NURS 2830 Test 1

A nurse is assessing a community of Native Americans. One important piece of health-related information that the nurse should obtain is the incidence of a) diabetes mellitus. b) congenital anomalies. c) tuberculosis. d) pregnancy-induced hypertension.

A

A nurse is assessing the blood pressure of a client using the Korotkoff's sounds technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record? a) There is an auscultatory gap b) There is an adult diastolic c) There is a widening in the diameter of the artery d) There is a nonauscultatory gap

A

A nurse must examine the rectum of a woman who has complained of bleeding from the anus and pain on defecating. Which of the following positions would be most appropriate for the client? a) Knee-chest b) Dorsal recumbent c) Prone d) Supine

A

A nurse obtains a client's blood pressure (BP) on admission in both arms: Right arm BP 130/75 mmHg and left arm BP 140/80 mmHg. Which arm should the nurse use for subsequent blood pressure reading? a) Left arm b) Both arms c) Right arm d) Dominant arm

A

A nursing instructor is teaching students about the pain experience. The instructor informs the students that a patient experiencing pain will have a stress repsonse. The students are aware that this stress repsonse causes the following: a) Release of epinephrine, cortisol, and norepinephrine b) Decrease in blood glucose and lactate levels c) Decrease in oxygen and energy consumption d) Decrease in muscle tension and stress

A

During the first assessment of the client, the nurse assesses the blood pressure in both arms. Which of the following findings is an acceptable variation? a) 118/78 mm Hg in the right arm and 122/80 mm Hg in the left arm b) 118/78 mm Hg in the right arm and 130/84 mm Hg in the left arm c) 140/90 mm Hg in the right arm and 150/96 mm Hg in the left arm d) 140/95 mm Hg in the right arm and 130/85 mm Hg in the left arm

A

Suzie is a 16-year-old daughter in the Hanes family. She is the youngest of five children. She has had a series of illnesses and does not seem to be regaining her strength. She likes school but is falling behind a bit. Her mother is very attentive to her needs but does not seem overly concerned with the continuing pattern of illness. Which of the following is most likely a Hanes family belief? a) The family values taking sick roles and caregiver roles. b) Education is highly valued for sons and daughters. c) Fathers are not involved with their children. d) Self-care is highly valued in the Hanes family.

A

The nurse is assessing a new patient's blood pressure using a manual sphygmomanometer. Which of the following sounds constitutes the patient's systolic blood pressure? a) The first appearance of faint but distinctive tapping sounds b) The first sound that is audible after the auscultatory gap c) The transition from tapping sounds to muffled sounds d) The last sound before there is complete and continuous silence

A

The nurse is performing a follow-up assessment and interview of a 72-year-old woman with a history of congestive heart failure. The nurse asks the client, "Have you been experiencing any activity intolerance since I last saw you?" What would be a more appropriate way for the nurse to elicit this information? a) "Has this been having an effect on your ability to carry out your routines and get around your home?" b) "Do you ever find yourself SOB when you're carrying out your daily routines?" c) "Has your congestive heart failure been affecting your activities of daily living recently?" d) "Has your heart failure been causing you any dyspnea lately?"

A

The ulnar edge of the hand is highly receptive to which of the following sensations? a) Contour and temperature b) Vibrations and moisture c) Moisture and contour d) Temperature and vibrations

A

What occurs during the termination phase of an interview? a) Planning for follow-up care b) Assessing the patient's mental status c) Addressing topics that have not yet been addressed d) Letting the patient know you understood all he or she has told you

A

When performing a cultural assessment, an important point to remember would be a) that definitions of family differ b) that the cultural/ethnic background is evident in the patient's appearance c) that alternative therapies are reasons for seeking care d) to use first names of those you are speaking to

A

Which of the following describes how the health history interview differs from a social conversation? a) The interview allows more time for the client to demonstrate self-awareness. b) The interview permits the clinician to express his or her needs and interests. c) The interview focuses on the client's needs to improve health and well-being. d) The interview is restricted to actual or potential illnesses.

A

Why is it important for a new nurse, working on a step-down unit, to know the standards of care for the facility in which the nurse is working? a) Standards of care often set the time frame for assessing the clients on the unit b) Standards of care dictate how to handle clients who have experienced trauma c) Standards of care tell the nurse how to get a good evaluation d) Standards of care instruct the nurse how to assess for a cardiac event

A

After assessment and documentation of the information obtained from the client, the nurse needs to analyze the data collected. Which nursing actions depend on accurate analysis of data during this phase of the nursing process? Select all that apply. a) Identification of the need for referrals b) Formulation of nursing diagnosis/es c) Identification of collaborative problems d) Assessment of the outcome of the care plan e) Development of a nursing care plan

A B C

Choice Multiple question - Select all answer choices that apply. Which of these clinical manifestations are physiologic responses to pain? Select all that apply. a) Perspiration b) Increased intestinal motility c) Sleeplessness d) Increased heart rate e) Increased insulin

A C D

Choice Multiple question - Select all answer choices that apply. A nurse is assessing a young woman for injuries who appears to be a victim of domestic violence. The nurse observes from the client's health record that her baseline vital signs are within normal limits. Which of the following objective findings would most tend to indicate pain? Select all that apply. a) Slumped shoulders b) Respiratory rate of 20 breaths per minute c) Edema at the elbow joint d) Heart rate of 90 beats per minute e) Blood pressure of 140/90 mm Hg

A C E

Choice Multiple question - Select all answer choices that apply. During a patient interview, the nurse is going to be listening for cultural influences particularly when assessing: (Select all that apply.) a) Health care beliefs and practices b) Employment history c) High-risk behaviors d) Cardiovascular status e) Nutrition

A C E

A nurse, conducting a functional assessment on an adult client, assesses overall psychosocial well-being by assessing what? a) Sleep/dreaming b) Coping/stress tolerance c) Family/friends d) Past history/genetic influence

B

After teaching a group of students about blood pressure and Korotkoff's sounds, the instructor determines that the teaching was successful when the students identify which of the following? a) Phase IV sounds are clear and repetitive. b) Phase II sounds appear muffled and swishing. c) Phase I reflects the diastolic pressure. d) Phase V reflects the systolic pressure.

B

From data collected during the health assessment, the nurse determines that a patient would benefit from smoking cessation information. What would be the best approach for the nurse to take when teaching smoking cessation to this patient? a) Remind the patient that smoking is a modifiable risk factor for health problems. b) Discuss with the patient if smoking cessation is a goal the patient may have. c) Explain the detrimental effects of smoking on the entire body. d) Tell the patient that smoking is expensive and is harmful to the body.

B

In preparing a care plan for a patient receiving opioid analgesics, the nurse selects which of the following as an applicable nursing diagnosis associated with side effects of opioid use? a) Impaired urinary elimination b) Constipation c) Diarrhea d) Bowel incontinence

B

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation? a) It provides and refers to client's problem by a number. b) It provides quick access to abnormal findings. c) It documents assessments on separate forms. d) It records progress under problems, interventions, and evaluation.

B

The community health nurse is caring for an older patient who states that she has not been taking the postoperative pain medication that she was prescribed. What question is most likely to be relevant? a) Will you take the medication if you are ordered to do so? b) Are you able to afford the prescribed medication? c) Is confusion causing you to refuse your pain medications? d) Are you too busy to take your prescribed pain medication?

B

The nurse is assessing a client who is experiencing a great deal of pain. Which assessment data would be considered normal under those circumstances? a) Hypoglycemia b) Decreased gastric motility c) Decreased heart rate d) Increased urinary output

B

The nurse is assessing the skin condition and color of an African-American client. Which of the following would the nurse document as an abnormal finding? a) Lack of visible pores b) Ashen gray skin color c) Light to medium dark brown skin d) Evenly distributed color

B

The nurse is reviewing the chart of a newly admitted client and identifies the client has Marfan's syndrome. What assessment finding would the nurse expect to find? a) Elongated bones of the face and hands b) Elongated fingers c) Decreased height and skeletal malformations d) Increased fat distribution in the chest, stomach and neck

B

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed a) entry. b) comprehensive. c) focused. d) exploratory

B

When performing a physical assessment on an older adult client, what should the nurse consider offering this client? a) A family member in the room b) An extra blanket c) Elevation of the head of the examination table d) A pillow

B

When the nurse places one hand flat on the body surface and uses the fist of the other hand to strike the back of the hand flat on the body surface, the nurse is using a) firm percussion. b) blunt percussion. c) direct percussion. d) indirect percussion.

B

A comprehensive health history includes which components? Select all that apply. a) Employment history b) Past health history c) History of present illness d) Reason for seeking care e) Income

B C D

Choice Multiple question - Select all answer choices that apply. The nurse explains to the client that smoking has what effect on the body? Select all that apply. a) Vasodilation b) Hypertension c) Vasoconstriction d) Hypotension e) Peripheral vascular disease

B C E

A nurse assesses a female client's core body temperature and finds that she has a slightly elevated temperature. Which of the following factors could explain this finding? Select all that apply. a) The client is hypoglycemic. b) The client just finished exercising. c) The client is ovulating. d) The client is starving. e) The client has hypothyroidism. f) The client is stressed.

B C F

An audit of a hospital unit's incident reports reveals that several errors have resulted from incomplete or inaccurate information during change-of-shift handoff. In order to prevent such errors, what practice should be encouraged on the unit? a) Encourage nurses to perform handoff as quickly as possible. b) Delegate handoff reports to unlicensed care providers who have fewer demands on their time. c) Involve as few people as possible in the verbal report. d) Use an intermediary to receive report from the first nurse and then provide the handoff report to the second nurse.

C

Learning about the effects of the illness does what for the nurse and the patient? a) Gives them the ability to communicate better b) Gives them each a better understanding of the other c) Gives them the opportunity to create a complete and congruent picture of the problem d) Gives them the basis to establish a trusting relationship

C

Mr. Smith presents to the clinic stating, "My face looks funny." You note that his face is asymmetric. What might you suspect is the patient's problem? a) Myocardial infarction b) Parafacial macrosomia c) Palsy d) Muscular dystrophy

C

The nurse is being oriented to the oncology unit. Which is a true statement regarding the potential population of this nursing unit? a) American Indians have lower rates of kidney cancer. b) African-American women rarely die from breast cancer. c) Hispanic women have higher rates of cervical cancer than white women. d) Asian men are more likely to have prostate cancer than African-American men.

C

The nurse is providing care for an 83-year-old woman with a history of hypotension who has been admitted to hospital following a fall. The nurse recognizes the need to assess for orthostatic hypotension. How should the nurse perform this assessment? a) Measure the client's blood pressure and heart rate while she is standing then after 10 minutes of lying supine. b) Estimate systolic blood pressure by palpation while the client is lying, then measure blood pressure when the client is standing. c) Alternate the scheduled blood pressure measurements between the standing and lying positions. d) Measure the client's heart rate and blood pressure while supine then within 3 minutes of standing.

D

The nurse understands that health promotion is a very important part of nursing care. When performing the health history, there are many different opportunities for the nurse to teach healthy behaviors. One way the nurse can do this is by focusing on which of the following topics: a) culture b) spirituality c) gender d) sexual history and pattern

D

The review of systems component of the health history is best described as a: a) Detailed investigation of questions about major body systems b) Series of questions that start at the head and finish at the feet c) Focus on diseases of the major body systems d) Focus on common questions and issues related to each of the different body systems

D

Which of the following is an average normal temperature in Centigrade for a healthy adult? a) rectal: 36.5°C b) tympanic: 34.4°C c) axillary: 37.5°C d) oral: 37.0°C

D

Which of the following would be most appropriate for the nurse to do to determine stroke volume? a) Measure the strength of the radial pulse. b) Add the radial pulse and the systolic blood pressure. c) Take the blood pressure while the client is standing. d) Calculate the difference between the diastolic and systolic pressures.

D

Fatigue is considered a common symptom of what? (Mark all that apply.) a) Infections b) Mild anemia c) Hyperthyroidism d) Panhypopituitarism e) Depression

A D E

A client with an inability to read billboards while driving arrives at the health care facility for an eye examination. Which piece of equipment should the nurse use to check the client's distant vision? a) Snellen chart b) Penlight c) Ophthalmoscope d) Opaque card

A

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's a) physiologic status. b) holistic wellness status. c) level of functioning. d) developmental history.

A

A nurse is assessing a Navajo client, who has presented to the health clinic with complaints of feeling endangered, confusion, bad dreams, and hallucinations. Which culture-bound syndrome should the nurse suspect in this client? a) Ghost sickness b) Hi-Wa itck c) Wacinko d) Arctic hysteria

A

A group of students is reviewing for a quiz on verbal and nonverbal communication. The students demonstrate a need for additional studying when they identify which of the following as an example of nonverbal communication? a) Silence b) Laundry list c) Attitude d) Facial expression

B

A nurse assesses the pulse rate of an athletic client during a routine checkup. The nurse should anticipate the pulse rate to be in what range of beats per minute? a) 85-100 b) 45-60 c) 65-80 d) 105-120

B

A nurse has documented the findings of a comprehensive assessment of a new client. What is the primary rationale that the nurse should identify for accurate and thorough documentation? a) Guaranteeing a continual assessment process b) Assuring valid conclusions from analyzed data c) Allowing for drawing inferences and identifying problems d) Identifying abnormal data

B

A nurse is caring for a client who was administered opioid narcotics. The client complains of constipation. Which of the following is another potential side effect of opioid narcotics? a) Insomnia b) Sedation c) Diarrhea d) Anxiety

B

A nurse is working on an acute neurological unit. Which assessment form would the nurse most likely use to document assessment data? a) Frequent assessment form b) Focused assessment form c) Ongoing assessment form d) Open-ended form

B

A nurse is working with an elderly Jewish man who is experiencing excruciating pain from a severe burn that he suffered earlier in the day. Given his cultural background, which expression of pain should the nurse most expect to find in this client? a) Pain is natural and honorable and should be dealt with by using mind over body b) Pain is expressed openly, with much complaining c) Pain must be endured as part of preparing for the next life in the cycle of reincarnation d) Pain is a challenge to be fought; it is inevitable and is to be endured

B

A nurse needs to measure the degree of flexion and extension that a student athlete has available at his knee joint 6 weeks after orthopedic surgery. Which of the following pieces of equipment would be best for the nurse to use? a) Flexible metric measuring tape b) Goniometer c) Reflex hammer d) Skinfold calipers

B

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and the temperature of the extremities. What is the purpose of this ongoing or partial assessment? a) Perform a rapid assessment for prompt treatment b) Determine any changes from the baseline data c) Collect subjective data related to the client's overall health d) Evaluate whether outcomes of treatment are met

B

A nurse will complete an initial comprehensive assessment of a 60-year-old client who is new to the clinic. What goal should the nurse identify for this type of assessment? a) Identify the most appropriate forms of medical intervention for the client. b) Establish a baseline for the comparison of future health changes. c) Identify the status of the client's airway, breathing, and circulation. d) Determine the most likely prognosis for the client's health problem.

B

A 60-year-old woman with a bunion will undergo surgery later today. The client tells the nurse in the surgical daycare admitting department, "I'm sure I've been asked these questions before. Can't we just focus on my foot and not all these other topics?" How should the nurse best explain the rationale for obtaining a health history? a) "The care team needs to cross-reference your diagnostic testing with the information that I'm asking you about." b) "In general, it's necessary for us to gather as much information about each client as possible." c) "We want to make sure your nursing care matches your needs as closely as possible." d) "We don't want to make the mistake of focusing solely on the medical problem that brought you here."

C

A client scheduled for surgery tells the nurse that he is very anxious about the surgery. What is an appropriate action by the nurse when interacting with this client? a) Refer the client to a spiritual guide. b) Approach the client in an in-control manner. c) Provide simple and organized information. d) Mirror the client's feelings.

C

A nurse is performing indirect percussion of the lungs on a young woman with pneumonia. Which of the following is the correct hand placement for this technique? a) The ulnar surface of one hand is placed against the body surface and vibrations are felt. b) One to two fingers are placed over the body structure and the fingertips are used to tap the skin surface. c) The middle finger of one hand is placed on the body surface and the other middle finger strikes. d) One hand is placed flat against the body and the fist of the other hand strikes the back of the flat hand.

C

A nurse observes that a young man's arm span appears to be greater than his height. Which condition should the nurse suspect in this client? a) Cushing's syndrome b) Gigantism c) Marfan's syndrome d) Anorexia

C

A student nurse is conducting her first patient interview. The student suddenly draws a blank on what to ask the patient next. What is a useful interview technique for the student to use at this point? a) Termination b) Transition c) Summarization d) Reassurance

C

The nurse palpates a client's pulse and notes that the rate is 61 beats per minute, with an amplitude that is weak and thready. How should the nurse respond to this assessment finding? a) Palpate the client's femoral pulse. b) Call a code blue from the bedside and prepare for resuscitation. c) Assess the client's pulse at the carotid site. d) Assess the client's jugular venous pressure

C

What are nurses able to detect through the health assessment? a) Areas that need referral to a specialist b) Areas that need in-hospital care c) Areas in need of health adjustments d) Areas that need continuous care

C

What is the expected respiratory rate (in breaths per minute) when inspecting the thorax of an adult client? a) 10-16 b) 12-18 c) 14-20 d) None of the above

C

While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using a) palpation. b) inspection. c) percussion. d) Doppler magnification.

C

A group of students is reviewing information about auscultation in preparation for a test. The students demonstrate understanding of the material when they identify which of the following? a) Auscultation can be performed through clothing. b) The bell of the stethoscope can detect bowel sounds. c) The binaurals connect the tubing to the chest piece. d) The diaphragm should be held firmly against the body part.

D

A nurse is conducting a health assessment. How will the information collected from the patient be used? a) as one component of medical care b) to facilitate nurse-patient caring c) to illustrate nursing competence d) as a basis for the nursing process

D

A nurse is working with an obese man who has type II diabetes mellitus. After interviewing this client, the nurse has established that he is aware of the seriousness and risks of his conditions, is motivated to make lifestyle changes to improve his health, and believes that following the diet and exercise plan that the nurse has helped him create is feasible and would be effective in helping him meet his health goals. The nurse is using which of the following tools or resources in assessment of this client? a) Healthy People 2020 b) U.S. Preventive Services Task Force c) Pender Health Promotion Model d) Health Belief Model

D

As a nurse is adjusting a client's hospital bed, the nurse accidently pinches a finger between the bed and the wall. Which of the following components is involved in the transduction of the pain the nurse feels? a) L-beta fibers b) K-fibers c) C-fibers d) A-delta fibers

D

Mistakes in charting can be costly to both the patient and nurse. The Joint Commission has listed a primary cause for these mistakes as a failure in communication. Life-threatening errors in health care have been labeled as which of the following: a) Mismanagement b) Side effects c) Adverse reactions d) Sentinel events

D

The nurse is assessing a client with unexplained lesions noted on the client's back. The nurse is going to palpate the area of the lesions. What type of palpation should the nurse use? a) Moderate b) Intermediate c) Deep d) Light

D

The nurse is interviewing a female Hispanic client who is scheduled for a cardiovascular education program. The client states, "I can't eat and I don't sleep because my daughter left to return to Mexico. I am sad and nervous. I need rest." The nurse suspects that she is suffering from susto. Which action by the nurse would be best? a) Refer her to a counselor. b) Give her a multivitamin supplement. c) Encourage her to exercise. d) Reschedule the education program.

D

The nurse is preparing to assess the mental status of a 90-year-old client who is being admitted to the hospital from a long-term care facility. Which of the following should the nurse assess first? a) The presence of any phobias b) The client's general intelligence c) The client's judgment and insight d) The client's sensory abilities

D