PNE 102 Midterm Exam Ch 11-14 Study guide

A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take?

Explain to the client what is about to happen

A 20-year-old client phones a telehealth nurse and reports fever, headache, and sore throat. The client wants to know where to have a throat culture performed. What is the appropriate nursing response?

"A doctor's office or student health clinic can perform this test." Explanation: Throat cultures can be performed in many different settings, and are not limited to being performed in an emergency department. The telehealth nurse should not assume that a throat culture is not needed. Asking why the client wants a throat culture does not address the question that the client has asked.

The nurse is performing a physical assessment of an older adult female client. The nurse documents scoliosis as part as the spinal assessment. What is scoliosis? (pg. 245)

A pronounced lateral curvature of the spine.

Question 6 / 9 Which of the following is most useful to control hyperglycemia in the treatment of diabetes?

Insulin Explanation: Exogenous (injected) insulin is needed when inadequate levels to meet metabolic needs are present. Those with type 1 diabetes will require exogenous insulin (often multiple times per day or by a continuous infusion pump) to survive. At first, those with type 2 diabetes may be able to control blood glucose levels without insulin injections by using nutritional therapy, exercise, oral agents, and noninsulin injectable agents. However, because diabetes is a progressive disease, over time those modalities may no longer adequately control blood glucose levels and insulin will be needed, especially during periods of illness or severe stress.

Pelvic examination

a physical inspection of the vagina/cervix w/palpation of the uterus/ovaries.

A nurse is completing a vision exam with the Snellen eye chart and records the client's vision as 20/30 or 6/9. The client asks the nurse, "What does that mean"? How should the nurse respond? (pg. 239)

You are able to read at 20 ft. (6m) what a person with normal vision can read at 30 ft. (9m).

A health care provider instructs the nurse to administer iodine orally to a client before an x-ray. What is the primary reason for the administration of iodine before an x-ray?

to make hollow body parts appear distinct. Explanation: A contrast medium is a substance such as barium sulfate or iodine that adds density to a body organ or cavity. The nurse administers iodine to make hollow body areas appear more distinct when imaged on x-ray film. Iodine or any other contrast medium will not affect thickness, thinness, or solidness of body parts.

The anterior hypothalamus promotes heat loss through _________________.

vasodilation and sweating. In humans, the hypothalamus acts as the center for temperature regulation.

Endoscopy

visual examination of internal structures

The nurse is educating an 18-year-old woman who just became sexually active. When should the nurse tell her that she should have her first Pap test?

when she is 21, 3 years after the onset of vaginal intercourse, but no later than 21. Explanation: The American Congress of Obstetricians and Gynecologists (ACOG) 2009 recommendations include that women should receive their first Pap test approximately 3 years after the onset of vaginal intercourse, but no later than 21 years of age.

Which client statement does the nurse assess as reflective of understanding about Pap test results?

"Class II means that my result is unusual, but not cancerous. Explanation: Class I reflects a negative result with no abnormal cells. Class II demonstrates an unusual result, but not a cancerous one. Class III reflects that the result is suggestive of cancer, but this is not definitive. Class IV is strongly suggestive of cancer, and Class V is definitely cancerous.

The nurse is preparing a client for a magnetic resonance imaging (MRI) of the brain. Which statement by the client would require immediate follow-up by the nurse?

"I have a mechanical aortic valve." Explanation: MRI is a technique for producing images by using atoms subjected to strong electromagnetic fields. Because of the use of magnets, an MRI is contraindicated in clients with implanted devices, metallic pins or screws, artificial heart valves, and tattooed eyeliner. If a client may be pregnant, the nurse will apply a lead apron over the abdomen/pelvis. The client would be asked to remove the hearing aids. A client who gets nervous in closed spaces may need additional assistance, but it is not a contraindication to the test.

The clinic nurse is reviewing a client's Papanicolaou (Pap) class I test results. How would the nurse explain the results to the client?

"The results show no abnormal cell changes." Explanation: A Pap test screens for abnormal cervical cells. A class I cellular examination result indicates that there are no abnormal cellular growths and the Pap test is negative.

A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse use to promote this discussion?

"What brought you to the hospital?"

The charge nurse has just completed an in-service to educate the staff about the principles of mobility when participating in physical activities. Which responses are appropriate for the charge nurse to share with the nurse after reviewing the image? Select all that apply.

"You can hurt yourself performing the activity in this manner." "Your posture is awkward and could increase the risk of back injuries." "Elevate the height of the bed to waist level when making the bed." Explanation: Adjusting the height of the bed to waist level or proper height for the health care personnel making the bed minimizes the risk for back injuries and muscle strain. Health care staff can injure themselves when leaning over a bed that is below waist level or improperly positioned for the staff member's height. The staff member's posture in the image is awkward and increases the risk of back injuries. Therefore elevating the height of the bed to waist level when making the bed can help improve performance of movements when making the bed.

An HIV-positive 34-year-old client asks the nurse how often she should have a Pap test. What is the best response by the nurse?

"You should have a Pap test more frequently than every 3 years." Explanation: A woman should be screened every 2 to 3 years at or after 30 years when three prior consecutive tests were normal or negative. More frequent screenings are advocated for women with a history of risk factors for cervical cancer, such as being HIV positive, immunosuppression secondary to organ transplantation, fetal exposure to diethylstilbestrol, previous diagnosis with cervical cancer, or continuing to shed abnormal cells after a hysterectomy.

A nurse is caring for a client with type 1 diabetes who is being treated in the hospital. The client has a dose of insulin ordered before each meal of the day and breakfast is distributed on the unit at around 0815 each morning. At what time each morning should the nurse check this client's blood glucose level?

0745 Explanation: The blood glucose level usually is measured about 30 minutes before eating to determine what are likely to be the lowest levels of glucose. This allows time for the client to increase or decrease food consumption or to administer insulin.

Elements of Informed Consent include: (3) (Box 14-2 p.258)

1. Capacity: Indicates that the client has the ability to make a rationale decision, if not, a spouse, parent or legal guardian must do so. 2. Comprehension: Indicates that the client understands the physician's explanation of the risks, benefits, & alternatives that are available. 3. Voluntariness: Indicates that the client is acting on his/her own free will w/o coercion or the threat of intimidation.

List 10 general nursing responsibilities related to assisting with special examinations and tests. (Box 14-1 p.258)

1. Determine the client's understanding of the procedure. 2. Witness the client's signature on a consent form. 3. Teach or follow test preparation requirements. 4. Obtain equipment and supplies. 5. Arrange the examination area. 6. Position and drape the client. 7. Assist the examiner. 8. Provide the client with physical and emotional support. 9. Care for specimens. 10. Record and report appropriate information.

Identify four word endings and their meanings that provide clues as to how tests or examinations are performed.

1. Graphy - to record, 2. gram- an image, 3. Scopy- to see, 4. scope- examination instrument 5. centesis - to puncture 6. metry - to measure 7. meter - instrument for obtaining measurements

The nurse is teaching the client to perform breast self-examination (BSE). The nurse should teach the client to perform the steps of the examination in what order?

1. Inspect the breast 2. Inspect the axilla 3. Palpate the breast from the center outward using the finger pads 4. Palpate the axilla 5. Palpate the nipple

Factors to consider when performing examinations/test on Older Adults:

1. Older adults may not be able to tolerate withholding of food/fluids for long periods. 2. Older adults are susceptible to dehydration. 3. Older adults become exhausted by preparations for GI examinations requiring laxatives and enemas. which may also deplete electrolyte balance, leading to weakness/dizziness. 4. Older adults fatigue easily. 5. Older adults may need additional clothing slippers extra covers. 6. Cognitively compound older adults should have family member present during the procedure.

Name the four testing procedures.

1. Paracentesis 2. Lumbar puncture 3. Throat culture 4. Measurement of capillary blood glucose

List four major steps involved in the admission process.

1. The process of admission involves obtaining authorization from a physician 2. obtaining billing information 3. completing nursing responsibilities such as orienting the client and obtaining a data base assessment 4. developing an initial plan for nursing care, and fulfilling medical responsibilities such as documenting the client's history and results of a physical examination

A nurse is teaching a client how to perform a self breast exam. Place the following examination techniques in the order they should be performed. (pg. 245-246 13-1). a.) a mirror, look at both breast with the arms relaxed at the side, with the hands pressing on the hips, and with the hands elevated above the head looking for dimpling in the skin or retraction or either nipple. b.) a pillow under the shoulder on the side where the first breast will be examined. c.) of the fingers in a up-and-down pattern from the underarm and across the breast from the clavicle to the base of the ribs to feel for changes in any area of the breast. d.) axilla of each arm to determine if there are any lumps or hard thickened area. e.) between the thumb and index finger to determine if there is any clear or blood discharge.

1. a mirror, look at both breast with the arms relaxed at the side, with the hands pressing on the hips, and with the hands elevated above the head look. 2. a pillow under the shoulder on the side where the first breast will be examined. 3. of the fingers in a up-and-down pattern from the underarm and across the breast from the clavicle to the base of the ribs to feel for changes in any area of the breast. 4. axilla of each arm to determine if there are any lumps or hard thickened area. 5. between the thumb and index finger to determine if there is any clear or blood discharge.

Name five positions commonly used during tests or examinations.

1. dorsal recumbent position 2. sim's or left lateral position 3. lithotomy position 4. knee-chest or genupectoral position, 5. modified standing position

Differentiate between an examination and a test.

1. laboratory test is a procedure that involves the examination of body fluids or specimens. It involves comparing the components of a collected specimen with normal findings. 2. A diagnostic examination may or may not include the collection of specimens.

List the steps involved in the discharge process.

1. obtaining a written medical order for discharge 2. completing discharge instructions 3. notifying the business office 4. helping the client leave the agency 5. writing a summary of the discharge in the medical record 6. requesting that the room be cleaned

List six commonly performed categories of tests or examinations.

1. pelvic examination, 2. radiography (X-ray/roentgenography) 3. endoscopic examinations (optical scopes) 4. radionuclide imaging (radioactive chemicals) 5. ultrasonography (high-frequency sound waves) 6. electrical graphic recording.

The nurse is assessing the blood glucose of a client 1 hour after the client has eaten a meal. The client is not known to have diabetes. For which blood glucose level will the nurse take no further action?

140 mg/dl (7.8 mmol/l) Explanation: The normal blood glucose level in a client who does not suffer from diabetes, taken 1 to 2 hours after a meal, is less than 140 mg/dl (7.8 mmol/l). An acceptable postprandial blood glucose level for a client who is known to have type 2 diabetes is 180 mg/dl (10.0 mmol/l). A blood glucose level of 64 mg/dl (3.5 mmol) would alert the nurse to the client being significantly hypoglycemic. This finding is unusual in a client who is not prescribed insulin therapy but, if assessed, would require that the nurse implement a hypoglycemic protocol as a blood glucose rescue. A blood glucose of 200 mg/dl (11.1 mmol) after a meal should alert the nurse to consult the client's health care provider and gather additional assessment data that may raise suspicion that the client may be developing type 2 diabetes or some other condition related to impaired metabolic regulation.

A nurse is examining a client with cirrhosis of the liver for edema. The nurse notes that the indentation remains for several seconds and the skin swelling is obvious on inspection. How should the nurse quantify the severity of the finding? (pg. 249)

3+ pitting edema (deep pit 6 mm, remains several seconds after pressing, skin swelling is obvious upon inspection)

The nurse is delegating glucose testing to unlicensed assistive personnel (UAP). How many minutes before a meal will the UAP perform the test?

30 minutes Rationale: The blood glucose level is usually measured approximately 30 minutes before eating and before bedtime to determine what are likely to be the lowest levels of glucose. These 30 minutes provide the UAP or the client with time to determine if an intervention is required based on the blood glucose reading acquired. The timing of taking the blood glucose allows time for the client to increase or decrease food consumption or, if insulin-dependent, to administer additional prescribed insulin. Any amount of time less than 30 minutes before a meal or bedtime is not sufficient for decision-making related to the blood glucose level acquired. Any time greater than 30 minutes can lead to changes in the blood glucose level that do not align with prescribed medication times, meal times or the client's desired bedtime.

The nurse is obtaining a capillary blood glucose level before lunch from a client with diabetes mellitus. What reading obtained would require immediate intervention by the nurse?

40 mg/dL Explanation: The American Diabetes Association recommends that the amount of blood glucose before meals should range between 70 and 130 mg/dL.

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

Assess the apical pulse for a full minute

While auscultating a client's heart sounds, the nurse hears turbulence between the S1 and S2 heart sounds. The nurse should document this finding as which of the following?

A systolic murmur

When assessing the sensory skin perception of an older adult client, the nurse strokes the skin with a cotton ball at various places on both sides of the body. What information does the nurse obtain from this assessment? (pg. 250)

Ability to identify fine touch

Question 12 / 12 Which of the following is a sign or symptom of diabetes type 1?

Absent Insulin Production Explanation: Type 1 diabetes is an immune-mediated disease caused by autoimmune destruction of the pancreatic beta cells, which is the site of insulin production. This results in the pancreas no longer being able to produce sufficient amounts of insulin to maintain normal glucose. Once this occurs, the onset of symptoms is typically rapid and patients will require insulin injections to sustain life.

Question 11 / 12 Which of the following is most likely a feature associated with diabetes type 2?

Adult Onset Explanation: Type 2 diabetes, formerly known as adult-onset diabetes or non-insulin-dependent diabetes, is usually seen in those age 35 or older, but can occur at any age with incidence increasing in children. It accounts for 90-95% of patients diagnosed with diabetes.

NCLEX-STYLE Review Questions #4 Which of the following nursing actions are correct when measuring a client's capillary blood glucose? Select all that apply. 1) Plan to perform the test 1 hour before a meal. 2) Check that the test strip code matches the one programmed in the glucometer. 3) Have the client wash his or her hands with soap and water before the test. 4) Pierce the central pad of the thumb or fingers with the lancet. 5)Cover the test spot on the test strip completely with a drop of blood. Test Taking Strategy: Analyze the options and select those that are accurate.

Answer: 2, 3, 4 2. check that the test strip code matches the one programmed in the glucometer, 3. have the client wash his or her hands with soap and water before the test, 4. pierce the central pad of the thumb of fingers with the lancet

NCLEX-STYLE Review Questions #5 When assisting with a pelvic examination during which a Pap smear will be obtained, place the following steps the nurse should follow in the order in which they are performed. Use all the statements. 1) Hand the examiner a brush applicator. 2) Deposit the applicator in a chemical fixative solution. 3) Place the client in a lithotomy position. 4) Lubricate the examiner's gloved fingers. 5) Provide the examiner with a vaginal speculum. Test Taking Strategy: Arrange the nursing actions in the sequence the nurse would follow when assisting with a pelvic examination and collection of cervical and endocervical cells.

Answer: 3, 5, 1, 2, 4 3. place the client in a lithotomy position, 5. provide the examiner with a vaginal speculum, 1. hand the examiner a brush applicator, 2. deposit the applicator in a chemical fixative solution 4. lubricate the examiners gloved fingers

NCLEX-STYLE Review Questions #3 Which of the following nursing instructions is most appropriate if a specimen for a Pap (Papanicolaou) test will be obtained at the time of a pelvic examination? 1) Do not douche for several days before your appointment. 2) Stop using any and all forms of contraception temporarily. 3) Drink at least 1 quart of liquid 1 hour before your appointment. 4) Take a mild laxative the night before your scheduled appointment. Test Taking Strategy: Use the key word and modifier "most appropriate" to select the one option that is better than any of the others.

Answer: do not douche for several days before your appointment.

NCLEX-STYLE Review Questions #2 Which nursing action is essential before performing a chest roentgenogram (X-ray)? 1) Make sure that the client does not eat food. 2) Remove the client's metal necklace. 3) Have the client swallow contrast dye. 4) Administer a dose of pain medication. Test Taking Strategy: Use the key word, "essential" to identify an option that represents a priority.

Answer: remove a clients metal necklace.

NCLEX-STYLE Review Questions #1 Following the nurse's preparation of a client who is scheduled for a sigmoidoscopy, which of the following indicates that a client needs more teaching? 1) The client says an anesthetic will be given before the examination. 2) The client says a light meal is allowed the evening before the examination. 3) The client says a flexible scope will be inserted into the rectum. 4) The client says prescribed medications may be taken in the morning. Test Taking Strategy: Analyze the information the question asks. In this question, select the client's statement that is incorrect.

Answer: the client says an anesthetic will be given before the examination.

A client is scheduled for an office visit by a new provider at the clinic. The nurse contacts that client. Which information does the nurse provide?

Arrive 30 minutes ahead to complete necessary paperwork. Explanation: Clients should arrive at least 30 minutes prior to a new visit appointment to ensure all paperwork is completed prior to appointment time. There is no indication that the client should not eat or drive or have someone drive them. A client needs to sign consent for the new provider to get access to previous lab work. This consent should be done in person at the clinic.

What technique should the nurse use to assess the pupillary light reflex on a client?

Bring a narrow beam light from the temple toward the eye, observing for direct and consensual pupillary constriction.

Pap smear test results (Ch 14 Table 14-3 p. 263)

Cellular Exam: 1. Class I = negative, no abnormal cells 2. Class II = unusual, but not cancerous 3. Class III = suggestive of cancer, but not definite 4. Class IV = strong suggestions of cancer 5. Class V = definitely cancerous

A client is scheduled for a diagnostic examination. What would the nurse do first?

Check the client's understanding of the procedure. Explanation: Before a client agrees to a procedure, the nurse determines whether the client understands its purpose and the activities involved. Then the client would give consent, with the nurse witnessing the client's signature on a consent form. Then the nurse would follow the test preparation requirements and obtain equipment and supplies. Once the examination area is arranged, the nurse would position and drape the client.

A nurse is performing the diagnostic positions test to observe extraocular movements on a client during a routine eye exam. Which of the findings would the nurse expect to observe? (pg. 240)

Coordinated movement of both eyes

A nurse is auscultating the lungs of a client during a physical exam. The nurse notes low-pitched, soft breaths sounds over the posterior middle lobes with intermittent, high-pitched, popping sounds in the posterior lower lobes, primarily during inspiration. What is the nurse's correct interpretations of these findings?

Crackles are audible in the posterior bases bilaterally, and they are abnormal.

During the physical assessment of a client, the nurse observes flat, round, colored, nonpalpable areas on the face. How should the nurse document this finding?

Macule

The nurse is collecting a sputum specimen from a client following chest physiotherapy (CPT). Which action should the nurse take when collecting and handling the specimen?

Deliver the specimen to the laboratory as soon as possible. Explanation: When collecting and handling a specimen, the nurse should deliver the specimen to the laboratory as soon as possible. The nurse should label the specimen at the bedside, not at the nurses' station. The client should collect the specimen in the appropriate container, since transferring containers could lead to contamination of the specimen. The nurse should verify the client's name and date of birth and sign the container. The client does not need to sign the container.

In anticipation of discharge, a nurse is teaching the daughter of an older adult client how to change the dressing on the client's venous ulcer. Which teaching strategy is most likely to be effective?

Demonstrate and explain the procedure and then have the daughter perform it. Explanation: All steps of a procedure such as a dressing change should be demonstrated, practiced, and provided in writing. The client or caregiver should then perform the procedure or treatment in the presence of the nurse to demonstrate understanding and ability to carry out the procedure. This is more likely to facilitate success than providing a passive multimedia resource, explaining, or providing written instructions alone without reciprocal demonstration.

Question 2 / 9 Which of the following is the most appropriate recommendation in the management of diabetes?

Diabetic Diet Explanation: The nutrient balance of a diabetic diet is essential to maintain blood glucose levels and meal planning should revolve around the individual's needs and balanced with insulin and exercise patterns. The key component is control of carbohydrates as these are composed of different forms of sugar, which contribute to elevated blood glucose levels. The amount of calories ingested at one time should be monitored and controlled in order to avoid severe spikes in blood glucose. High protein diets are not recommended for weight loss.

Question 1 / 9 In type 1 diabetes mellitus, which complication is most likely associated with ketone bodies in urine?

Diabetic Ketoacidosis (DKA) Explanation: Diabetic ketoacidosis (DKA) is a medical emergency and complication of diabetes characterized by blood sugars above 250 mg/dL, metabolic acidosis with pH below 7.3 and bicarbonate below 18 with ketones present in the urine. Patients have increased insulin requirements, which leads to a shortage. As a response, the body begins burning excess fat, causing ketone body buildup.

A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse?

Dorsal Pedis artery

Question 7 / 9 Which of the following most likely decreases the risk of developing complications from diabetes?

Early Diagnosis Explanation: Early detection and treatment of diabetes can significantly decrease the risk of developing complications. Diagnosis involves blood tests including a fasting blood glucose, postprandial blood glucose, or an A1C test, also referred to as the HbA1c or glycohemoglobin test.

__________ is performed using optical scopes for a visual examination of internal structures.

Endoscopy

The nurse is caring for a client who requires an abdominal ultrasound. The client states," I do not really know anything about this test. I am not exactly sure why I am to having it." What action will the nurse take first when responding to the client?

Explore the client's understanding of the procedure and clarify misperceptions. Explanation: In some cases, a signed consent form is required before performing examinations or tests. Legally, consent must contain three elements: capacity, comprehension, and voluntariness. Although health care providers are responsible for giving clients sufficient information to obtain informed consent, not all clients fully understand the information. Some clients are too anxious to process details, other clients feel too insecure to ask questions, and still other clients express additional concerns after the health care provider has left the room. Often the nurse must repeat, simplify, clarify, or expand the original explanation. There are no exact rules for clarifying explanations. In general, it is best to find out how much of the health care provider's explanation the client understands and use the client's questions as a guide for providing further information. If the client is unsatisfied with the nurse's explanation or rationale, the health care provider should be contact to provide further clarification and confirm the client is willing to provide voluntary informed consent. Although it is important that the nurse acknowledge any anxiety the client may have regarding care, the nurse will not assume this is the reason underlying the client's statement. Exploring the client's understanding and clarifying misperceptions is the nurse's first priority. A client should not provide consent if the client does not agree with or understand a treatment or procedure; however, it is the nurse's responsibility to make every effort to ensure the client has all of the required information to make the best decision. Telling the client he or she should not have the test without providing additional contextual information may constitute unethical behavior.

T/F: During ultrasonography, a probe called a transducer is inserted into the body.

FALSE

Which phrase best describes continuity of care?

Facilitating transition between settings. Explanation: Continuity of care is a process by which health care providers give appropriate uninterrupted care and facilitate the client's transition between different settings and levels of care. The other choices do not describe continuity of care, as they focus on only one area--such as an acute care setting or hospital, the needs of children, and single-episode care services--rather than on the transition between settings.

T/F: A contrast medium makes dense body areas appear hollow when imaged on an x-ray film.

False

T/F: The Sims position is a reclining position with the knees bent, hips rotated outward, and feet flat.

False

T/F: Radiography uses elements whose molecular structures are altered to produce radiation.

False. Radiography uses roentgen rays, or x-rays, to produce images of body structures.

T/F: Ultrasonography uses x-rays to examine clients?

False. Ultrasonography uses a transducer that projects sound waves through the body's surface.

A nurse is caring for a client reporting lower back pain. The nurse uses the body systems approach to assess the client. What are the advantages for using this approach for data collection? (pg. 237)

Findings tend to be clustered, making problems more easily identifiable.

Question 4 / 9 Which of the following is most useful for achieving glycemic goals?

Glucose Monitoring Explanation: Glucose monitoring is a tool for achieving and maintain specific glycemic goals. It allows for the appropriate action to be taken regarding food intake, activity, medication dosage, and identification of complications such as hyperglycemia or hypoglycemia. The frequency of monitoring depends on factors such as the patient's glycemic goals, type of diabetes, or the patient's willingness to test.

Question 7 / 12 Which of the following is a sign or symptom of gestational diabetes?

Glucose intolerance Explanation: Glucose intolerance is a classic sign of gestational diabetes in which the body does not produce adequate amounts of insulin to deal with increased blood sugar that occurs during pregnancy. Blood sugars may remain high and treatment revolves around the goal of keeping blood sugar levels within the required limits for the duration of the pregnancy.

A client is advised by her health care provider to receive a Papanicolaou (Pap) test at 21 years of age. What are the recommended guidelines for the client to follow after the first Pap test has been completed?

Have a combination Pap test and HPV screening every 5 years at or after 30 years of age. Explanation: When a pelvic examination is being used to screen for cervical cancer, the American Cancer Society, the Association of Reproductive Health Professionals, and the American College of Obstetricians and Gynecologists (ACOG) recommend the following revised guidelines (2017) for cancer screening: (1) Women aged 21-29 years should have a Pap test alone every 3 years. Human papillomavirus (HPV) testing is not recommended; (2) Women aged 30-65 years should have a Pap test and an HPV test (co-testing) every 5 years (preferred). It is also acceptable to have a Pap test alone every 3 years; (3) Discontinue cancer screenings for women older than 65 who have had adequate prior screening histories and are not at high risk; and (4) More frequent screenings are advocated for women who have a history of risk factors for cervical cancer, such as being human immunodeficiency virus (HIV)-positive, immunosuppressed secondary to an organ transplantation, exposed to diethylstilbestrol as a fetus, previously diagnosed with cervical cancer, or continuing to shed abnormal cells after a hysterectomy.

A nurse is completing an assessment on a client with no history of nutrition-related problems. Which activity should the nurse complete as part of an initial nutritional screening? (pg. 236)

Height and weight

A physician is performing a procedure on a patient, who reports discomfort. What intervention provided by the nurse may help the patient endure the temporary discomfort?

Hold the patient's hand and offer words of encouragement. Explanation: Holding the patient's hand and offering words of encouragement help the patient to endure the temporary discomfort. The nurse communicates assessments of the patient to the examiner, who may choose to shorten or modify the examination in some manner.

The nurse is teaching a client how to collect a blood glucose sample for a glucometer. Which statement by the client would indicate to the nurse that further teaching is required?

I will puncture my finger directly on the pad of my finger." Explanation: When teaching a client how to collect a blood glucose sample for a glucometer, the nurse should instruct the client to wash hands every time, calibrate the glucometer daily for accuracy, and touch the strip to the hanging drop of blood. The client should be instructed to avoid direct puncture of the pad of the finger. The client should puncture the sides of the fingers.

A nurse is assessing the bowel sounds of a client with abdominal pain. The nurse would describe the client's bowel sounds as hyperactive: (pg. 251)

If bowels sounds are frequent.

A nurse is assessing the bowel sounds of a client with abdominal pain. The nurse would describe the client's bowel sounds as hypoactive: (pg. 251)

If sounds occurs after a long interval

A nurse is assessing the bowel sounds of a client with abdominal pain. The nurse would describe the client's bowel sounds as normal: (pg. 251)

If the sounds resemble clicks/gurgles and occur 5 to 34 times a minute.

A client is to undergo a throat culture. The nurse checks the client's chart and sees that the client is taking amoxicillin. What should the nurse do next?

Inform the client's health care provider. Explanation: Amoxicillin is an antibiotic commonly prescribed for strep throat. Antibiotics can affect the results of the throat culture, rendering an unreliable result. The nurse's next action is to inform the client's health care provider so a decision can be made regarding effectively moving forward with the throat culture. It is within the nurse's scope of knowledge to know the use of widely prescribed antibiotics such as amoxicillin, asking the client why the medication is being taken is not the nurse's priority. The nurse will not take a serum blood sample instead, because this specimen would only provide diagnostic data about an infection if the client had become septic.

A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should the nurse take first?

Inspect

During the assessment, the nurse observes that the client has a yellow discoloration on the skin. What is the nurse's appropriate action? (pg. 243

Inspect the sclera and mucous membranes (jaundice shows up in the eyes as well).

Question 10 / 12 Which of the following is a sign or symptom of diabetes type 2?

Insulin Resistance Explanation: The primary defect in those with type 2 diabetes is insulin resistance. The pancreas continues to produce insulin; however, it is either insufficient for the body's needs or is poorly used by the tissues.

Question 9 / 9 Lipodystrophy is most likely the result of which of the following?

Insulin Therapy Explanation: Complications of insulin therapy may include hypoglycemia, allergic reactions, lipodystrophy (atrophy of subcutaneous tissue), or the Somogyi effect. The Somogyi effect, also known as rebound hyperglycemia, occurs due to undetected hypoglycemia throughout the night (possibly due to too much insulin or lack of a bedtime snack), which causes the body to release counterregulatory hormones, thus stimulating the release of stored glucose and hyperglycemia occurs. It is often treated by decreasing the insulin dosage before bed. The Dawn Phenomenon, which is hyperglycemia upon awakening, occurs with many diabetics, especially young adults who are still growing (presence of growth hormone).

A nurse is assessing a client who seems to have a developed a hearing impairment after working at a construction site for a few months. The nurse is using the Weber test to assess the client's hearing acuity. What is the purpose of the Weber test?

It determines the equality or disparity of bone conducted sound.

A nurse is caring for a client reporting lower back pain. The nurse uses the head-to-toe approach to assess the client. What are the advantages for using this approach for data collection? (pg. 237)

It reduces the number of position changes required of the client.

Question 6 / 12 Which of the following is most likely a feature associated with diabetes type 1?

Juvenile Onset Explanation: Type 1 diabetes, formerly known as juvenile-onset diabetes or insulin-dependent diabetes, is more common in young people but can occur at any age. It accounts for about 5% of all people with diabetes with signs and symptoms usually occurring abruptly, but the disease process may be present for several years before proper diagnosis.

Question 9 / 12 Which of the following is a sign or symptom of diabetes type 1?

Ketosis Prone Explanation: Diabetic ketoacidosis (DKA) is a medical emergency resulting from a shortage of insulin in which the body switches to burning fatty acids and producing acidic ketone bodies. Those with type 1 diabetes are more prone to experiencing ketosis, especially at onset or during insulin deficiency.

A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client?

Kyphosis

A nurse greets a new client and asks the client to accompany the nurse to an appropriate location for assessment. During this initial interaction with the client, the nurse is able to ascertain the client's what? (pp. 235-236)

Level of conscious

Prone position

Lying on his/her abdomen with head turned to one side for comfort, the arms may be above head or alongside the body. USED: To examine the posterior (the back of the head, spine, back, buttocks, and extremities).

Question 5 / 9 Due to the progressive and debilitating nature of diabetes, which of the following is recommended?

Monitor for Complications Explanation: There are a number of acute and chronic complications that can occur as a result of diabetes due to its progressive and debilitating nature. Acute complications may involve the misuse of insulin, being unaware of the symptoms of hyperglycemia and hypoglycemia, which can lead to conditions such as diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar nonketotic syndrome (HHNS). Chronic complications can include retinopathy, peripheral vascular disease, neuropathy, and nephropathy.

Question 3 / 12 Which of the following is a disease or disorder is associated with diabetes?

Nephropathy Explanation: Nephropathy is kidney damage because of a microvascular complication related to destruction of small blood vessels that supply the glomeruli of the kidney. Seen in about 20-40% of people with diabetes, nephropathy serves as the leading cause of end-stage kidney disease in the US. Risk factors include hypertension, genetics, smoking, and chronic hyperglycemia.

Question 4 / 12 Which of the following is a disease or disorder is associated with diabetes?

Neuropathy Explanation: Neuropathy is nerve damage that occurs as a result of excess sugar injuring the walls of the blood vessels. Sensory neuropathy is the most common type and may include symptoms such as tingling, numbness, burning, pain, and typically occurs at the tips of fingers and toes and can spread upward. If left untreated, one can lose sensation in the extremity, with extreme cases resulting in amputation.

The nurse is preparing a client who has been confirmed with the COVID-19 virus for a chest x-ray in a hospital where mobile imaging is not available. Which action will the nurse prioritize when transferring this client to the imaging department?

Notify client transfer and diagnostic personnel regarding isolation precautions. Explanation: In preparation for transferring client from a hospital unit to the diagnostic department, the first action the nurse will take is to clearly communicate the client's isolation status to medical personnel who will be in close contact with the client. For intra-hospital transfers, the client transport personnel such as porters must be notified because they are required to don PPE for contact and droplet precautions. The personnel in the imaging department will also need to be aware, because they too will prepare to receive the client by donning PPE for contact and airborne precautions. In addition, they will need to plan to disinfect per agency protocol after the client's diagnostic procedure is complete. By prioritizing this action, the nurse ensures the diagnostic procedure can be carried out seamlessly, without unnecessary delays that may put others at risk. If the client is able, the nurse will ask the client to wear a medical mask, a respirator should not be placed on the client, because the filter increases the risk of transmission to others. The nurse will dispose of all PPE worn in the client's room and don ew PPE to escort the client if needed; however, this action is taken when the diagnostic department has confirmed they are ready to take the client for the procedure. The chest X-ray cannot be placed on hold until the client is exhibiting less symptoms, because these client data are required to make effective treatment decisions immediately.

Question 1 / 12 Which of the following is a risk factor of diabetes type 2?

Obesity Explanation: Obesity is a major risk for developing type 2 diabetes, especially abdominal and visceral adipose tissue. Other risk factors include lack of exercise, increased age, and family history.

Question 8 / 12 Which of the following is a sign or symptom of gestational diabetes?

Onset During Pregnancy Explanation: Gestational diabetes develops during pregnancy and occurs in approximately 2-10% of expecting mothers. Women at increased risk should be screened at their first prenatal visit, which includes those who are obese, are of advanced maternal age, or have a family history of diabetes.

Question 3 / 9 Biguanides and sulfonylureas are examples of which of the following types of medications?

Oral Hypoglycemics Explanation: Oral hypoglycemics are used only in the treatment of type 2 diabetes and include Biguanides, Sulfonylureas, Meglitinides, Alpha-glucosidase inhibitors, Thiazolidinedione's, and Dipeptidyl Peptidase-4 (DPP-4) inhibitors. These drugs work to improve the mechanisms by which the body produces and uses insulin and glucose by targeting the three defects of type 2 diabetes, which involves insulin resistance, decreased insulin production, and increased hepatic glucose production.

A nurse is assessing a client and observing jaundice on the skin and hard palate on the sclera bilaterally. What is the appropriate action of the nurse?

Palpate the liver for enlargement.

A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse?

Palpates the abdomen prior to performing auscultation

A nurse is teaching a class on health promotion and illness prevention. The nurse should include that which of the following is an example of secondary prevention?

Performing monthly breast self-examinations

Question 5 / 12 Which of the following is a disease or disorder is associated with diabetes?

Peripheral Vascular Disease Explanation: People with diabetes are at increased risk of developing peripheral vascular disease (PVD), commonly called peripheral artery disease (PAD), which refers to the obstruction or occlusion of arteries. The risk of developing lower extremity PAD is proportional to the severity and duration of diabetes, accounting for up to 70% of nontraumatic amputations. Fatty deposits can build up in the inner linings of the artery walls and hinder blood flow.

A nurse is listening to the lung sounds of a severely dehydrated client. The nurse hears sounds that are described as grating or leathery. What type of adventitious sounds are these?

Pleural frictions rubs (grating or leathery)

A pregnant client visits the health clinic with pain in the abdomen. What intervention should the nurse anticipate the physician will order at this time?

Prepare the client for an ultrasound procedure. Explanation: The physician should instruct the nurse to prepare the client for ultrasound. Because ultrasound examinations do not involve radiation or contrast media, they are extremely safe diagnostic tools. Any surgical procedure, such as endoscopy, should be avoided as far as possible. X-rays are avoided during pregnancy if at all possible because a developing fetus is at greater risk for cellular damage from x-rays. Pregnancy is a crucial stage at which medicines should not be administered without proper investigation.

The nurse is examining the anus of a client with a history of chronic constipation. What is indicative of chronic constipation? (pg. 252)

Presence of rectal fissures (indicative of chronic constipation)

Roentgenography, also known as _______________, produces images of body structures using x-rays that produce electromagnetic energy that passes through body structures, leaving an image of dense tissue on special film.

Radiography

Lithotomy position

Reclining position with the feet in metal supports called stirrups. USED: 1. Internal pelvic examination (female) 2. Obstetric delivery 3. Cystoscopic (bladder) examination 4. Rectal examination

Dorsal recumbent position

Reclining position with the knees bent, hips rotated outward, and feet flat. USED: 1. External genitalia inspection 2. Vaginal examination 3. Rectal examination 4. Urinary catheter insertion

A nurse is preparing to administer an enema to a client with severe arthritis. When positioning the client for administration of the enema, which position is appropriate for this client?

Sims Explanation: The Sims position would be most appropriate and comfortable for a client with arthritis. In the Sims position, the client lies on the left side with the chest leaning forward, the right knee bent toward the head, the right arm forward, and the left arm extended behind the body. The lithotomy position is used to facilitate female reproductive and urologic examinations, whereas the knee-chest position is very difficult for most clients, especially older adult clients, for any length of time. The modified standing position is used primarily for examining the prostate gland.

The nurse is preparing a client for a fasting blood glucose test when the client reports the last meal was eating 5 hours ago. What is the nurse's next action?

Report the error promptly. Explanation: The error needs to be reported promptly, because it needs to be determined if the test should be cancelled or rescheduled. It is still possible to move forward with the test if it can be rescheduled within 3 hours and the client is able to remain in a fasted state. While each of the other actions is plausible, the nurse will first report the error to care coordination and management. The nurse would then document the error in the client record to ensure the necessary departments are aware of the reason for cancellation or rescheduling. The history also provides information about the client, for example, the client may require additional teaching or have knowledge deficits about test preparation. While an additional nurse can be consulted, it is more important that the nurse inform the client's health care provider of the missed test and reason for missed testing. If results were required more rapidly, it is important for the care team to know there will be a delay.

Question 2 / 12 Which of the following is a disease or disorder associated with diabetes?

Retinopathy Explanation: Chronic and progressive impairment of the retinal circulation that eventually causes hemorrhage as a result of chronic hyperglycemia and hypertension. Diabetic retinopathy is estimated to be the most common cause of new causes of adult blindness.

Question 8 / 9 Which of the following is the most appropriate recommendation in the management of diabetes?

Routine Exercise Explanation: Regular exercise is an important aspect of diabetes management, as it can decrease insulin resistance and have a direct effect on lowering blood glucose levels. Recommendations include at least 150 minutes per week of moderate-intensity aerobic activity. Those with type 2 diabetes are also encouraged to participate in resistance training 3 times per week. Be sure to monitor blood glucose levels before, during, and after exercise.

The nurse is assisting with performing a Papanicolaou (Pap) test. The client receiving the test underwent a surgical procedure for a hip injury 2 months ago and is still recovering. Which is the best position will the nurse assist the client into for this test?

Sims Explanation: In the Sims position, the client lies on the left side with the chest leaning forward, the right knee bent toward the head, the right arm forward, and the left arm extended behind the body. Indications are similar to those for the lithotomy position. It is an alternative gynecologic or urologic position when a client cannot abduct the hips (move the legs outward from midline) because of restricted joint movement such as that caused by hip injury. The supine position is one in which the client is lying flat with the face up.

Which position may be used as an alternative to the lithotomy position during a rectal examination?

Sims position

Sims' position

The client lies on the left side with the chest leaning forward, the right knee bent toward the head, the right arm forward, and the left arm extended behind the body. USED: 1. Rectal exams 2. Vaginal exams 3. Rectal temp assessment 4. Suppository insertion 5. Enema administration

Knee-chest position (genupectoral)

The client rests on the knees and chest and turns the head, which is supported on a small pillow, to one side USED: 1. Rectal/lower intestinal exams 2. Prostate gland exams

Modified standing position

The client stands with the upper half of the body leaning forward. USED: 1. Prostate gland exams

A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers?

The left second intercostal space

A nurse is completing a vision exam with the Snellen eye chart and records the client's vision as 20/30. The client asks the nurse, "What does that mean"? How should the nurse respond? (pg. 239)

The top number indicates the distance the person is standing from the chart, the denominator gives the distance at which normal eye can see.

A nurse is assessing the lung sounds of a client with respiratory disorders. What is a normal bronchial sound? (pg. 248)

They are shorter on inspiration than expiration with a pause between them.

When assessing lung sounds, the nurse applies the stethoscope's chest piece to the client's upper back, but avoids placing it over the scapulae or ribs. How does this intervention help in the assessment? (pg. 247)

This method facilitates hearing sounds in the upper and lower lobes and reduces competing sounds from the heart.

Discuss the purpose of a minimum data set (MDS).

To determine the level of care a client requires, federal law requires licensed extended care facilities to complete a Minimum Data Set assessment form on admission and every 3 months thereafter or whenever the client's condition changes

A nurse is performing a physical assessment for a client using the palpation technique. What is one of the purposes of using this technique?

To obtain information about the skin temperature and moisture.

T/F: A laboratory test involves comparing the components of a collected specimen with normal findings.

True

T/F: Older adults are more susceptible to dehydration.

True

A nurse is conducting a mental status assessment for a client admitted to a health care facility following a motor vehicle accident. Under which conditions would the nurse need to collect more objective assessment data?

When the client has taken an overdose of drugs.

A client has presented to the clinic for a scheduled diagnostic test. The nurse at the clinic is aware of the importance of client education for individuals undergoing diagnostic testing. What subject should the nurse prioritize when providing this client education?

a thorough description of the procedure that the client will undergo. Explanation: Before a client agrees to a procedure, the nurse determines whether the client understands its purpose and the activities involved. It is not normally the nurse's responsibility to describe the implications of test results or to specify the particular medical risks of the procedure. Referral to a website is of little use if the client will undergo the procedure imminently.

During the physical assessment of a 12-year-old who sustained injuries in a bicycle fall, the nurse observes an area near the elbow that has been rubbed away by friction. How should the nurse document this finding? (Pg. 242) a.) Abrasion (rubbed away by friction) b.) Wound (a break in the skin) c.) Laceration (is a torn, jagged wound) d.) Scar (a mark left by healing of a wound/lesion) e.) Ulcer (is open, crater like area) f.) Fissure (a crack in the skin especially in or near the mucous membranes)

a.) Abrasion (rubbed away by friction)

A nurse is assessing the skin of a client who had been on a hiking trip and developed a number of inflamed red patches on his hands and face as an allergic reaction. How should the nurse document this finding? (g. 243) a.) Erythema (superficial burns, local inflammation, carbon monoxide poisoning) b.) Pallor (pale, anemia/blood loss) c.) Flushed (pink, fever/hypertension) d.) Ecchymosis (purple, trauma to soft tissue)

a.) Erythema (superficial burns, local inflammation, carbon monoxide poisoning).

A nurse is completing vital signs on a client who was brought into the emergency department by ambulance. Which assessment findings require immediate attention? Select all that apply. a.) Temp is 101.4 F (38.6 C) b.) BP is 130/78 mmHg c.) Respiratory rate is 16 bpm d.) Heart rate is 130 bpm e.) Oxygen saturations is 90% f.) Pain is 8 on scale of 1 to 10

a.) Temp is 101.4 F (38.6 C) d.) Heart rate is 130 bpm e.) Oxygen saturations is 90% f.) Pain is 8 on scale of 1 to 10

A nurse has explained the purpose and procedure for a comprehensive assessment and has directed the client to an appropriate position on the bed. The nurse has also provided a drape with which to cover the client. What is the primary purpose of providing a drape during the assessment process?

a.) To provide the client with modesty during the assessment. Rationale: A drape provides more modesty than warmth. Not used to keep the skin dry and should not palpate/percuss through the drape.

A nurse is preparing for a skin care certification course and needs to correctly identify various lesions that may be seen on the skin. Which definitions are correct? (Select all that apply) pg. 243 a.) Vesicle is an elevated, round lesion filled with serum (ex: blister) b.) Cyst, is an elevated, circumscribed lesion filled with fluid beneath the skin (ex: tissue growth) c.) Papule is an elevated palpable solid mass (ex: wart) d.) Nodule, is an elevated solid mass, deeper and firmer than papule (ex: enlarged lymph node) e.) Wheal, is an elevated mass with an irregular border and no free fluid (ex: hives) f.) Pustule, elevated raised border, filled with pus (ex: boil) g.) Macule, flat, round, colored, nonpalpable area (ex: freckles)

a.) Vesicle is an elevated, round lesion filled with serum (ex: blister) c.) Papule is an elevated palpable solid mass (ex: wart) d.) Nodule is an elevated solid mass, deeper and firmer than papule (ex: enlarged lymph node)

A physician suspects that a client has narrowed blood vessels. The nurse would likely assist with client teaching about what procedure?

angiography Explanation: Angiography is x-ray of the blood vessels. It is used to determine the location where and the extent to which blood vessels have narrowed, or evaluates improvement after treatment. A chest x-ray detects pneumonia, broken ribs, lung tumors, and enlarged heart. Myelography is x-ray of the spinal canal and detects spinal tumors, ruptured intervertebral disks, and bony changes in the vertebrae. Intravenous pyelography (IVP) helps identify urinary malformations, tumors, stones, cysts, and obstructions in the kidneys and ureters.

What does the cerebellum regulate _______________?

balance

Why do newborns and young infants tend to experience temperature fluctuations?

because they have a 3 times greater surface area relative to their mass from which heat is lost, and a metabolic rate twice that of adults.

Why do infants and older adults have difficulty maintaining normal body temperature?

because they have limited, not large, amounts of subcutaneous white adipocytes (fat cells that provide heat insulation and cushioning of internal structures).

A client comes to the physician's office with a fever and cough. What diagnostic test does the nurse anticipate will reveal if the client has pneumonia?

chest x-ray Explanation: A chest x-ray may detect pneumonia, broken ribs, lung tumors, or an enlarged heart.

A client is being prepared for a test to detect gallstones. For what test does the nurse anticipate preparing the client?

cholecystography Explanation: A cholecystography is performed to help determine the presence of gallstones or obstruction in the flow of bile.

Throat culture procedure

collecting infectious specimens or microorganisms from the throat and examining their characteristics with a microscope.

A client is scheduled for a laboratory test. When explaining the test to the client, which would the nurse most likely include as being involved?

collection of a body fluid specimen Explanation: A laboratory test is a procedure that involves the examination of body fluids or specimens. Ultrasound uses high-frequency sound waves. Radiography involves the use of x-rays. An endoscopy involves a visual examination of internal structures.

Pap (Papanicolaou) test (A.K.A Pap smear)

collects a specimen of the cervical secretions. screening test that detects abnormal cervical cells, the status of reproductive hormone activity, or the presence of normal or infectious microorganisms in the uterus or vagina. Women should receive their first Pap test approximately 3 years after the onset of vaginal intercourse, but no later than 21 years of age. They should then have annual Pap tests thereafter until 30 years of age.

A client has just been administered a barium contrast medium, and the nurse is providing postprocedural education on management of the medium's side effects. For which side effect will the nurse provide instruction?

constipation Explanation: Using barium as a contrast medium can lead to constipation and bowel obstruction. Barium may also cause side effects such as stomach cramps, diarrhea, and pale skin. Clients who are undergoing this procedure are reminded to consume plenty of fluids after the procedure to prevent constipation and related gastrointestinal upset.

The medulla, which contains the respiratory center in the brain, and ____________________.

controls ventilation

The nurse will be inserting an indwelling urethral catheter into a female client. What position should the nurse place the client in preparation for the procedure?

dorsal recumbent Explanation: The dorsal recumbent position is a reclining position with the knees bent, hips rotated outward, and feet flat. It is commonly used for external genitalia inspection, vaginal examinations, rectal examinations, and urinary catheter insertion.

Radionuclide imaging

elements whose molecular structures are altered to produce radiation

The nurse needs to place a client in the Sims' position for an enema. Which action by the nurse is correct?

having client turn to the left side and bend right knee towards the chest Explanation: To place a client in the Sims' position, the nurse would have the client lie on the left side, right knee bent and towards the chest, with the right arm forward and left arm extended above head.

The posterior hypothalamus promotes ________________________ and ________________.

heat conservation and heat production.

Glucometer

instrument that measures the amount of glucose in capillary blood

The nurse is assisting with a sigmoidoscopy. Before the examination begins, the nurse will assist the client into which position?

knee-chest Explanation: A sigmoidoscopy is a procedure in which the care provider will use a lighted flexible scope inserted via the rectum to visualize the colon. The knee-chest position is typically used for procedures related to rectal examinations. In the knee-chest position, also called a "genupectoral position," the client rests on the knees and chest. The client turns the head, which is supported on a small pillow, to one side. The nurse places a pillow under the client's chest for added comfort. The arms are above the head or bent at the elbows so that they rest alongside the client's head. The nurse places a drape to cover the client's back, buttocks, and thighs. The Sims position can be used for this type of examination as well.

The __________ position is used to facilitate gynecologic, urologic, and sometimes rectal examinations.

lithotomy

The nurse is preparing a client who is having a gynecologic examination for a routine Pap test. Into what position will the nurse place the client?

lithotomy Explanation: Lithotomy position is used for gynecologic examinations.

A nurse is preparing to position a client who will be undergoing a pelvic examination. Then nurse will assist the client into which position for this type of procedure?

lithotomy Explanation: The lithotomy position is a reclining position with the feet in metal supports called "stirrups." It is used to facilitate gynecologic (female reproductive), urologic, and sometimes rectal examinations. The nurse uses a drape to cover the client's exposed perineum and legs.

The nurse is preparing the client for a pelvic examination. What position would the nurse place the client in for the examination?

lithotomy Explanation: The reclining lithotomy position has the client's feet in metal supports called "stirrups." It is used to facilitate gynecologic, urologic, and sometimes rectal examinations. The nurse uses a drape to cover the client's exposed perineum and legs.

Which test does the nurse anticipate will be ordered for a client presenting to the emergency department that is suspected of having meningitis?

lumbar puncture Explanation: A lumbar puncture is done to diagnose meningitis, and other conditions that raise pressure within the brain. Paracentesis is a procedure done to withdraw fluid from the abdominal cavity. A throat culture is done to identify and treat the cause of a throat infection (commonly caused by streptococcal bacteria). Capillary blood glucose is measured to determine how well blood glucose levels are regulated.

Supine position

lying flat on back, facing upward. USED: To examine the anterior (the head, neck, chest, abdomen, & extremities).

A client scheduled for a diagnostic test has an implanted pacemaker. Which test will have to be cancelled because of the pacemaker?

magnetic resonance imaging (MRI) Explanation: An implanted pacemaker is a metal device, which prohibits the client from having an MRI.

Measurement of capillary blood glucose procedure

measuring the amount of glucose in capillary blood

A nurse is reviewing the medical record of a client and notes that the client is scheduled for an electromyogram. The nurse identifies this procedure as evaluating the electrical activity of the:

muscles. Explanation: Electromyography examines the energy produced by stimulated muscles. An electrocardiogram examines the electrical activity of the heart; an electroencephalogram examines the electrical activity of the brain.

A ________________ is a procedure for withdrawing fluid from the abdominal cavity.

paracentesis

A physician will be performing a procedure to relieve abdominal pressure for a client with ascites. With what procedure does the nurse anticipate assisting?

paracentesis Explanation: A paracentesis is a procedure for withdrawing fluid from the abdominal cavity. A physician always performs it with the assistance of a nurse. A paracentesis is done most commonly to relieve abdominal pressure and to improve breathing, which generally becomes labored when fluid crowds the lungs.

A ____________ examination is the physical inspection of the vagina and the cervix with palpation of the uterus and the ovaries.

pelvic

Paracentesis procedure

procedure for withdrawing fluid from the abdominal cavity

Lumbar puncture (LP) procedure

procedure for withdrawing spinal fluid

Laboratory test

procedure that involves examining body fluids or specimens and comparing the components of a collected specimen with normal finding.

Diagnostic examination

procedure that involves physical inspection of body structures and evidence of their function.

Radiography

procedures that use roentgen rays, or x-rays, to produce images of body structures.

The nurse is assisting a male client into the modified standing position. What procedure will this client most likely be having?

prostate gland examination Explanation: The modified standing position is used for prostate gland examination.

Electrical graphic recordings:

recording electrical impulses from structures such as the heart, brain, and skeletal muscles

The pituitary gland secretes hormones for a variety of ________________.

regulatory functions.

Ultrasonography

soft tissue examination using sound waves