NUR103 EXAM 2

CH. 10-A nurse is preparing to discuss the cycle of violence with a group of women who have been victims of abuse. Which of the following would the nurse include as part of phase 3 of this cycle?

A) A reconciliation period

CH 14-The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an itching rash. Which question would be most important for the nurse to ask?

A) Are you allergic to foods, medications, or other substances?

CHAPTER 6-The nurse notes that an older adult client is wearing multiple layers of clothing on a warm fall day. Which of the following would be the nurse's priority assessment at this time?

A) Asking whether the client often feels cold

CH. 10-A nurse is preparing a program to address family violence prevention. Which of the following would be most important for the nurse to incorporate into the program?

A) Children raised with intimate partner violence are more likely to use violence as adults.

CHAPTER 6-An emergency department nurse has utilized the Confusion Assessment Method CAM in the assessment of a 79-year-old client with a new onset of urinary incontinence. This assessment tool will allow the nurse to confirm the presence of what health problem?

A) Delirium

Assessment of a client's skin reveals several individual and distinct 2-mm lesions on the client's back. The nurse would document the configuration as which of the following?

A) Discrete

CH 10-A 36-year-old woman has been a client of a fertility clinic for 2 years and has now scheduled an appointment, believing that she is pregnant. The nurse who provides care at the clinic should screen the woman for intimate partner violence IPV at what time?

A) During the woman's first prenatal visit to the clinic

CH 14-The nurse's assessment of an adult female client reveals the presence of excessive hair on her face and chest. The nurse should plan further evaluation of which body system?

A) Endocrine

CH 10-A nurse is admitting a 30-year-old female client and recognizes the need to screen the client for abuse. Prior to doing so, the nurse should do which of the following?

A) Ensure a private setting.

CH 10-The nurse is assisting a female client who has been physically abused about a safety plan. The client prefers to return home. Which of the following would the nurse need to do first?

A) Have the client complete a danger assessment.

CHAPTER 6-A nurse who provides care on a medical unit utilizes the Alcohol Use Disorders Identification Test AUDIT as part of the standard admission protocol. After obtaining a score of 9 from a recently admitted client, the nurse should recognize the possibility of which of the following?

A) Hazardous and harmful alcohol use

CHAPTER 6-A 21-year-old woman has been admitted to the emergency department following an accident that is suspected of being a suicide attempt. When assessing the client's perceptions, what question should the nurse ask the client?

A) How would you describe your health these days?

CH 10-A group of students is reviewing the events associated with the cycle of violence. Which statement by the students demonstrates understanding of the topic?

A) It occurs in a predictable pattern.

A nurse is providing a client with instructions on how to perform self-examination of the skin. The nurse would encourage the client to perform this examination at which frequency?

A) Monthly

CH 10-The nurse has identified that a female client desires to leave her abusive husband and move with her children to her parents' house. Which of the following would be the most appropriate nursing diagnosis?

A) Readiness for enhanced family processes

CH 10-When assessing a client for possible abuse, which of the following would most likely suggest that the client is a victim of abuse?

A) Repeated emergency department visits for injuries

CH. 6-The nurse is assessing an older adult client's mental status. Consistently, the client pauses after the nurse poses a question, but then the client provides a response that is correct or appropriate. How should the nurse best interpret this characteristic of the client?

A) Slight delays in mental processing are normal in older adults.

CH. 10-While the nurse is interviewing a client who is a victim of abuse, the client states that she blames herself for not satisfying her husband's demands. Applying Walker's Cycle of Violence theory, the client would be in which of the following phase?

A) Tension-building phase

CH 10-A pediatric nurse is assessing a 7-year-old boy who is suspected of being the victim of psychological abuse by his stepfather. What criterion would the nurse use to determine whether the stepfather's actions constitute abuse?

A) The behavior is a threat to the child's well-being.

CHAPTER 6-A nurse in the emergency department is utilizing the SAD PERSONAS assessment guide during the mental status assessment of a client. What is the most likely rationale for the nurse's choice of this assessment tool?

A) The client may have a high risk for suicide.

A nurse is providing care for a client who has decreased mobility secondary to a recent stroke. Which of the following assessment findings would be indicative of a stage I pressure ulcer?

A) There is a nonblanching reddened area on the client's coccyx region.

The nurse is conducting an assessment of an adult client who describes herself as being in good health. Inspection of the client's nail beds reveals the presence of a bluish tone. The nurse should recognize that this finding is most likely attributable to what phenomenon?

A) Vasoconstriction

The nurse is assessing a dark-skinned client whose forearms are hands have distinct regions of depigmentation. The nurse should document the presence of what health problem?

A) Vitiligo

CH 10-The nurse is examining a 4-year-old girl who is being treated for a burn. When determining whether the burn may be the result of abuse, what assessment parameters should the nurse consider? Select all that apply.

ABCD A) The nurse's scope of practice requires extensive documentation. B) The nurse's documentation may be used as legal evidence. C) The documentation must be validated with the client. D) The nurse's documentation must be notarized once it is complete.

CHAPTER 6-A woman brings her 69-year-old husband to the clinic for an evaluation because he has become increasingly forgetful. Which of the following would lead the nurse to suspect that the client has Alzheimer's disease? Select all that apply.

ACDE A) He repeats the same story, word for word, over and over again. C) I have to balance the checkbook now because he just won't do it. D) If I don't tell him when to shower, he won't and will fight me on it. E) He got lost walking to the pharmacy around the corner the other day.

CHAPTER 6-When assessing the mental status of a 67-year-old woman, the nurse detects some difficulty with free-flow of thought and the woman's ability to follow directions. Which of the following would the nurse do first?

Assess the client's vision and hearing

CHAPTER 6-A nurse is providing care for a client who has chronic alcohol abuse. The nurse's assessment reveals that the client often provides incorrect answers to assessment questions. What nursing diagnosis is suggested by these assessment data?

B) Acute Confusion related to hepatic encephalopathy

Assessment of a client's nails reveals the presence of Beau's lines. The nurse interprets this finding as suggestive of which of the following?

B) Acute illness

CHAPTER 6-The nurse observes a client's entire body posture to be somewhat stiff, with his shoulders elevated upward toward the ears. The nurse would most likely interpret this to indicate that the client is experiencing which of the following?

B) Anxiety

CH 14-A client has sought care because he is concerned that a mole on his scalp may be evidence of skin cancer. During assessment using the mnemonic ABCDE, which finding would the nurse identify as being most suggestive of melanoma?

B) Asymmetric, irregular borders

CH 14-Assessment of a client's nails reveals brownish-black discoloration and crumbling of the nail plate. The nurse should suspect which of the following etiologies?

B) Bacterial infection

A client's recent episode of becoming lost near his home has prompted the nurse to use the Saint Louis University Mental Status SLUMS Assessment Tool. The nurse should begin this assessment by asking what question?

B) Can I ask you some questions about your memory?

CH 10-A new graduate nurse asks a clinical nurse educator, I know abuse is a problem, but why must we screen all women during routine health contacts for potential abuse? Which response by the more experienced nurse would be most appropriate?

B) Consistent risk factors for women at risk have not been identified.

CH 10-When preparing a discussion about violence, which of the following would the nurse include?

B) Family violence is a public health problem.

CH 15-A client's history reveals that he has been taking oral steroid therapy for several years for the treatment of an autoimmune disorder. During assessment, the nurse would expect the client's skin to have what characteristic?

B) Increased thinness

CHAPTER 6-A nurse is assessing a client who is exhibiting decorticate posturing. Which of the following would the nurse observe?

B) Internally rotated lower extremities

CH 14-During an integumentary assessment, the nurse notes that the client's fingernails are very thin and concave. The nurse knows the client needs medical follow-up for further assessment to rule out which condition?

B) Iron deficiency anemia

CH 10-A client tearfully admits to the nurse that her husband beats her when he drinks alcohol excessively. How should the nurse best respond to the client's statement?

B) It took a great deal of courage for you to tell me that.

CHAPTER 6-A nurse asks a client the following question: What do you do if you have pain? The nurse is assessing which of the following aspects of cognitive function?

B) Judgment

CH 14-A 15-year-old boy shows the school nurse a bump on his neck. The nurse observes a raised, erythematous, solid, 0.3-cm by 0.2-cm mass. The nurse would document the presence of which of the following?

B) Papule

CH 10-A woman and her partner come to the emergency department. The woman has bruising on both upper extremities and a fracture of the left arm. The client states that she fell down the stairs. Which of the following would lead the nurse to suspect that the client is a victim of violence?

B) Partner states that client is very clumsy and accident prone

CH 14-A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the exam, the nurse notices areas of hyperpigmentation around the neck and in the axillae. Which of the following should the nurse do next?

B) Perform a random blood sugar test.

CH 14-While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse should recognize the presence of which of the following?

B) Petechiae

CH 14-During assessment of the resident's skin, the nurse notes a break in the skin, and a sm all amount of serosanguineous. Inspection reveals that the area appears blister-like. The nurse should interpret this finding as indicating which stage of pressure ulcer?

B) Stage II

CH. 10-A nurse is preparing a presentation for a local community group on family violence and child abuse. Which of the following would be most appropriate for the nurse to research when defining child abuse in legal terms?

B) The Child Abuse Prevention and Treatment Act

A nurse is assessing an older adult client's risk for pressure ulcers using the Braden Scale for Predicting Pressure Sore Risk. Which aspect of the client's current health status would be reflected in her score on this scale?

B) The client is consistently incontinent of urine.

CH 14- A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale?

B) The client's ability to change position

CHAPTER 6-The nurse begins the physical examination of a newly admitted client by assessing the client's mental status. What is the nurse's best rationale for performing the mental status exam early in the assessment?

B) The exam can provide clues about the validity of the client's responses now and throughout.

CH 10-The nurse has completed an assessment of a 36-year-old woman who was assaulted by her boyfriend. The nurse should ensure that documentation is particularly detailed and accurate for what reason?

B) The nurse's documentation may be used as legal evidence.

CH 10-A nurse is interviewing a child who is suspected of being abused. Which of the following would be most appropriate?

B) Use direct, nonleading questions.

CH 14-An older adult client reports that he is experiencing severe trunk pain and is concerned that he might have shingles. Which type of lesion would the nurse most likely assess?

B) Vesicle

CH 10-An emergency department nurse asks a client to complete an intimate partner violence assessment screening. How should the nurse best explain the rationale for this assessment?

B) We routinely screen everyone because violence affects so many people.

CHAPTER 6-A nursing student has been assigned to the care of a client whose history suggests the need for a mental status assessment. This client most likely has a history of health problems affecting what body system?

B.) Neurologic

CH. 6-During the mental status assessment of a new client, asked the client to describe some of the similarities and differences between a tennis ball and a soccer ball. The client is unable to state any similarities or differences. The nurse should document what assessment finding?

C) A deficit in abstract reasoning

CH 10-Which of the following principles should inform the nurse's practice when assessing a client for possible physical abuse?

C) Abuse may start at any time during a relationship.

CH 10-The nurse recognizes the need to screen a middle-aged client for intimate partner violence, but the client's partner is remaining close to the client. As a result, the nurse is unable to screen the client in privacy. What action should the nurse next take?

C) Closely observe the client's interactions with the partner.

Assessment of a client who has suffered a recent stroke reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the client's level of consciousness as which of the following?

C) Coma

CH 10-Which of the following would the nurse do first when collecting subjective data from a client when domestic violence is suspected?

C) Create a safe environment.

CH. 10-The nurse in a prenatal clinic is performing an assessment on a pregnant client. When it is noted that clumps of hair are missing from the client's scalp, the nurse should ask what assessment question?

C) Do you feel safe in your home setting?

CH 14-The nurse is preparing to examine a client's skin. Which of the following actions would be most important for the nurse to do?

C) Expose only the body part that is being examined.

CH 10-A nurse is interviewing a client who is a suspected victim of abuse. Which of the following practices should the nurse avoid during this phase of assessment?

C) Interjecting often to clarify information

CHAPTER 6-A nurse is reviewing a depression questionnaire completed by a client. Which of the following would the nurse interpret as being suggestive of depression?

C) It usually takes me over an hour to fall

CH 10-A victim of intimate partner violence tells a nurse, I don't know how I'd live if I left my husband. And what about my children? I have no skills and haven't worked since I was a teenager. When developing the plan of care for this client, which nursing diagnosis would most likely apply?

C) Low self-esteem related to lack of confidence in ability

CHAPTER 6-A gerontologic nurse is assessing the speech of an older adult client. Which of the following would the nurse characterize as an expected assessment finding?

C) Moderate pace

CH 10-A middle-aged client with a periorbital hematoma admits to the nurse that the injury occurred when her husband punched her in a rage. Following assessment and treatment, the client expresses her intention to return home to her husband. How should the nurse best respond?

C) Remind the client of the threat to her safety and of her options for shelter.

CHAPTER 6-The intensive care nurse is working with a client who has increased a traumatic brain injury. The nurse is performing the hourly assessment. How should the nurse first stimulate the client to assess for arousability?

C) Speak to the client clearly from a close distance.

CHAPTER 6-A woman has accompanied her 80-year-old husband to a scheduled clinic visit and expresses concern about subtle declines in his cognition. Which of the following principles should guide the nurse's assessment of the client's mental status?

C) The nurse must differentiate between age-related changes and the signs and symptoms of dementia.

CHAPTER 6-As part of a mental status assessment, the nurse asks a client to draw the face of a clock. This will allow the nurse to assess which of the following domains of mental status?

C) Visual perceptual and constructional ability

CH 10-When assessing an older adult about possible mistreatment, which of the following questions would be most appropriate to use initially?

C) What is a typical day in your life like?

A nurse is implementing appropriate infection control precautions while performing a client's skin assessment. During which of the following components of the assessment should the nurse wear gloves?

C) When palpating lesions on the client's skin

CHAPTER 6-The nurse is assessing a client using the Glasgow Coma Scale following an acute hypoglycemic episode and obtains a score of 14. The nurse interprets this as indicating which of the following?

D) Alert and oriented

CH. 6-An 88-year-old woman has been admitted to the acute medical unit for the treatment of a urinary tract infection that is thought to be progressing to urosepsis. When assessing the client's orientation, how should the nurse best gauge the client's orientation to time?

D) Are you able to tell the month and the year that we're in?

CH 14-An older adult male client states that he has trouble cutting his toenails because they are hard and thick, and the nurse notes that they are very long and unkempt. Which system would be most important for the nurse to assess?

D) CirculatoryAssessment of a client's nails reveals brownish-black discoloration and crumbling of the nail plate. The nurse should suspect which of the following etiologies?

The nurse is assessing a middle-aged female client who is new to the clinic. The nurse observes the presence of significant facial hair that is uncharacteristic of the client's ethnicity. What assessment question should the nurse consequently ask?

D) Do you take steroid medications on a regular basis?

CH 10-The nurse has completed the objective and subjective assessment of a client who required care after an incident of intimate partner violence. How should the nurse document the client's injuries?

D) Document using an injury map.

CH 10-A nurse on a medical unit is reviewing a client's electronic health record. What finding should suggest to the nurse that the client has a possible history of intimate partner violence?

D) Documentation of three separate injuries during her pregnancies

CHAPTER 6-When preparing to obtain information about a client's mental and psychosocial status, which of the following would the nurse need to do first?

D) Explain the purpose of the exam and types of questions.

CHAPTER 6-A nurse is conducting a mental status assessment of a 70-year-old male client who is being treated for depression. When assessing the client's facial expression and eye contact, the nurse should consider which of the following?

D) Eye contact is strongly influenced by cultural norms.

CHAPTER 6-A client has presented to the emergency department (ED) with a lower leg laceration that she suffered while I was on a bender last night. The nurse recognizes the need to screen for alcohol use and will implement the CAGE questionnaire. What question will the nurse ask during this assessment?

D) Have you ever felt guilty about your alcohol use?

A nurse is assessing a 49-year-old client who questions the nurse's need to know about sunburns he experienced as a child. How should the nurse best explain the rationale for this subjective assessment?

D) Having bad sunburns when you're a child puts you at risk for skin cancer later in life.

A client has sought care because of the development of pruritic lesions between her toes, which the nurse suspects are attributable to a fungal etiology. How can the nurse best corroborate this suspicion?

D) Illuminate the area using a Wood's light.

CH 14-The nurse is performing an assessment of a client admitted to the emergency department in status asthmaticus. The nurse should carefully inspect which part of the body in an effort to differentiate central cyanosis from peripheral cyanosis?

D) Oral mucosa

CH 14-In which health condition would the nurse most likely expect to assess a capillary refill time that is longer than 2 seconds?

D) Peripheral vascular disease

CH 14-The nurse is assessing a fair-skinned, Caucasian woman with red hair and freckled skin. During health promotion, the nurse should focus education on which of the following topics?

D) Risks of sun exposure

CH 14-An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what?

D) Sebum production

CHAPTER 6-A nurse is working in a clinic in a low-income neighborhood and assesses a female adult client who states that she has a UTI. The client mentions that she was evicted from her apartment two weeks ago. Which nursing diagnosis would the nurse most likely identify for this client?

D) Self-care deficit related to possible homelessness

CH. 10-A group of community nurses are reviewing the theories associated with abuse. The nurses are addressing the psychopathology theory when they identify that violence results from which of the following?

D) The abuser's personality disorder

A nurse is preparing for an assessment by reviewing a new client's electronic health record, which documents the presence of macules on the client's left flank and mid-back regions. The nurse should recognize what characteristic of these skin lesions?

D) The lesions will not be palpable.

CHAPTER 6-The nurse utilizes the Depression Questionnaire on a client who has recently moved to a long-term care facility. The total score is 22. Which of the following would be most appropriate for the nurse to do next?

Refer for further evaluation.

CHAPTER 6-The nurse is preparing to assess the remote memory of a client who has a diagnosis of early stage Alzheimer's disease. Which question would be most appropriate for the nurse to use?

When did you get your first job?