Nursing assesment exam 1

The nurse is assessing an adult client for the presence of Piaget's formal operations stage of development. What assessment question should the nurse ask the client?

"How do you usually go about making difficult decisions?"

You are doing a dietary assessment with your new client. The client asks you why the hospital wants to know all this information about the way they eat. They specifically ask you "Are you asking all these questions because I am Middle Eastern?" What would be the most correct response you could give this client?

"We know that culture and religious practices often determine dietary prohibitions and we do not want to offend any of our clients."

The nurse plans care for an older client who does not possess formal operational thinking. What care will this client need?

Actions to stay as healthy as possible Completion of activities of daily living Teaching on the correct way to take medication

pain categories

Acute pain, chronic pain, nociceptive pain, and neuropathic pain

Parents of 13-year-old Kara express concern about whether Kara will always be short. Her mother is 5 feet, 2 inches and her father is 5 feet, 8 inches. In inches, what would be an accurate estimate of potential adult height for Kara? Record your answer to the first decimal place.

Add the mother's height and the father's height in either inches or centimeters. Add 5 inches (13 centimeters) for boys or subtract 5 inches (13 centimeters) for girls. Divide by two. = 62.5

Three main nutritional disorders

Anorexia, Bulimia and Binge-eating disorder

A female client is admitted to the health care facility due to reports of decreased appetite, loss of sleep, feelings of being unsafe in her own home, and inability to concentrate. She appears pale; her hair is disheveled, she is not wearing makeup, and she will not make eye contact. Based on this data, which nursing diagnosis can the nurse confirm?

Anxiety

The nurse is collecting data from a client. Which of the following best reflects objective data?

Appearance

Which abnormal skin color should a nurse anticipate assessing on a dark-skinned client?

Ashen gray

low blood pressure

Below 100/60

A nurse is preparing to evaluate an elderly client's risk for developing pressure sores after a 2-week stay in the hospital. Which of the following pieces of equipment will this nurse need for this purpose?

Braden scale

Which of the following would be most appropriate for the nurse to do to determine stroke volume?

Calculate the difference between the diastolic and systolic pressures.

Which technique demonstrates the proper positioning of the client's arm by a nurse when measuring a blood pressure?

Client sitting with arm slightly flexed and even with the heart

When performing the steps of the assessment phase of the nursing process, which of the following would the nurse do first?

Collect subjective data

What will be the nurse's initial role when conducting a health assessment with a client reporting abdominal pain?

Collecting data regarding the nature of the pain

When obtaining an oral temperature on a client, the nurse inserts the thermometer:

Deep in the posterior sublingual pocket

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use?

Dorsal surface

In what stage of Erik Erikson's model of development does the older adult come to terms with his or her life choices?

Ego integrity vs. despair

A nurse is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently underwent amputation of her lower leg. Which skill will the nurse most need to perform this assessment?

Empathy

Trust vs. Mistrust

Erikson's first stage during the first year of life, infants learn to trust when they are cared for in a consistent warm manner

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?

Establish a baseline for the comparison of future health changes.

A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment?

Evaluation

A nurse at a long-term care facility is completing the nutrition assessment of a man who has just moved to the facility. After determining the client's venous filling and emptying each take approximately 10 seconds, the nurse would perform further assessments related to what health problem?

Fluid volume deficit

Erikson's stage of social development in which middle-aged people begin to devote themselves more to fulfilling one's potential and doing public service

Generativity vs. Stagnation

The nurse completes her interview of a 39-year-old female client who seems happily married with four healthy children who are doing very well in school and who works part time as a college professor. The nurse would be able to conclude that this client is in which of the following psychosocial developmental stages?

Generativity.

A nurse will be performing a complete physical examination of a man who has emphysema with a chronic productive cough, including an assessment of his oral cavity. Which pieces of personal protective equipment should the nurse wear?

Gloves, mask, protective eye goggles, gown

A nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds?

Heart murmur

In the course of performing a client's physical assessment, the nurse has changed from using the diaphragm of the stethoscope to using the bell. The nurse is most likely assessing which of the following?

Heart sounds

The nurse explains to the client that smoking has what effect on the body?

Hypertension Vasoconstriction Peripheral vascular disease

Know the proper order of assessment process

INSPECTION- inspect each body system using vision, smell, and hearing to assess normal conditions and deviations PALPATIONS- requires for you to touch the patient the patient with different parts of hands using varying degrees of pressure PERCUSSION-involves tapping your fingers and hands quickly and sharply against parts of the patient's body to help locate organ borders identify or organ shape and position AUSCULTATION- involves listening for various lung, heart and bowel sounds with sethoscope. Provide quiet environment.

When doing an overall assessment of a client, the nurse is able to utilize findings and do what?

Identify in what areas the client needs the most care

The nurse notes that an adolescent client demonstrates confusion and the inability to focus on tasks. According to Erikson, which central task is this client having difficulty completing?

Identity versus role confusion

When teaching a nutrition class, what would you recommend for adults older than the age of 50?

Increase foods rich in vitamin B12 and calcium

The client is exercising. The nurse understands that exercise has what effect on the body?

Increased heart rate Increased blood pressure Increased cardiac output

The nurse when caring for clients of a culture different from the nurse's should be respectful of different viewpoints and aware that culture can affect the following areas of growth and development

Independence/dependence Self-motivation/interdependence Intimate relationships/family relationships

Which of the following techniques are used in a physical assessment?

Inspection Palpation Auscultation

Order of Assessment

Inspection - I Palpation - Picked Percussion- Peter Auscultation- Again

A client is receiving an intradermal injection to evaluate general immunity during a nutritional assessment. What conclusion is suggested if the client has no reaction?

It may be immunosuppression resulting from undernourishment.

A nurse obtains the blood pressure in a client who is lying down. Which of the following would the nurse expect?

It will be slightly lower than standing readings.

Ego versus despair stage

Late Adulthood

The nurse is applying Piaget's theory of development to a client's health history. This approach to analysis will prioritize what activity on the part of the client?

Learning

Hypoxia

Low oxygen saturation of the body, not enough oxygen in the blood

As the density of tissue decreases, the percussion note becomes:

Lower pitched

A nurse is distracted during her assessment of a client and does not take as thorough or as accurate notes as usual. Her supervisor, who is familiar with the client, reads the client's chart and questions the nurse. The supervisor should point out to the nurse that which of the following errors is most likely to occur due to the nurse's lapse?

Making incorrect nursing judgments or diagnoses

A nurse recognizes that a thorough and accurate assessment of a client is important to prevent what error from occurring when utilizing the nursing process?

Making incorrect nursing judgments or diagnoses

A nurse needs to record the height of a client who refuses to stand because of blisters on the feet. What alternative method should the nurse implement to obtain the client's height?

Measure the arm span to estimate height

Which of the following is the best example of holistic data collection by a nurse?

Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings

Which of the following is the best example of assessment in everyday life?

Measuring the remaining tread on a car tire to determine whether it is time to replace it

Which of the following should the nurse do before conducting a physical examination of a client?

Obtain and check needed equipment. Identify ways to ensure client privacy. Wash hands.

abnormal temperature

Oral 100 F (37.8C) Rectal/Ear 101 F (38.3C) Pediatric Temp of 100.4 rectal is a fever

A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure?

Over the client's thigh

In interviewing a client about his heart rate, the nurse asks whether he has noticed any alteration to his heartbeat. The client responds that he sometimes feels his heart race even when he has not been exerting himself physically. This alteration is known as which of the following?

Palpitation

You note that your client has developed mental status changes and paresthesias. What would you know to assess as a possible cause for these changes?

Patient's hydration status Patient's vitamin intake

A parent tells the nurse she is concerned that her 5 year old has an imaginary friend. The nurse understands that the child is in what stage of Piaget's cognitive development.

Preoperational

The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, the nurse periodically performs a partial assessment primarily for which reason?

Reassess previously detected problems

A nurse is taking a client's temperature and wants the most accurate measurement, based on core body temperature. What site should be used?

Rectal

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which of the following observations can be made by the nurse and athletes by measuring the blood pressure?

The ability of the arteries to stretch

As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure?

The blood pressure increases.

A community health nurse is assessing an older adult client in the client's home. When the nurse is gathering subjective data, which of the following would the nurse identify?

The client's feelings of happiness

A nurse on the hospital's subacute medical unit is planning to perform a client's focused assessment. Which of the following statements should inform the nurse's practice?

The focused assessment addresses a particular client problem.

Which is an example of inspection?

The nurse notes a fine rash covering the individual's thorax. The nurse notes symmetry of the individual's thorax. The nurse detects foul odor of the urine.

Which of the following statements is true regarding Piaget's concept of transductive thinking?

Transductive thinking can be used by formal operational thinkers.

The nurse believes that a middle-aged adult client is able to cope with stress. What observation caused the nurse to make this clinical determination?

Vents frustrations to significant other

A client describes probable night blindness. Intake of what vitamin should be evaluated?

Vitamin A

Which measurement should the nurse add to the body mass index to increase the predictive ability for the client?

Waist circumference

The nurse is assessing a client's respiratory rate. Which of the following should the nurse do to ensure accuracy of this assessment?

Watch chest movement before removing the stethoscope after counting the apical beat

intimacy-versus-isolation stage

according to Erikson, a period during early adulthood that focuses on developing close relationships

Know vital signs

b.p. 120/80 hr 60-100 resp 12-20 temp 98.6

a condition of physical wasting away due to the loss of weight and muscle mass that occurs in patients with diseases such as advanced cancer or AIDS

cachexia

chronic pain

episode of pain that lasts for 6 months or longer; may be intermittent or continuous

intiative vs guilt

erickson's 3rd stage during which a child finds independence in planning activities

identity versus role confusion

fifth stage of personality development in which the adolescent must find a consistent sense of self

The result of a nursing assessment is the

formulation of nursing diagnoses.

high blood pressure

greater than 120/80

Hypertension

high blood pressure

pain intensity

how much pain the patient feels

objective data

information that is seen, heard, felt, or smelled by an observer; signs

cachexia

loss of weight and generalized wasting that occurs during a chronic disease

Hypotension

low blood pressure

moderate pain

pain in the 4 to 6 range

acute pain

pain that is felt suddenly from injury, disease, trauma, or surgery

During a health class, the nurse is emphasizing exercise and healthy eating. The level of prevention being utilized by the nurse is

primary prevention

Tachypnea

rapid breathing

autonomy verus shame and doubt

second stage of personality development in which the toddler strives for physical independence

Bradycardia

slow heart rate

subjective data

things a person tells you about that you cannot observe through your senses; symptoms

Erik Erikson stages of development

(1) Trust vs. Mistrust; (2) Autonomy vs. Shame; (3) Initiative vs. Guilt; (4) Industry vs. Inferiority; (5) Identity vs. Confusion; (6) Intimacy vs. Isolation; (7) Generativity vs. Self-absorption; (8) Integrity vs. Despair.

abnormal respirations

-Below 12 and above 20 respirations per minute

Effective Communication Techniques

-Introduction -Use attentive skills/Active listening -Open-ended questions -Share Observations with client -Clarification -Summarizing -Use of Silence - read back orders to DR

documentation protocol

-never erase, white out. Single line through error with initials

To calculate the ideal body weight for a woman, the nurse allows

100 pounds for 5 feet of height.

A nurse has an order to obtain orthostatic blood pressure readings on a client admitted with dehydration. The sitting blood pressure is 140/75mmHg. Which blood pressure reading with the client standing should the nurse recognize as orthostatic hypotension?

120/55 mmHg

A nurse is assessing 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?

45 to 60

A client's blood pressure while lying supine is recorded as 124/76 mmHg. The nurse records the client's pulse pressure as which of the following?

48 mmHg

BMI values

>18.5 -- underweight 18.5-24.9--normal 25-29.9 -- overweight 30-34.9 -- obesity class 1 35-39.9 --obesity class 2 >40 -- obesity class 3

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. What would the nurse do next?

Assess the client's pulse at the carotid site.

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?

Assuring valid conclusions from analyzed data

A nurse has completed gathering some basic data about a client who has multiple health problems that stem from heavy alcohol use. The nurse has then reflected on her personal feelings about the client and his circumstances. The nurse does this primarily to accomplish which of the following?

Avoid biases and judgments

Two nurses collaborate in assessing an apical-radial pulse on a client. The pulse deficit is 16 beats/min. What does this indicate?

Not all of the heartbeats are reaching the periphery.

The nurse is exhibiting critical thinking in which client care situation?

Performing a focused assessment on a client who is complaining of shortness of breath.

Cheyne-Stokes

Periods of difficult breathing (dyspnea) followed by periods of no respirations (apnea)

A client with a body mass index of 28 tells the nurse she is concerned about her risk for hypertension. What can the nurse recommend to this client?

Reducing her weight by 5% can lower her risk

A nurse often has the option to use an alcohol-based hand rub for hand hygiene, but proper technique is essential in its use. What is the proper technique for the use of an alcohol-based hand rub?

Rub the hands and fingers until dry

The nurse is assessing an older adult with the Mini-Cog. The older adult is unable to recall the three unrelated words. Which type of memory is the nurse assessing?

Short-term memory

A nurse is providing nutritional instruction at a health fair. She instructs passersby on the characteristics of a nutrient that is the body's first source of energy, sparing use of other nutrients for this purpose, that raises the blood glucose level, is found in fruit juices, and that can be converted quickly into energy. To which of the following nutrients is the nurse referring?

Simple carbohydrates

A client suffering from decreased muscle strength has been diagnosed with a low Vitamin D level. The nurse should recommend that the client increase intake of which vitamin source?

Sunshine

The nurse is utilizing the Health Belief Model in the care of a client whose type 1 diabetes is inadequately controlled. When implementing this model, the nurse should begin by assessing which of the following?

The client's motivation for change

The nurse is caring for the client who is receiving heparin. The nurse plans to:

Wear clean gloves when administering heparin to the client

Identify the steps in order of priority the nurse takes for performing hand hygiene, from first step to last.

Wet the hands. Apply soap. Scrub the hands together vigorously for 15 seconds. Rinse the hands. Dry hands Turn off faucet with paper towel.

industry-versus-inferiority stage

according to Erikson, the period from age 6 to 12 characterized by a focus on efforts to attain competence in meeting the challenges presented by parents, peers, school, and the other complexities of the modern world

BMI calculation

is calculated as weight in kilograms divided by height in meters squared (m2) weight in lbs / 2.2 1 inch = 0.0254 meters 12 inches= 1 foot Square the height once in meters and divide weight in KG by number