways of expressing feelings and about crisis hotlines and community support systems should also be part of the care plan. The nurse hasn't established that the mother is angry, so anger-management therapy may not be necessary. The infant may not be crying due to hunger; assessing the mother's coping will help provide the basis for teaching the essential skills.

When performing a physical assessment, what technique should the nurse always perform first? (A) palpating (B) inspection (C) percussion (D) auscultation

B

The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed? (A) avoid palpation of reportedly tender areas because palpation in these areas my cause pain (B) palpate a tender area quickly to avoid any discomfort that the patient may experience (C) start the assessment with deep palpation, while encouraging the patient to relax and take deep breaths (D) begin the assessment with light palpation to detect surface characteristics and to accustom the patient to being touched

D

A physician orders a bland, full-liquid diet for a client. Which response, if made by the client, would indicate to the nurse that the client has understood the nurse's dietary teaching?

"Today i can have apple juice, chicken broth, and vanilla ice cream" A bland, full-liquid diet may include some fruit juices and foods from all of the food groups. On this diet, the client should avoid gastric irritants, such as orange juice, coffee, tea, colas, cocoa, breads, bran (fiber), and highly seasoned foods.

A client asks the nurse how to identify rheumatoid nodules with rheumatoid arthritis. What characteristic will the nurse include?

Located over bony prominence Rheumatoid nodules usually are nontender, movable, and evident over bony prominences, such as the elbow or the base of the spine. The nodules are not reddened.

Assessment of a client reveals evidence of a cystocele. The nurse interprets this as which of the following?

Bulging of the bladder into the vagina A cystocele is the bulging of the bladder into the vagina. A rectocele is a herniation of the rectum into the vagina. An enterocele is a protrusion of the intestinal wall into the vagina. An uterovaginal prolapse is the downward displacement of the cervix anywhere from low in the vagina to outside the vagina.

Over the past 2 months, a client has been receiving treatment for multiple ear infections and tonsillitis. The client reports a curdy white vaginal discharge and burning with urination. What is the most likely cause of these symptoms?

Candida alibicans Candida albicans presents with a thick, curdy white discharge, accompanied by a strong odor and burning with urination. Trichomonas vaginalis presents with a foamy, yellow-white discharge, accompanied by a foul odor and severe itching. Gardnerella vaginalis presents with a watery, gray-white discharge, accompanied by a fishy odor and more discharge after intercourse.

A middle-aged client presents to the ED reporting severe chest discomfort. Which finding is most indicative of a possible myocardial infarction (MI)?

Chest discomfort not relieved by rest or nitroglycerin Chest pain or discomfort not relieved by rest or nitroglycerin is associated with an acute MI. The other findings, although associated with acute coronary syndrome or MI, may also occur with angina and, alone, are not indicative of an MI.

The nurse is assessing a patient with a probable diagnosis of first-degree AV block. The nurse is aware that this dysrhythmia is evident on an ECG strip by what indication?

Delayed conduction, producing a prolonged PR interval First-degree AV block may occur without an underlying pathophysiology, or it can result from medications or conditions that increase parasympathetic tone. It occurs when atrial conduction is delayed through the AV node, resulting in a prolonged PR interval.

Which type of fracture involves a break through only part of the cross-section of the bone?

Incomplete An incomplete fracture involves a break through only part of the cross-section of the bone. A comminuted fracture is one that produces several bone fragments. An open fracture is one in which the skin or mucous membrane wound extends to the fractured bone. An oblique fracture runs across the bone at a diagonal angle of 45 to 60 degrees.

A client has a history of chronic obstructive pulmonary disease (COPD). Following a coughing episode, the client reports sudden and unrelieved shortness of breath. Which of the following is the most important for the nurse to assess?

Lung sounds A client with COPD is at risk for developing pneumothorax. The description given is consistent with possible pneumothorax. Though the nurse will assess all the data, auscultating the lung sounds will provide the nurse with the information if the client has a pneumothorax.

An adolescent presents with large round ring with a swollen border on the left arm.The adolescent often plays ball games in a field behind the school.what condition does the nurse suspect?

Lyme disease Lyme disease, which results from a tick bite, is characterized by a large round ring with a raised swollen border at the site of the bite. Treatment at this stage can prevent systemic involvement that could lead to cardiac, neurologic, and musculoskeletal symptoms. Impetigo is a clustering of vesicles that ooze and form a crust on the skin. Cellulitis is caused by a microorganism entering through broken skin, resulting in red, painful, swollen skin that is hot and tender. Actinic keratosis appears on sun-exposed surfaces like the arms and neck and causes thick, scaly, and discolored skin that is sometimes red or pink.

Which disorder is characterized by a group of symptoms produced by an excess of free circulating cortisol from the adrenal cortex?

Cushing syndrome The client with Cushing syndrome demonstrates truncal obesity, moon face, acne, abdominal striae, and hypertension. Regardless of the cause, the normal feedback mechanisms that control the function of the adrenal cortex become ineffective, and the usual diurnal pattern of cortisol is lost. The signs and symptoms of Cushing syndrome are primarily a result of the oversecretion of glucocorticoids and androgens, although mineralocorticoid secretion also may be affected.

Which assessment parameter is important for the client diagnosed with congestive heart failure?

Distended veins During a head-to-toe assessment of a client with congestive heart failure, the nurse checks for dyspnea, auscultates apical heart rate, counts radial heart rate, measures BP, checks for distended neck veins, and documents any signs of peripheral edema, lethargy, or confusion. The nurse need not examine joints for crepitus, eyes for excess tearing, or signs of photosensitivity because these are not symptoms of congestive heart failure.

The nurse in an outpatient clinic is conducting a follow-up assessment on a child who had a severe streptococcal infection 1 week ago. The client is doing better, and the nurse is providing teaching to the parents about continuing to monitor the client for possible complications of the infection. Which information is most important for the nurse to discuss with the parents?

"Return immediately if acute flank or mid-abdominal pain occurs" Acute glomerulonephritis is a major complication of streptococcal infections in children. The onset is often marked by a sudden occurrence of acute flank or mid-abdominal pain. The child may show signs of fluid retention, such as weight gain and edema. Hypertension also commonly occurs.

The nurse has provided preoperative instructions to a client scheduled for surgery at an ambulatory care center. Which statement, made by the client, would indicate that further instruction is needed?

"The nurse will explain the details of the surgery before i sign consent" Further instruction would be needed to clarify that the physician, not the nurse, explains the details of the surgery and obtains voluntary consent for the procedure. It is correct that preoperative instructions must be followed prior to surgery for the safety of the client, medical records are present for review prior to surgery, and the physician speaks with the family following the procedure and provides instructions for discharge.

A client comes to the clinic for evaluation because of complaints of dizziness and difficulty walking. Further assessment reveals a staggering gait, marked muscle incoordination, and nystagmus. A brain tumor is suspected. Based on the client's assessment findings, the nurse would suspect that the tumor is located in which area of the brain?

Cerebellum Findings such as ataxic or staggering gait, dizziness, marked muscle incoordination, and nystagmus suggest a cerebellar tumor. A frontal lobe tumor frequently produces personality, emotional, and behavioral changes. A tumor in the motor cortex produces seizure-like movements localized on one side of the body. Occipital lobe tumors produce visual manifestations.

A patient who had a colon resection 3 days ago is complaining of discomfort in the left calf. How should the nurse assess Homan's sign to determine if the patient may have a thrombus formation in the leg?

Dorsiflex the foot while the leg is elevated to check for calf pain Homan's sign is indicated by pain in the calf after the foot is sharply dorsiflexed.

The nurse is obtaining a history on a patient who comes to the clinic. What symptom described by the patient is one of the first symptoms associated with esophageal disease?

Dysphasia Dysphagia (difficulty swallowing), the most common symptom of esophageal disease, may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute odynophagia (pain on swallowing).

A nursing instructor is discussing the causes of the increasing number of people with chronic conditions. Which of the following would the nurse correctly identify as a cause?

Early detection and treatment of diseases

A nurse is assessing a neonate. When maternal estrogen has been transferred to the fetus which sign will the nurse see in the neonate?

Enlarged breast tissue It's common to see enlarged breast tissue in both male and female neonates in the first few days of life because of maternal estrogen transmitted to the fetus. Weak sucking response isn't related to estrogen. Soft skin and vernix caseosa are signs of full-term, well-developed neonates and aren't related to estrogen.

While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects

Melanoma The "ABCDs" of melanoma are Asymmetry of the lesion, Borders that are irregular, Colors that vary in shades, and increased Diameter. Fair skin with a history of sunburn and the location of the lesion on the leg (the most common site in women) suggest melanoma. Squamous cell carcinoma commonly develops on the skin of the face, the ears, the dorsa of the hands and forearms, and other sun-damaged areas. Early lesions appear as opaque, firm nodules with indistinct borders, scaling, and ulceration. Actinic keratosis is a premalignant skin lesion. Basal cell carcinoma presents as lesions that are lightly pigmented. As they enlarge, their centers become depressed and their borders become firm and elevated.

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note:

Yellow sclerae Yellow sclerae are an early sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools don't occur in common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively.

A nurse is caring for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority?

Assessing the extremity for neuro-vascular integrity Although all measures are correct, assessing neurovascular integrity takes priority because a decrease in neurovascular integrity could compromise the limb. The pull of the traction must be continuous to keep the client from sliding. Sufficient countertraction must be maintained at all times by keeping the ropes over the center of the pulley. The line of pull is maintained by allowing the weights to hang free.

A nurse determines that a patient has poor nutrition based on which assessment finding?

Beefy-red tongue Signs of poor nutrition include a beefy-red tongue, palpable thyroid gland, pale eye membranes, and flaccid, poorly toned, wasted, or underdeveloped muscles.

The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response by the nurse? (A) maybe she is just teething (B) I will check for an ear infection (C) are you sure she is really having pain? (D) describe what she is doing to indicate she is having pain

D

the nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment? (A) the functional assessment assesses how the individual is coping with life at home (B) it determines how children are meeting developmental milestones (C) the functional assessment can identify any problems with memory the individual may be experiencing (D) it helps determine how a person is managing day-to-day activities

D

During physical examination of the male reproductive system, which method would best provide the nurse information about the prostate's size as well as evidence of tumor?

Digital rectal examination A digital rectal examination (DRE) is performed to assess the prostate for size as well as evidence of tumor.

A physician orders a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance?

Hypokalemia A loop diuretic removes water and, along with it, sodium and potassium. This may result in hypokalemia, hypovolemia, and hyponatremia.

The nurse identifies a potential collaborative problem of electrolyte imbalance for a client with severe acute pancreatitis. Which assessment finding alerts the nurse to an electrolyte imbalance associated with acute pancreatitis?

Muscle twitching and finger numbness Muscle twitching and finger numbness indicate hypocalcemia, a potential complication of acute pancreatitis. Calcium may be prescribed to prevent or treat tetany, which may result from calcium losses into retroperitoneal (peripancreatic) exudate. The other data indicate other complications of acute pancreatitis but are not indicators of electrolyte imbalance.

During a routine eye examination, a patient complains that she is unable to read road signs at a distance when driving her car. What should the patient be assessed for?

Myopia Some people have deeper eyeballs, in which case the distant visual image focuses in front of, or short of, the retina; those with myopia Impaired Vision are said to be nearsighted and have blurred distance vision.

When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing

Poor tissue perfusion Chronically poor perfusion may result in hair loss in the affected area, discolored skin, thickened nails, and shiny, dry skin indicative of inadequate tissue nutrition.

Which is indicative of a right hemisphere stroke?

Spatial-perceptual deficits Clients with right hemisphere stroke exhibit partial perceptual deficits, left visual field deficit, and paralysis with weakness on the left side of the body. Left hemisphere damage causes aphasia; slow, cautious behavior; and altered intellectual ability.

A female client reports to a nurse that she experiences a loss of urine when she jogs. The nurse's assessment reveals no nocturia, burning, discomfort when voiding, or urine leakage before reaching the bathroom. The nurse explains to the client that this type of problem is called:

Stress incontinece Stress incontinence is a small loss of urine with activities that increase intra-abdominal pressure, such as running, laughing, sneezing, jumping, coughing, and bending. These symptoms occur only in the daytime. Functional incontinence is the inability of a usually continent client to reach the toilet in time to avoid unintentional loss of urine. Reflex incontinence is an involuntary loss of urine at predictable intervals when a specific bladder volume is reached. Total incontinence occurs when a client experiences a continuous and unpredictable loss of urine.

A nurse is caring for a client with schizophrenia. Which outcome requires revising the client's care plan?

The client spends more time alone The client with schizophrenia is commonly socially isolated and withdrawn; therefore, having the client spend more time alone wouldn't be a desirable outcome. Rather, a desirable outcome would specify that the client spend more time with other clients and staff on the unit. Delusions are false personal beliefs. Reducing or eliminating delusional thinking through use of talking therapy and antipsychotic medications would be a desirable outcome. Protecting the client and others from harm is a desirable client outcome achieved through close observation, removal of any dangerous objects, and medication administration. Because the client with schizophrenia may have difficulty meeting self-care needs, fostering the ability to independently perform self-care is a desirable client outcome.

An older adult client who has been living in an assisted living facility for several months informs a visiting family member that a nurse is coming to do some kind of checkup. Which type of check would be most appropriate for the nurse to perform on this client?

Time-lapsed assessment A time-lapsed assessment is scheduled to compare a client's current status to the baseline data obtained earlier. Most clients in residential settings and those receiving nursing care over longer periods of time are scheduled for this type of check. An emergency assessment is conducted if the client is having an emergency such as chest pain or hemorrhaging from the hand. Focused assessment is performed on clients focusing on the system or systems involved in the client's problem. Developmental stage assessment is the process of mapping a child's performance compared with children of similar age.

The spleen acts as a filter for old red blood cells, holding a reserve of blood in case of hemorrhagic shock. It is also an area where lymphocytes can concentrate. It can become enlarged (splenomegaly) in certain hematologic disorders and cancers. To assess an enlarged spleen, the nurse would palpate the area of the:

Upper left quadrant of the abdomen The spleen is located to the left of the stomach, in the upper left of the abdomen. It plays an important role in the immune system.

The nurse is assessing a client for constipation. Which review should the nurse conduct first to identify the cause of constipation?

Usual pattern of elimination Constipation has many possible causes and assessing the client's usual pattern of elimination is the first step in identifying the cause. The nurse should obtain a description of the bowel elimination pattern, asking about the frequency, overall appearance and consistency of stool, blood in the stool, pain, and effort necessary to pass stool. It is also essential for the nurse to review the client's current medications, diet, and activity levels.

The nurse is caring for a client with herpes zoster. The nurse documents the lesions as

Vesicles The lesions form herpes zoster are vesicles, defined as circumscribed, elevated, palpable masses that contain serous fluid and are less than 0.5 cm in diameter. Wheals are elevated masses with transient, irregular borders. Pustules are pus-filled lesions. Cysts are encapsulated fluid-filled or semisolid masses in the subcutaneous tissue or dermis.