Unit 6 (ASSESSMENT, PERFUSION, THERMOREGULATION, SENSORY, PERCEPTION, COGNITION) Questions

A client is coming in to the clinic for the first time. In order for the nurse to allow the client the most comfort during the interview, what should the nurse do? 1. Sit next to the client, a few feet apart. 2. Sit behind a desk. 3. Stand at the side of the clients chair. 4. Stand at the counter to take notes during the interview.

Correct Answer: 1 Rationale 1: A seating arrangement in which the client and nurse are seated in chairs, a few feet apart, at right angles to each other and with no table between, creates a less formal atmosphere, with the nurse and client feeling on equal terms. This would allow for more comfort and relaxation during the interview phase. Rationale 2: Sitting behind a desk creates a formal arrangement that suggests a business meeting between a superior and subordinate. Rationale 3: Standing and looking down at a client who is in a chair risks intimidating the client. Rationale 4: Standing and taking notes infers that the nurse is not really interested in the client.

While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused from the tape used to secure the dressing. In which phase of the nursing process is the nurse working? 1. Assessment 2. Diagnosis 3. Implementation 4. Evaluation

Correct Answer: 1 Rationale 1: Assessment is the collection, organization, validation, and documentation of data. Assessment is carried throughout the nursing process, as in this case. Even though performing the dressing change is implementation, noticing the new skin breakdown is assessment. Rationale 2: Diagnosis is identifying the clients response to the problem. Implementation is what the nurse does to help the client reach a goal, and then the goal is evaluated. Rationale 3: Even though performing the dressing change is implementation, noticing the new skin breakdown is assessment. Rationale 4: The goal of the intervention is evaluated, but that is not what is being described in this scenario.

The nurse is preparing to conduct a mental status assessment. What should the nurse include in this assessment? 1. Cognitive and affective functions 2. Cognitive and effective functions 3. Affective and memory functions 4. Affective and knowledge functions

Correct Answer: 1 Rationale 1: Cognitive (intellectual) and affective (emotional) functions are assessed. Rationale 2: There are no effective functions. Rationale 3: The mental status assessment does not include an assessment of memory. Rationale 4: A mental status assessment does not include a knowledge assessment.

The nurse is greeting a newly admitted client. What statement should the nurse make to establish rapport with this client? 1. Hello, Im your nurse and Ill be taking care of you today. 2. Youre lucky there are no students on the unit today. 3. Good morning, is there anything you need right now? 4. Hi. If you need anything, put on your call light.

Correct Answer: 1 Rationale 1: Establishing rapport is a process of creating goodwill and trust and usually begins with a greeting and self-introduction, accompanied by nonverbal gestures such as a smile, a handshake, and a friendly manner. Making introductions, especially offering the use of name, is especially good in establishing rapport. Rationale 2: Telling a hospitalized client he or she is lucky is probably not the best therapeutic comment. Rationale 3: Establishing rapport is a process of creating goodwill and trust and usually begins with a greeting and self-introduction, accompanied by nonverbal gestures such as a smile, a handshake, and a friendly manner. Rationale 4: Establishing rapport is a process of creating goodwill and trust and usually begins with a greeting and self-introduction, accompanied by nonverbal gestures such as a smile, a handshake, and a friendly manner.

When assessing a clients oxygen saturation reading, the nurse realizes that what will affect this reading? 1. Activity 2. Environmental conditions 3. Nutrition 4. Skin color

Correct Answer: 1 Rationale 1: Factors affecting oxygen saturation readings are hemoglobin, circulation, and activity. If there is shivering or excessive movement of the sensor site, this will interfere with an accurate reading. Rationale 2: Environmental conditions do not affect an accurate oxygen saturation reading. Rationale 3: Nutrition does not affect an oxygen saturation reading. Rationale 4: Skin color does not affect an oxygen saturation reading.

The nurse is assisting the physician who is preparing to test a sexually active female client for cervical cancer. What should the nurse expect the health care provider to perform? 1. Pap test 2. Breast exam 3. Rectal exam 4. Abdominal exam

Correct Answer: 1 Rationale 1: For sexually active adolescent and adult women, a Papanicolaou test (Pap test) is used to detect cancer of the cervix. Rationale 2: A breast examination is not done specifically for sexually active clients. Rationale 3: A rectal exam is not done specifically for sexually active clients. Rationale 4: An abdominal exam is not done specifically for sexually active clients.

Unlicensed assistive personnel measure a newly admitted clients vital signs to be: temperature = 99.3(F), respirations = 26, pulse = 98 bpm, and blood pressure = 200/146. What should the nurse do to validate this data? 1. Retake the vital signs. 2. Call the physician. 3. Continue with the physical assessment as soon as possible. 4. Report the findings to the charge nurse.

Correct Answer: 1 Rationale 1: Guidelines for validating assessment data that are out of normal range include repeating the measurements, using another piece of equipment as needed to confirm abnormalities, or asking someone else to collect the same data. In this situation, the nurse needs to be sure that the vital signs are accurate. Rationale 2: Calling the physician would be premature. Rationale 3: The physical assessment should be done as soon as possible anyway, but not until after the vital signs have been validated. Rationale 4: Reporting the findings to the charge nurse before they have been validated would be premature.

The nurse is preparing to measure a clients temperature. What is the first thing that the nurse should do to ensure an accurate temperature reading? 1. Assess that the equipment used is working properly. 2. Place the client in a position that is most comfortable for the health care provider. 3. Take the temperature with a chemical disposable thermometer when the client is perspiring. 4. Wait at least 10 minutes before taking the temperature after a client has been smoking.

Correct Answer: 1 Rationale 1: If the equipment is not working properly, no accuracy will be obtained in the readings. Rationale 2: The type of equipment or method that is chosen will dictate client position, not the position of the health care provider. Rationale 3: If the equipment is not working properly, no accuracy will be obtained in the readings. The type of equipment or method that is chosen will dictate client position, not the position of the health care provider. In order to use a chemical disposable thermometer, the clients skin must be dry for the thermometer to adhere to the skin. Rationale 4: The recommended time to wait to assess an oral temperature is 30 minutes after one smokes, not 10 minutes.

The nurse is assessing the peripheral vascular status of an older client. Which finding should the nurse consider as being normal for this client? 1. Easy to palpate upper extremity arteries 2. Easy to palpate lower extremity arteries 3. Reduction in the number of varicosities 4. Increase in diastolic blood pressure

Correct Answer: 1 Rationale 1: In some older clients, arteries may be palpated more easily because of the loss of supportive surrounding tissues. Rationale 2: The most distal pulses of the lower extremities are more difficult to palpate, not easier to palpate, because of decreased arterial perfusion. Rationale 3: The number of varicosities increases in the older client. Rationale 4: The systolic blood pressure might increase.

The nurse is completing a health history with a client who has complications from chronic asthma. Which open-ended question should the nurse use? 1. How would you describe your sleep pattern? 2. Can you describe your coughing pattern? 3. Is there anything that makes your breathing worse? 4. What medications are you on?

Correct Answer: 1 Rationale 1: Open-ended questions invite clients to discover and explore, elaborate, clarify, or illustrate their thoughts or feelings. They specify only the broad topic to be discussed. Open-ended questions invite long answerslonger than one or two words. Rationale 2: Closed questions can be answered with short, factual, and specific information. Rationale 3: Closed questions can be answered with short, factual, and specific information. Rationale 4: Closed questions can be answered with short, factual, and specific information.

The nurse is assessing a clients blood pressure. What should the nurse hear during phase 2 of Korotkoffs sounds? 1. A muffled, whooshing, or swishing sound 2. Disappearance of sound 3. Faint, clear tapping sound 4. Increased intensity of sound

Correct Answer: 1 Rationale 1: Phase 2 produces a muffled, whooshing, or swishing sound. Rationale 2: Phase 5, the final phase, is where the sound disappears. Rationale 3: Phase 1 of Korotkoffs sounds starts with a faint, clear tapping sound. Rationale 4: Phase 3 is marked by an increased intensity of sound.

The nurse is preparing to assess a clients blood pressure. Which artery will the nurse use for this assessment? 1. Brachial 2. Femoral 3. Radial 4. Ulnar

Correct Answer: 1 Rationale 1: The brachial is the most common artery used to assess a blood pressure reading because it is the most accessible. Rationale 2: The femoral is not as accessible as the brachial. Rationale 3: The radial could be used but it is not as accurate as the brachial artery. Rationale 4: The ulnar could be used but it is not as accurate as the brachial artery.

The RN needs vital signs assessed for four clients. Which client should the nurse address and not assign to the UAP? 1. Cardiac catheterization client returning to the nursing unit 2. COPD client on 2 Lpm oxygen via nasal cannula 3. Pneumonia client nearing discharge 4. Post-op client of 2 days from gallbladder surgery

Correct Answer: 1 Rationale 1: The cardiac catheterization client will need a thorough assessment because she is just returning to the nursing unit. Invasive procedures, such as a catheterization, will need to be closely assessed. More than likely a Doppler will be needed to ensure the pedal pulse is present and stable in the extremity used during the procedure. Unlicensed personnel are not usually delegated Doppler ultrasound device use. Rationale 2: The COPD client is a chronic condition client, and her vital signs would be considered routine. Rationale 3: The client with pneumonia nearing discharge would be considered medically stable. Therefore, assisting this client is within the UAPs capability. Rationale 4: The client who is 2 days post-op from gallbladder surgery would be considered medically stable. Therefore, assisting this client is within the UAPs capability.

The nurse assesses phase 1 Korotkoffs sound occurring at 136 and phase 5 Korotkoffs sound occurring at 72. How should the nurse document this clients blood pressure reading? 1. 136/72 2. 72/136 3. 136-72 4. 72-136

Correct Answer: 1 Rationale 1: The first tapping phase 1 Korotkoffs sound is the systolic blood pressure. The last sound heard during phase 5 Korotkoffs sound is the diastolic blood pressure. The nurse would document the blood pressure as being 136/72. Rationale 2: The diastolic blood pressure is not documented before the systolic blood pressure. Rationale 3: The systolic blood pressure and diastolic blood pressure are not separated by a minus sign. Rationale 4: This places the diastolic reading first and uses the minus sign, which is incorrect to use.

Kozier & Erbs Fundamentals of Nursing, 10/E Chapter 51 Question 1 After a cardiac catheterization, an infant is diagnosed with a malformation of the mitral valve. The nurse will monitor the client for the development of a problem associated with the delivery of 1. oxygenated blood to the body. 2. deoxygenated blood to the lung. 3. oxygenated blood to the right atrium. 4. deoxygenated blood to the left ventricle.

Correct Answer: 1 Rationale 1: The mitral valve separates the left ventricle from the left atrium. Problems with this valve will impede the flow of oxygenated blood from the left atrium into the left ventricle for delivery to the body. Rationale 2: The pulmonic valve separates the right ventricle from the pulmonary artery. Problems with this valve would impede the delivery of deoxygenated blood back to the lung. Rationale 3: The blood that returns to the right atrium is deoxygenated. Rationale 4: The blood delivered to the left ventricle is oxygenated.

The nurse is preparing a client for an abdominal examination. What should the nurse done before beginning the examination? 1. Ask the client to urinate. 2. Ask the client to drink 8 ounces of water. 3. Assess vital signs. 4. Assess heart rate.

Correct Answer: 1 Rationale 1: The nurse should ask the client to urinate because an empty bladder makes the assessment more comfortable. Rationale 2: Drinking fluids will cause the clients bladder to fill and cause discomfort. Rationale 3: The clients vital signs do not need to be assessed prior to an abdominal examination. Rationale 4: The client does not need to have an apical heart rate assessed prior to having an abdominal assessment.

The nurse is collecting equipment to assess a clients ankle/brachial index (ABI). What equipment should be taken to the clients bedside? 1. Blood pressure cuff and a Doppler ultrasound device 2. None, as no special equipment is needed 3. Stethoscope and penlight 4. Reflex hammer and tuning fork

Correct Answer: 1 Rationale 1: The nurse should take a blood pressure cuff and a Doppler ultrasound device to the bedside for this measurement. Rationale 2: The nurse should take a blood pressure cuff and a Doppler ultrasound device to the bedside for this measurement. Rationale 3: No other equipment is used in this assessment. Rationale 4: No other equipment is used in this assessment.

The nurse is performing a musculoskeletal assessment on a client admitted with a possible stroke. When testing for muscle grip strength, the nurse should ask the client to perform which action? 1. Grasp the nurses index and middle fingers while the nurse tries to pull the fingers out. 2. Hold an arm up and resist while the nurse tries to push it down. 3. Flex each arm and then try to extend it against the nurses attempt to keep the arm in flexion. 4. Shrug the shoulders against the resistance of the nurses hands.

Correct Answer: 1 Rationale 1: This is the technique to assess muscle grip strength. Rationale 2: This is a technique to assess muscle strength but not grip strength. Rationale 3: This is a technique to assess muscle strength but not grip strength. Rationale 4: This is a technique to assess muscle strength but not grip strength.

The nurse is planning a physical examination of a client following a head-to-toe format. In which order should the nurse conduct this assessment? 1. Head, upper extremities, abdomen, lower extremities 2. Neck, head, vital signs, chest and back 3. Lower extremities, abdomen, upper extremities, chest and back 4. Head, neck, lower extremities, abdomen

Correct Answer: 1 Rationale 1: When conducting a physical examination from head to toe, the nurse would start with the head, move down to the upper extremities, then to the abdomen, and finally to the lower extremities. Rationale 2: The neck should not be examined before the head. Vital signs are assessed before the head is examined. Rationale 3: The lower extremities and abdomen would not be assessed before the upper extremities or the chest and back. Rationale 4: The lower extremities would not be assessed before the abdomen.

When documenting a clients axillary temperature on the graphic sheet, how should the nurse identify the method of assessing the temperature? 1. AX 2. O 3. R 4. SL

Correct Answer: 1 Rationale 1: When documenting the temperature in the client record, an axillary temperature should be recorded with an AX. Rationale 2: The letter O is not used when documenting a clients temperature. Rationale 3: The letter R would indicate a rectal temperature and not an axillary temperature. Rationale 4: The letters SL are not used when documenting a clients temperature.

The nurse is assessing the musculoskeletal status of a 4-year-old child. What findings should the nurse consider as being expected in this client? Standard Text: Select all that apply. 1. Lordosis 2. Genu valgus 3. Genu varum 4. Pronation of the feet 5. Asymmetric leg abduction

Correct Answer: 1, 2 Rationale 1: Lordosis (swayback) is common in children before age 5. Rationale 2: Genu valgus (knock-knee) is normal in preschool and early-school-age children. Rationale 3: Genu varum (bowleg) is normal in children for about 1 year after beginning to walk. Rationale 4: Pronation and toeing in of the feet are common in children between 12 and 30 months of age. Rationale 5: Asymmetric abduction of the legs (Ortolani and Barlow tests) assesses for developmental dysplasia of the hip in infants.

A client has been receiving a new medication to address specific symptoms. The nurse will perform a physical examination to determine Standard Text: Select all that apply. 1. the progress of the clients health problem. 2. the physiological impact of the prescribed medication. 3. baseline data. 4. data to support nursing diagnoses. 5. areas for health promotion.

Correct Answer: 1, 2 Rationale 1: The nurse will perform a physical examination on a client to determine the progress of the clients health problem. Rationale 2: The nurse will perform a physical examination on a client to determine the physiological impact of the prescribed medication. Rationale 3: The nurse will not be performing a physical examination to collect baseline data. Rationale 4: The nurse will not be performing a physical examination to support nursing diagnoses. Rationale 5: The nurse will not be performing a physical examination to identify areas for health promotion.

The nurse is assessing the nose and sinuses of a client. Which findings should the nurse identify as being within normal limits? Standard Text: Select all that apply. 1. Nose straight 2. Nares symmetrical 3. No tenderness over the bridge 4. Air movement restricted in one nare 5. Clear drainage from one nare

Correct Answer: 1, 2, 3 Rationale 1: A straight nose is a normal finding. Rationale 2: Symmetrical nares are a normal finding. Rationale 3: No tenderness over the nose bridge is a normal finding. Rationale 4: Air movement restricted in one nare is an abnormal finding. Rationale 5: Clear drainage from one nare is an abnormal finding.

The nurse is preparing to complete a physical examination on a client. What should the nurse realize as being the purpose for this examination? Standard Text: Select all that apply. 1. Obtain baseline data. 2. Obtain data to help determine nursing diagnoses. 3. Identify areas for disease prevention. 4. Identify the clients employment status. 5. Obtain data about the clients leisure activities.

Correct Answer: 1, 2, 3 Rationale 1: One purpose of the physical examination is to obtain baseline data. Rationale 2: One purpose of the physical examination is to obtain data to help determine nursing diagnoses. Rationale 3: One purpose of the physical examination is to identify areas for disease prevention. Rationale 4: The physical examination is not done to identify the clients employment status. Rationale 5: The physical examination is not done to obtain data about a clients leisure activities.

The nurse is preparing to assess a client with the Glasgow Coma Scale. Which areas is the nurse assessing in this patient? Standard Text: Select all that apply. 1. Eye response 2. Motor response 3. Verbal response 4. Orientation 5. Musculoskeletal response

Correct Answer: 1, 2, 3 Rationale 1: The Glasgow Coma Scale tests in three major areas: eye response, motor response, and verbal response. Rationale 2: The Glasgow Coma Scale tests in three major areas: eye response, motor response, and verbal response. Rationale 3: The Glasgow Coma Scale tests in three major areas: eye response, motor response, and verbal response. Rationale 4: The Glasgow Coma Scale is not used to assess orientation. Rationale 5: The Glasgow Coma Scale is not used to assess musculoskeletal response.

When assessing a clients respirations, the nurse realizes that the respiratory centers and chemoreceptors respond to changes in which factors? Standard Text: Select all that apply. 1. Oxygen concentration 2. Carbon dioxide concentration 3. Hydrogen ions 4. Potassium level 5. Serum calcium level

Correct Answer: 1, 2, 3 Rationale 1: The respiratory centers and chemoreceptors respond to changes in the concentration of oxygen. Rationale 2: The respiratory centers and chemoreceptors respond to changes in the concentration of carbon dioxide. Rationale 3: The respiratory centers and chemoreceptors respond to changes in the concentration of hydrogen ions. Rationale 4: The respiratory centers and chemoreceptors do not respond to changes in the potassium level. Rationale 5: The respiratory centers and chemoreceptors do not respond to changes in the serum calcium level.

The nurse is planning to assess a clients pulse. What characteristics should the nurse include in this assessment? Standard Text: Select all that apply. 1. Rate 2. Rhythm 3. Volume 4. Tone 5. Viscosity

Correct Answer: 1, 2, 3 Rationale 1: When assessing the pulse, the nurse collects data about the rate. Rationale 2: When assessing the pulse, the nurse collects data about the rhythm. Rationale 3: When assessing the pulse, the nurse collects data about the volume. Rationale 4: Tone is not a characteristic of a pulse. Rationale 5: Viscosity is not a characteristic of a pulse.

The nurse is utilizing the technique of inspection during a physical examination with a client. When using this technique, the nurse will take which actions? Standard Text: Select all that apply. 1. Visually observe a body area. 2. Obtain information through the sense of smell. 3. Obtain information through the sense of hearing. 4. Examine the body through the use of touch. 5. Strike the body to elicit a sound from a body part.

Correct Answer: 1, 2, 3 Rationale 1: When using inspection, the nurse will visually observe a body area. Rationale 2: In addition to visual observation, olfactory cues are noted. Rationale 3: In addition to visual observation, auditory cues are noted. Rationale 4: Examining the body through use of touch describes palpation. Rationale 5: Striking the body to elicit a sound from a body part describes percussion.

The nurse is planning to perform indirect percussion on an area of a clients body during a physical examination. Which actions should the nurse take to use this assessment technique? Standard Text: Select all that apply. 1. Place the middle finger of the nondominant hand on the clients skin. 2. Use the tip of the flexed middle finger of the other hand to strike the middle finger of the nondominant hand. 3. Perform a striking motion by moving the wrist. 4. Perform short, rapid, firm blows. 5. Use a stethoscope to transmit sounds to the ears.

Correct Answer: 1, 2, 3, 4 Rationale 1: Placing the middle finger of the nondominant hand on the clients skin is the first step when performing indirect percussion. Rationale 2: Using the tip of the flexed middle finger of the other hand to strike the middle finger of the nondominant hand is the second step when performing indirect percussion. Rationale 3: The nurse should perform a striking motion by moving the wrist. Rationale 4: The nurse should perform short, rapid, firm blows. Rationale 5: Using a stethoscope to transmit sounds to the ears is done during auscultation, not indirect percussion.

Prior to assessing a clients blood pressure, the nurse reviews factors that could affect the reading. Which factors could impact blood pressure? Standard Text: Select all that apply. 1. Stress 2. Race 3. Obesity 4. Medications 5. Employment

Correct Answer: 1, 2, 3, 4 Rationale 1: Stimulation of the sympathetic nervous system increases cardiac output and vasoconstriction of the arterioles, increasing the blood pressure reading. Rationale 2: African Americans over 35 years of age tend to have higher blood pressures than do European Americans of the same age. Rationale 3: Both childhood and adult obesity predispose to hypertension. Rationale 4: Many medications, including caffeine, can increase or decrease the blood pressure. Rationale 5: Employment is not a factor that affects blood pressure.

A client is experiencing abdominal pain. What assessments should the nurse perform to assess this complaint? Standard Text: Select all that apply. 1. Inspect the abdomen. 2. Auscultate the abdomen. 3. Palpate the abdomen. 4. Assess vital signs. 5. Assess peripheral pulses.

Correct Answer: 1, 2, 3, 4 Rationale 1: The nurse should inspect the clients abdomen. Rationale 2: The nurse should auscultate the abdomen. Rationale 3: The nurse should auscultate the abdomen. Rationale 4: The nurse should assess vital signs. Rationale 5: Although peripheral pulses may be palpated, this is not specific to a client with abdominal pain.

Even though a UAP is available to assist with vital sign assessment, the nurse is going to conduct these assessments independently in which situations? Standard Text: Select all that apply. 1. Client who complains of chest pain 2. Client returning from surgery 3. Prior to administering a medication that affects blood pressure 4. Client who complains of dizziness after ambulating. 5. Client being admitted to the care area

Correct Answer: 1, 2, 3, 4 Rationale 1: When a client reports symptoms such as chest pain, the nurse should conduct the assessment. Rationale 2: When a client returns from surgery, the nurse should conduct the assessment. Rationale 3: When the client is prescribed a medication that could affect the vital signs, the nurse should conduct the assessment. Rationale 4: When the client reports symptoms such as dizziness after ambulation, the nurse should conduct the assessment. Rationale 5: When the client is being admitted to a care area, the nurse could delegate the vital sign assessment to the UAP.

The nurse is preparing to conduct an assessment of the heart. Where should the nurse place the stethoscope to auscultate heart sounds? Standard Text: Select all that apply. 1. Aortic region 2. Pulmonic region 3. Tricuspid valve region 4. Abdomen 5. Mitral valve region

Correct Answer: 1, 2, 3, 5 Rationale 1: The nurse will auscultate heart sounds over the aortic region. Rationale 2: The nurse will auscultate heart sounds over the pulmonic region. Rationale 3: The nurse will auscultate heart sounds over the tricuspid valve region. Rationale 4: The abdomen is not assessed during the assessment of the heart. Rationale 5: The nurse will auscultate sounds over the mitral valve region.

The nurse is preparing to perform an eye assessment. What equipment should the nurse have available to complete this assessment? Standard Text: Select all that apply. 1. Penlight 2. Snellens chart 3. Sterile gloves 4. Gauze square 5. Millimeter ruler

Correct Answer: 1, 2, 4, 5 Rationale 1: When performing an eye examination, the nurse will need a penlight. Rationale 2: When performing an eye examination, the nurse will need a Snellens chart. Rationale 3: Sterile gloves are not needed to perform an eye assessment. Rationale 4: When performing an eye examination, the nurse will need a gauze square. Rationale 5: When performing an eye examination, the nurse will need a millimeter ruler.

A nurse is performing an initial assessment on a new admission. What information should the nurse consider as being a part of the database? Standard Text: Select all that apply. 1. Reports from physical therapy the client received as an outpatient 2. Documentation of the nurses physical assessment 3. Physicians orders 4. A list of current medications 5. Information about the clients cultural preferences 6. Discharge instructions

Correct Answer: 1, 2, 4, 5 Rationale 1: The database is all the information about a client. It includes the nursing health history, physical assessment, the physicians history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. Rationale 2: The database is all the information about a client. It includes the nursing health history, physical assessment, the physicians history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. Rationale 3: The database is all the information about a client. It includes the nursing health history, physical assessment, the physicians history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. It would not include the physicians orders for this admission, or discharge instructions. Rationale 4: The database is all the information about a client. It includes the nursing health history, physical assessment, the physicians history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. Current medications would be a part of this database. Rationale 5: The database is all the information about a client. It includes the nursing health history, physical assessment, cultural preferences, the physicians history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. Rationale 6: The database is all the information about a client. It includes the nursing health history, physical assessment, the physicians history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. It would not include discharge instructions.

The nurse is reviewing the nursing process with a firstyear nursing student. What should the nurse explain as being the purpose of the diagnosis phase? Standard Text: Select all that apply. 1. Develop a list of problems. 2. Identify client strengths. 3. Develop a plan. 4. Specify goals and outcomes. 5. Identify problems that can be prevented.

Correct Answer: 1, 2, 5 Rationale 1: Diagnosing is analyzing and synthesizing data in order to identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions as well as developing a list of nursing and collaborative problems. Rationale 2: Diagnosing is analyzing and synthesizing data in order to identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions as well as developing a list of nursing and collaborative problems. Rationale 3: Developing a plan is part of the planning phase. Rationale 4: Specifying goals and outcomes is part of the planning phase. Rationale 5: Diagnosing is analyzing and synthesizing data in order to identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions as well as developing a list of nursing and collaborative problems.

A client comes to the emergency department with a temperature of 104F. Which assessment findings should the nurse use to determine if this client is experiencing heat stroke? Standard Text: Select all that apply. 1. Delirious 2. Pale and dizzy 3. Skin warm and flushed 4. No evidence of sweating 5. Had been playing tennis in the sun

Correct Answer: 1, 3, 4, 5 Rationale 1: Persons experiencing heat stroke may be delirious. Rationale 2: Heat "exhaustion" is a result of excessive heat and dehydration. Signs of heat exhaustion include paleness and dizziness. Rationale 3: Persons experiencing heat stroke generally have warm, flushed skin. Rationale 4: Persons experiencing heat stroke often do not sweat. Rationale 5: Persons experiencing heat stroke generally have been exercising in hot weather.

The nurse is conducting an interview with a new client. Which actions indicate that the nurse is implementing effective communication guidelines? Standard Text: Select all that apply. 1. Looking directly at the client to ensure good eye contact 2. Managing the conversation to avoid periods of silence 3. Providing personal experiences to help the client focus 4. Sitting in a chair next to the client who is in bed 5. Keeping arms unfolded and in a relaxed position

Correct Answer: 1, 4, 5

The nurse is concerned that an older client has nutritional deficiencies. What did the nurse find when assessing this clients nails to make this clinical decision? Standard Text: Select all that apply. 1. White spots 2. Curved nails 3. Deep purple areas 4. Spoon-shaped nails 5. Bands across the nails

Correct Answer: 1, 4, 5 Rationale 1: White spots may indicate zinc deficiency. Rationale 2: Curved nails may be a normal finding or indicate a breathing difficulty. Rationale 3: Deep purple areas indicate an injury to the nail region. Rationale 4: Spoon-shaped nails may indicate iron deficiency. Rationale 5: Bands across the nails may indicate protein deficiency.

What dietary teaching should the nurse provide to the client who has homocysteine elevation? 1. Reduce salt intake. 2. Take a B-complex vitamin supplement daily. 3. Increase fluid intake to 2,000 mL per day. 4. Avoid alcohol intake.

Correct Answer: 2 Rationale 1: Although reduction of salt intake may help to prevent hypertension, there is no connection to homocysteine levels. Rationale 2: Supplementation with a vitamin that provides folate, vitamin B6, vitamin B12, and riboflavin can reduce homocysteine levels, although results can vary. Rationale 3: An increase in fluid intake is not associated with decreased homocysteine levels. Rationale 4: Alcohol in moderation can reduce the risk of heart disease.

A newly admitted client is angry because nursing staff continue to ask the same questions. What should the nurse respond to this client? 1. In order to make sure all of your information is complete, I need to ask these questions. 2. Youre right. Let me know if theres anything you need right now. 3. Ill be done shortly, just give me a few more minutes. 4. You shouldnt be upset. Were only doing our jobs.

Correct Answer: 2 Rationale 1: Before asking more questions, the nurse should review what is already at hand. Rationale 2: Repeated questioning can be stressful and annoying, especially for hospitalized clients, and cause concern about the lack of communication among health professionals. The nurse should review previous records that contain data about the clients occupation, religion, and marital status, as well as take time to review all the information the previous nurse collected. Validating the clients feelings is always a good idea and helps to build rapport between the nurse and client. Rationale 3: This option does not address the clients legitimate concern, nor does it acknowledge the clients feelings. Rationale 4: Telling the client were only doing our jobs is belittling to the client and doesnt offer a therapeutic response.

The nurse is performing a health assessment and notes a yellow tinge to the sclera of the eye. The nurse should document this as being 1. cyanosis. 2. jaundice. 3. pallor. 4. erythema.

Correct Answer: 2 Rationale 1: Cyanosis is a bluish color to the skin, mucous membranes, or nails. Rationale 2: Jaundice is a yellow tinge that is abnormal and is often noticed in the sclera of the eye. Rationale 3: Pallor is a term used to describe paleness. Rationale 4: Erythema is a term used to describe redness.

When assessing a clients peripheral pulse, the health care provider is also assessing which of the following? 1. Depth 2. Rhythm 3. Sound 4. Stress

Correct Answer: 2 Rationale 1: Depth is a term used when assessing edema. Rationale 2: When assessing peripheral pulses, one of the characteristics being assessed is rhythm, along with rate, volume, and equality. Rationale 3: Heart sounds are assessed with the apical pulse. Rationale 4: Stress will affect the rate of both pulse and respiration, but it is not a characteristic of pulse assessment.

A client is unconscious and in respiratory distress after being in a motor vehicle crash. Which should the nurse realize as being a factor that caused a change in this clients respiratory rate? 1. Exercise 2. Increased intracranial pressure 3. Increased environmental temperature 4. Stress

Correct Answer: 2 Rationale 1: Exercise increases respiration rates. Rationale 2: Factors that decrease respirations include increased intracranial pressure. Rationale 3: Increased environmental temperatures increase respiration rates. Rationale 4: Stress increases respiration rates.

A client has been admitted for acute dehydration, secondary to nausea and diarrhea. When is the best time for the nurse to conduct this clients interview? 1. As soon as the client gets to the floor 2. After the client has settled in and been oriented to the room 3. When the family is available to help 4. After the client has been medicated

Correct Answer: 2 Rationale 1: Interviews should be planned when the client is physically comfortable and free of pain, and when interruptions by the family are minimal. Rationale 2: After the client has been oriented to the bathroom and nurse call light, the nurse should start the interview process. In this situation, the nurse may have to pace the interview according to the clients comfort level. Rationale 3: Interviews should be planned when the client is physically comfortable and free of pain, and when interruptions by the family are minimal. Rationale 4: Medication may affect the clients ability to think clearly, so getting as much information as quickly as possible is important.

A nurse has been assigned a new client who cannot speak English. How should the nurse facilitate communication with this client? 1. Have a member of the housekeeping staff who speaks the same language translate. 2. Use the translation services supplied by the hospital. 3. Make sure a family member who does speak English is available. 4. Conduct the interview using hand gestures.

Correct Answer: 2 Rationale 1: Nurses must be cautious when asking family members, client visitors, or agency nonprofessional staff to assist with translation. Issues of confidentiality or gender mismatch can interfere with effective communication. Rationale 2: Live translation is preferred because the client can then ask questions for clarification. Many large facilities are establishing their own translator services for the languages commonly spoken in their geographical regions. Rationale 3: Nurses must be cautious when asking family members, client visitors, or agency nonprofessional staff to assist with translation. Issues of confidentiality or gender mismatch can interfere with effective communication. Rationale 4: Using hand gestures is not an appropriate way to communicate with a client when other options are available.

During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed, and says leave me alone. Which subjective data should the nurse document? 1. Restlessness 2. Leave me alone 3. Not talkative 4. Pale and diaphoretic

Correct Answer: 2 Rationale 1: Restlessness is observable so it is not subjective data. Rationale 2: Subjective data can be described or verified only by that person and are apparent only to the person affected. Subjective data include the clients sensations, feelings, beliefs, attitudes, and perceptions of personal health status and life situations. Rationale 3: Not being talkative is observable so it is not subjective data. Rationale 4: Paleness with diaphoresis is observable so this is not subjective data.

During an initial interview, the client says I dont understand why I have to have surgery; Im really not that sick or in pain right now. How should the nurse respond to the client? 1. Its OK to be worried. Surgery is a big step. 2. What kind of questions do you have about your surgery? 3. I think these are things you should be asking your doctor. 4. Have you had surgery before?

Correct Answer: 2 Rationale 1: Simply noting the concern, without dealing with it, can leave the impression that the nurse does not care about the clients concerns or dismisses them as unimportant. Rationale 2: The nurse should use a combination of directive and nondirective approaches during the interview to determine areas of concern for the client. Rationale 3: Passing the questions off for the doctor would leave the impression that the nurse does not care about the clients concerns or dismisses them as unimportant. Rationale 4: A closed question (Have you had surgery before?) does not allow the client to offer much information, besides yes/no or one-word answers.

The nurse needs to measure the temperature of a client who has a history of heart disease and has eaten a bowl of vegetable soup 45 minutes ago. Which site should the nurse use? 1. Axilla 2. Oral 3. Popliteal 4. Rectal

Correct Answer: 2 Rationale 1: The axilla is the preferred site for newborns, not adults. Rationale 2: Body temperature is frequently measured orally even if the client has eaten or drank something cold or hot. One only needs to wait 30 minutes, and then this site can be used. Rationale 3: The popliteal site would not be used given the history of heart disease. There could be circulatory issues that might affect accurate reading because this site is much farther away from the heart. Rationale 4: The rectal site would be contraindicated in this client given the history of heart disease. With the diagnosis of heart disease, the nurse would need to assess for the presence of hemorrhoids.

The client has complaints of being tired, listless, and unable to tolerate activity at usual levels. Which laboratory value should the nurse review first while assessing this complaint? 1. Blood urea nitrogen 2. Hemoglobin and hematocrit 3. Blood sugar 4. Serum potassium

Correct Answer: 2 Rationale 1: The clients symptoms may or may not be associated with the blood urea nitrogen level. Rationale 2: Hemoglobin is the oxygen-carrying portion of the blood, and anemia (decrease in hemoglobin and hematocrit) is often associated with client complaints of being tired, listless, and unable to tolerate normal activities. Rationale 3: These symptoms may or may not be seen in a client with an alteration in the blood sugar level. Rationale 4: These symptoms may or may not be seen in a client with an altered serum potassium level.

The nurse is preparing to administer a cardiotonic drug to a client. Which assessment should the nurse perform before administering the medication? 1. Respiratory rate 2. Apical pulse 3. Popliteal pulse 4. Capillary blanch test

Correct Answer: 2 Rationale 1: The nurse does not need to assess the clients respiratory rate before providing the medication. Rationale 2: The apical pulse should be assessed before administering any cardiotonic medication. Rationale 3: The clients popliteal pulse does not need to be assessed prior to receiving this medication. Rationale 4: The clients capillary blanching does not need to be assessed prior to receiving this medication.

The nurse needs to assess a clients respiratory status. Which client position would be the best for this assessment? 1. Prone 2. Semi-Fowlers 3. Side-lying 4. Supine

Correct Answer: 2 Rationale 1: The prone position increases the volume of blood inside the thoracic cavity and compresses the chest, compromising the clients respirations. Rationale 2: Persons in a semi-Fowlers position will better aid themselves and the nurse to assess their respiratory status. Rationale 3: The side-lying position increases the volume of blood inside the thoracic cavity and compresses the chest, compromising the clients respirations. Rationale 4: The supine position increases the volume of blood inside the thoracic cavity and compresses the chest, compromising the clients respirations.

While performing a health assessment, in which position should the nurse place the client for inspection of the jugular veins? 1. 90-degree angle 2. 30- to 45-degree angle 3. 15-degree angle 4. 60-degree angle

Correct Answer: 2 Rationale 1: This is not the correct angle. Rationale 2: The nurse should place the client in the semi-Fowlers position (30- to 45-degree angle) while inspecting the jugular veins for distention. Rationale 3: This is not the correct angle. Rationale 4: This is not the correct angle.

The nurse notes a widely bizarre pattern on the clients cardiac monitor. What is the nurses priority action? 1. Call a code blue. 2. Check the clients pulse. 3. Immediately defibrillate the client. 4. Check the rhythm in a different lead.

Correct Answer: 2 Rationale 1: This is not the first thing that the nurse should do. Rationale 2: The nurse should always remember to verify any changes on the cardiac monitor by assessing the client (in this case, checking the pulse). The cardiac monitor reports electrical activity that may not directly reflect the mechanical activity occurring in the heart. Rationale 3: The nurse should not immediately defibrillate the client. Rationale 4: The nurse should not check the rhythm in a different lead first.

The nurse determines that unlicensed assistive personnel (UAP) are not to be delegated client blood pressure measurements. What did the nurse observe to make this clinical decision? Standard Text: Select all that apply. 1. The valve on the bulb was closed. 2. The client was sitting with the legs crossed. 3. The arm was below the level of the heart. 4. The UAP waited 2 minutes before re-measuring. 5. The cuff bladder was placed over the brachial artery.

Correct Answer: 2, 3 Rationale 1: The valve on the bulb needs to be closed to pump up the cuff. Rationale 2: The adult client should be sitting with both feet on the floor. Crossed legs can cause elevations in systolic and diastolic blood pressures. Rationale 3: The elbow should be slightly flexed with the palm of the hand facing up and the arm supported at heart level. The blood pressure increases when the arm is below heart level. Rationale 4: After taking a measurement, 1 to 2 minutes should transpire before making any further measurements. Rationale 5: The cuff should be placed evenly around the upper arm and the bladder center placed directly over the artery.

The nurse is reviewing the laboratory results of a client who is being observed for possible myocardial infarction. Which laboratory result would be most important for the nurse to discuss with the physician? 1. Increased hemoglobin 2. Decreased creatine kinase 3. Increased troponin 4. High normal potassium

Correct Answer: 3 Rationale 1: An increased hemoglobin level is significant; however, it is not the most important result for the nurse to discuss with the physician. Rationale 2: A decreased creatine kinase level is significant; however, it is not the most important result for the nurse to discuss with the physician. Rationale 3: Of these options, the most important finding to discuss with the physician is the increase in troponin, which may help diagnose myocardial infarction. Rationale 4: A high normal potassium level is significant; however, it is not the most important result for the nurse to discuss with the physician.

In the palpatory method of blood pressure determination, instead of listening for the blood flow sounds, light to moderate pressure is used over the artery as the pressure in the cuff is released. When will the nurse read the pressure from the sphygmomanometer? 1. When the cuff is applied 2. When the cuff is being deflated 3. When the first pulsation is felt 4. When the second pulsation is felt

Correct Answer: 3 Rationale 1: Assessing the pulse before the cuff is inflated is not the pressure. Rationale 2: This is not the clients blood pressure if the cuff is just being deflated. Rationale 3: The first pulsation that is felt after the cuff is slowly deflated is the blood pressure reading that is recorded if the palpatory method is used to assess a clients blood pressure. Rationale 4: If the second pulsation is recorded, that would be an inaccurate reading.

The nurse provides a back rub to a client after administering a pain medication with the hope that these two actions will help decrease the clients pain. Which phase of the nursing process is this nurse implementing? 1. Assessment 2. Diagnosis 3. Implementation 4. Evaluation

Correct Answer: 3 Rationale 1: Assessment is gathering data, and this is not what is described in the question. Rationale 2: Diagnosis is identifying patterns and making inferences, and this is not what is described in the question. Rationale 3: Implementation is that part of the nursing process in which the nurse applies knowledge to perform interventions. Rationale 4: Evaluation is making criterion-based evaluations, and this is not what is described in the question.

While waiting for the physician to respond regarding a clients elevated temperature, what can the nurse do to assist the client? 1. Bathe the client with ice water. 2. Give the client an antipyretic. 3. Increase fluid intake. 4. Lower the room temperature.

Correct Answer: 3 Rationale 1: Bathing the client in ice water would lower the clients temperature too fast, possibly causing hypothermia. Rationale 2: Giving a client an antipyretic requires a doctors order. Rationale 3: Elevated body temperature contributes to dehydration, which leads to body tissues drying out and malfunctioning. Rehydrating the clients tissues will allow the temperature to return to normal. Rationale 4: Dropping the temperature of the room would lower the clients temperature too fast, possibly causing hypothermia.

The nurse is assessing peripheral pulses on a client with suspected peripheral vascular disease. Which finding should the nurse report to the physician immediately? 1. Pulses equal bilaterally 2. Full pulsations 3. Thready pulses 4. Pulses present bilaterally

Correct Answer: 3 Rationale 1: Bilateral equal pulses is a normal assessment finding. Rationale 2: Full pulsations is a normal assessment finding. Rationale 3: Thready, weak, or decreased pulses are abnormal and should be reported to the physician. Rationale 4: Bilaterally present pulses is a normal assessment finding.

The nurse is assessing a clients level of pain. Which open-ended question should the nurse use for this situation? 1. Is your pain worse at night? 2. What brought you to the clinic? 3. How has the pain impacted your life? 4. Youre feeling down about having pain, arent you?

Correct Answer: 3 Rationale 1: Closed questions can be answered with one or two words. Rationale 2: A neutral question is open-ended and is used in nondirective interviews, which is what would be used if the nurse didnt understand the reason for the clients visit. Rationale 3: An open-ended question would be beneficial to explore more about the clients experience and should be asked with a how or what. Rationale 4: A leading question is usually closed and directs the clients answer (the nurse stating how the client is feeling, for example).

The postmyocardial infarction client asks the nurse about return to exercise. What information should the nurse give this client? 1. It is better to exercise when it is cold. 2. Environmental temperatures have little impact on cardiac function. 3. Avoid exercise when the weather is hot or cold. 4. Hot temperatures increase peripheral blood vessel contraction.

Correct Answer: 3 Rationale 1: Cold temperatures increase peripheral blood vessel contraction and therefore peripheral vascular resistance, making it more difficult for the heart to circulate blood. Rationale 2: The nurse should advise the client to avoid exercise in hot or cold weather, as these extremes of temperature increase the workload on the heart. Rationale 3: The nurse should advise the client to avoid exercise in hot or cold weather, as these extremes of temperature increase the workload on the heart. Cold temperatures increase peripheral blood vessel contraction and therefore peripheral vascular resistance, making it more difficult for the heart to circulate blood. Hot temperatures decrease systemic vascular resistance by dilating peripheral vessels. This decrease makes the heart rate increase, thereby increasing the hearts workload. Rationale 4: Hot temperatures decrease systemic vascular resistance by dilating peripheral vessels. This decrease makes the heart rate increase, thereby increasing the hearts workload.

The nurse suspects that a client with a history of injuries is a victim of abuse. What did the nurse use to come to this conclusion? 1. Observation of cues 2. Validation 3. Inference 4. Judgment

Correct Answer: 3 Rationale 1: Cues are subjective or objective data that can be directly observed by the nurse. Rationale 2: Validation is the act of double-checking or verifying data to confirm that they are accurate and factual. Rationale 3: Inferences are the nurses interpretations of conclusions made based on the cues, which in this case would be the frequent visits to the emergency department and the clients injuries. Data must be based on cues, and the nurse must be careful not to jump to conclusions. Rationale 4: Judgment is not part of validation.

Kozier & Erbs Fundamentals of Nursing, 10/E Chapter 11 The student is learning the steps of the nursing process. What is the first thing that the student should realize about the purpose of this process? 1. Deliver care to a client in an organized way. 2. Implement a plan that is close to the medical model. 3. Identify client needs and deliver care to meet those needs. 4. Make sure that standardized care is available to clients.

Correct Answer: 3 Rationale 1: Delivery of organized care is not part of the nursing process, although each phase is interrelated. Rationale 2: The nursing process is not part of the medical model, as nurses treat the clients response to the disease or problem. Rationale 3: The purpose of the nursing process is to identify a clients health status and actual or potential health care problems or needs, to establish plans to meet the identified needs, and to deliver specific nursing interventions to meet those needs. Rationale 4: The nursing process is individualized for each clients care plan. It is not about standardizing care.

The nurse decides to seek wound care alternatives for a clients stasis ulcer that is not healing after treatment for 2 weeks. In which phase of the nursing process is the nurse functioning? 1. Diagnosis 2. Implementation 3. Evaluation 4. Assessment

Correct Answer: 3 Rationale 1: Diagnosis is problem identification. Rationale 2: Implementation is carrying out (or delegating) the planned nursing interventions. Wound care would be the implementation of this particular case. Rationale 3: Evaluation is measuring the degree to which goals/outcomes have been achieved and identifying factors that positively or negatively influence goal achievement. Activities of evaluation include judging whether goals/outcomes have been achieved and making decisions about problem status. The clients wound is not healing and the nurse decides to modify the nursing interventions. Rationale 4: Assessment is collecting and organizing data.

The client has experienced a myocardial infarction with damage to the inferior portion of the heart. Due to this history, the nurse monitors the client for the development of rhythm disturbances that are most directly based upon which factor? 1. The resultant change in blood sugar 2. Electrolyte disturbances from tissue damage 3. The automaticity of cardiac cells 4. Decreased blood flow to the liver

Correct Answer: 3 Rationale 1: Each cardiac cell can generate its own electrical impulse. Myocardial infarction interferes with the flow of blood to these cells, and the resultant ischemia makes the cells more irritable and more likely to generate an impulse. These uncontrolled impulses result in rhythm disturbances. Although extreme changes in blood sugar can result in cardiac disturbances, the most likely cause of rhythm disturbance following myocardial infarction is insult to the cells causing them to be irritable. Rationale 2: Each cardiac cell can generate its own electrical impulse. Myocardial infarction interferes with the flow of blood to these cells, and the resultant ischemia makes the cells more irritable and more likely to generate an impulse. These uncontrolled impulses result in rhythm disturbances. Although electrolyte disturbances can result in cardiac disturbances, the most likely cause of rhythm disturbance following myocardial infarction is insult to the cells causing them to be irritable. Rationale 3: Each cardiac cell can generate its own electrical impulse. Myocardial infarction interferes with the flow of blood to these cells, and the resultant ischemia makes the cells more irritable and more likely to generate an impulse. These uncontrolled impulses result in rhythm disturbances. The most likely cause of rhythm disturbance following myocardial infarction is insult to the cells causing them to be irritable. Rationale 4: Each cardiac cell can generate its own electrical impulse. Myocardial infarction interferes with the flow of blood to these cells, and the resultant ischemia makes the cells more irritable and more likely to generate an impulse. These uncontrolled impulses result in rhythm disturbances. Although extreme changes in blood flow to the liver can result in cardiac disturbances, the most likely cause of rhythm disturbance following myocardial infarction is insult to the cells causing them to be irritable.

While performing an assessment of the integument system, the nurse notes the clients eyeballs are protruding and the upper eyelids are elevated. What term should the nurse use to document this finding? 1. Erythema 2. Cyanosis 3. Exophthalmos 4. Normocephalic

Correct Answer: 3 Rationale 1: Erythema is a term used to describe redness. Rationale 2: Cyanosis is a term used to describe a bluish cast to the skin, nails, or mucous membranes. Rationale 3: Hyperthyroidism can cause exophthalmos, a protrusion of the eyeballs with elevation of the upper eyelids, resulting in a startled or staring expression. Rationale 4: Normocephalic is a term used to describe a normal sized head.

A client in the emergency department has a non-lifethreatening wound. The unit is busy with other clients, families, and people in the waiting room. How should the nurse conduct an interview with this client? 1. Have the client wait until the department quiets down, as the wound is not too serious. 2. Tell the client to wait in the waiting room and fill out the paperwork. 3. Draw curtains around the client and nurse to provide as much privacy as possible. 4. Make sure the clients back is to the rest of the room so as not to be heard by passersby.

Correct Answer: 3 Rationale 1: Having the client wait may cause an unnecessary delay in treatment. Rationale 2: Having the client wait and fill out paperwork may cause an unnecessary delay in treatment. Rationale 3: The interview setting should be in a well-lighted, well-ventilated room that is relatively free of noise, movements, and distractions in order to encourage communication. The interview should also take place in an area where others cannot overhear or see the client if possible. In this situation, at least pulling a privacy curtain will help keep the client from view of others in the department. Rationale 4: Making sure the clients back is to the rest of the room is not acceptable.

The RN assesses a client who is recovering from femoral popliteal bypass surgery and discovers that it is difficult to assess the dorsalis pedis pulses. Which nursing intervention would be most appropriate for the nurse to use? 1. Ask another nurse to assess the pulses. 2. Document the findings. 3. Obtain a Doppler ultrasound stethoscope. 4. Wait and try again later.

Correct Answer: 3 Rationale 1: If one nurse is having difficulty with the pulse and accuracy, getting another nurse is not going to be the best choice. Rationale 2: Just documenting the findings does not address the problem of getting an accurate pulse reading. Rationale 3: Obtaining a Doppler ultrasound stethoscope is the appropriate action to take. The Doppler will ensure accuracy by helping to exclude environmental sounds. Rationale 4: Waiting until later may be harmful to the client, creating an unsafe environment.

Family of a client demonstrating confusion state that this is not the clients usual behavior. How should the nurse document this data? 1. Inference 2. Subjective data 3. Objective data 4. Secondary subjective data

Correct Answer: 3 Rationale 1: Inference is making a judgment, and that is not what is described in the question. Rationale 2: The information provided by the spouse is not subjective because it is an observation by someone familiar with the clients usual behavior. Rationale 3: Information supplied by family members, significant others, or other health professionals are considered subjective if it is not based on fact. Because this information is factual, in that the spouse is able to provide the nurse with information about the clients routine behavior and patterns, this is objective data. Rationale 4: The information provided by the spouse is not subjective because it is an observation by someone familiar with the clients usual behavior.

While preparing a client for a procedure, the nurse notes that the client has become unresponsive and respirations have become shallow. What type of assessment should the nurse complete at this time? 1. Initial assessment 2. Problem-focused assessment 3. Emergency assessment 4. Time-lapsed assessment

Correct Answer: 3 Rationale 1: Initial assessment is performed within a specific time after admission to a health care agency. Rationale 2: Problem-focused assessment is an ongoing process integrated with nursing care. Rationale 3: An emergency assessment is performed during any physiologic or psychologic crisis of the client to identify life-threatening problems. Rationale 4: Time-lapsed assessment occurs several months after the initial assessment to compare the clients current status to baseline data previously obtained.

Kozier & Erbs Fundamentals of Nursing, 10/E Chapter 30 Question 1 The nurse is preparing to perform a health assessment of the abdomen. In which order should the nurse perform the assessment? 1. Auscultate, percuss, palpate, inspect 2. Inspect, auscultate, palpate, percuss 3. Inspect, auscultate, percuss, palpate 4. Palpate, percuss, auscultate, inspect

Correct Answer: 3 Rationale 1: Inspection should occur first. Palpation should always be performed last when performing an abdominal health assessment. Auscultation is done before palpation and percussion because palpation and percussion cause movement or stimulation of the bowel, which can increase bowel motility and thus heighten bowel sounds, creating false results. Rationale 2: Inspection should occur first. Palpation should always be performed last when performing an abdominal health assessment. Auscultation is done before palpation and percussion because palpation and percussion cause movement or stimulation of the bowel, which can increase bowel motility and thus heighten bowel sounds, creating false results. Rationale 3: Inspection should occur first. Palpation should always be performed last when performing an abdominal health assessment. Auscultation is done before palpation and percussion because palpation and percussion cause movement or stimulation of the bowel, which can increase bowel motility and thus heighten bowel sounds, creating false results. Rationale 4: Inspection should occur first. Palpation should always be performed last when performing an abdominal health assessment. Auscultation is done before palpation and percussion because palpation and percussion cause movement or stimulation of the bowel, which can increase bowel motility and thus heighten bowel sounds, creating false results.

A nurse has worked in the trauma critical care area for several years. Which noise may become indiscriminate for this particular nurse? 1. A client with audible breathing 2. Moaning of a client in pain 3. Whirring of ventilators 4. Co-workers discussing their clients conditions

Correct Answer: 3 Rationale 1: Nurses often need to focus on specific data in order not to be overwhelmed by a multitude of data. Observing involves discriminating data in a meaningful manner (i.e., noticing things that may indicate cause for concern or action on the nurses part). Listening to a clients breathing helps the nurse become attentive to changes in breathing patterns. Rationale 2: Nurses often need to focus on specific data in order not to be overwhelmed by a multitude of data. Observing involves discriminating data in a meaningful manner (i.e., noticing things that may indicate cause for concern or action on the nurses part). A clients moans of pain should never become easy to listen to. Rationale 3: The noises of machines and other equipment noises, except alarms, would be easy to ignore, as these are the usual, normal sounds of the unit. Rationale 4: Nurses often need to focus on specific data in order not to be overwhelmed by a multitude of data. Observing involves discriminating data in a meaningful manner (i.e., noticing things that may indicate cause for concern or action on the nurses part). Listening to coworkers discuss other clients on the unit is helpful in case the nurse has to attend to any one of them.

The nurse is preparing to assess a clients reflexes. What equipment should the nurse gather before entering the room? 1. Sterile gloves 2. Clean gloves 3. Percussion hammer 4. Penlight

Correct Answer: 3 Rationale 1: Sterile gloves are not needed to test reflexes. Rationale 2: Clean gloves are not needed to test reflexes. Rationale 3: A percussion hammer is used to test reflexes. Rationale 4: A penlight is not used to test reflexes.

The nurse is performing a lung assessment on a client with suspected pneumonia. Which finding should the nurse report to the physician immediately? 1. Chest symmetrical 2. Breath sounds equal bilaterally 3. Asymmetrical chest expansion 4. Bilateral symmetric vocal fremitus

Correct Answer: 3 Rationale 1: Symmetrical chest expansion is an expected finding. Rationale 2: Bilaterally equal breath sounds is a normal assessment finding. Rationale 3: Chest expansion should be symmetrical. Rationale 4: Bilaterally equal vocal fremitus is a normal assessment finding.

The nurse is admitting an infant to the care area. The parents and grandmother are present. What should the nurse use as the best source of data for this client? 1. Medical record from the childs birth 2. Grandmother 3. Parents 4. Admitting physician

Correct Answer: 3 Rationale 1: The babys birth record is able to provide necessary information, but not to the same extent as the parents. Rationale 2: Although the grandmother can support the parents during this time and may be able to offer some helpful information, she would not be the best source. Rationale 3: The best source of data is usually the client, unless the client is too ill, young, or confused to communicate clearly. The parents would be able to provide the nurse with the most accurate, current information regarding the baby (diet, schedule, symptoms, etc.). Rationale 4: The admitting physician will be able to provide necessary information, but not to the same extent as the parents.

During the assessment of a clients breasts, the nurse finds both breasts rounded, slightly unequal in size, skin smooth and intact, and nipples without discharge. What should the nurse do next? 1. Notify the charge nurse. 2. Notify the physician. 3. Document the findings in the nurses notes as normal. 4. Document the findings in the nurses notes as abnormal.

Correct Answer: 3 Rationale 1: The findings are all normal, so the nurse does not need to notify the charge nurse. Rationale 2: The findings are all normal, so the nurse does not need to notify the physician. Rationale 3: The findings are all normal, so the nurse would document the assessment in the nurses notes as normal. Rationale 4: The findings are all normal, so the nurse would not document the findings as abnormal.

During assessment, the nurse notes a cardiac murmur that occurs between S1 and S2. The nurse documents this murmur as being 1. diastolic. 2. holosystolic. 3. systolic. 4. pansystolic.

Correct Answer: 3 Rationale 1: The period of the cardiac cycle between S1 and S2 is ventricular systole. Any extra heart sounds heard during this period of time would be documented as systolic. The period of time between S2 and the next S1 is diastole. Rationale 2: The period of the cardiac cycle between S1 and S2 is ventricular systole. Any extra heart sounds heard during this period of time would be documented as systolic. Holosystolic is not a type of murmur. Rationale 3: The period of the cardiac cycle between S1 and S2 is ventricular systole. Any extra heart sounds heard during this period of time would be documented as systolic. The period of time between S2 and the next S1 is diastole. Rationale 4: The period of the cardiac cycle between S1 and S2 is ventricular systole. Any extra heart sounds heard during this period of time would be documented as systolic. Pansystolic is not a type of murmur.

The client is admitted with a possible deep vein thrombosis. Nursing interventions should be designed to prevent which complication? 1. Myocardial infarction 2. Renal failure 3. Pulmonary embolism 4. Pneumonia

Correct Answer: 3 Rationale 1: The thrombus is less likely to cause a myocardial infarction. Rationale 2: The thrombus is not going to cause renal failure. Rationale 3: The presence of a deep vein thrombosis is a risk factor for the development of a pulmonary embolism. The nurse should design interventions to help prevent that development. Rationale 4: The thrombus is not going to cause pneumonia.

The nurse assessing a 1-day-old infant discovers the heart rate is 140 and irregular. What action should the nurse take? 1. Immediately contact the infants physician. 2. Prepare to resuscitate the infant. 3. Note this normal finding in the infants medical record. 4. Stimulate the infant gently.

Correct Answer: 3 Rationale 1: There is no need to contact the infants physician. Rationale 2: This infant does not need resuscitation. Rationale 3: An irregular heart rate of 140 is common and normal in an infant of this age. The finding should be recorded in the medical record. Rationale 4: This infant does not need stimulation.

The nurse is preparing for morning rounds. What should the nurse avoid delegating to unlicensed assistive personnel? 1. Vital signs 2. Filling of water pitchers 3. Skull and face assessment 4. Ambulation of surgical clients

Correct Answer: 3 Rationale 1: Vital signs can appropriately be delegated to unlicensed assistive personnel. Rationale 2: Filling of water pitchers can be appropriately delegated to unlicensed assistive personnel. Rationale 3: Assessment of the skull and face may not be delegated to unlicensed assistive personnel. Rationale 4: Ambulation of surgical clients can be appropriately delegated to unlicensed assistive personnel.

The nurse is planning teaching for a client that focuses on Healthy People 2020 objectives for cardiovascular health. Which modifiable risk factors should the nurse include in this teaching? Standard Text: Select all that apply. 1. Age 2. Gender 3. Obesity 4. Smoking 5. Hypertension

Correct Answer: 3, 4, 5 Rationale 1: Age is a nonmodifiable risk factor. Rationale 2: Gender is a nonmodifiable risk factor. Rationale 3: Many of the Healthy People 2020 objectives for cardiovascular health relate to modifiable risk factors. Modifiable risk factors include obesity. Rationale 4: Many of the Healthy People 2020 objectives for cardiovascular health relate to modifiable risk factors. Modifiable risk factors include smoking. Rationale 5: Many of the Healthy People 2020 objectives for cardiovascular health relate to modifiable risk factors. Modifiable risk factors include hypertension.

A client has been using the call light routinely throughout the evening. Upon entering the room, the nurse observes the following details. Organize them according to priority sequencing (1 is first priority; 5 is least priority). Standard Text: Click and drag the options below to move them up or down. Choice 1. The family is at the bedside. Choice 2. The IV pump is running on battery. Choice 3. The ECG monitor shows tachycardia. Choice 4. The client reports being restless. Choice 5. O2 tubing is not attached to wall regulator.

Correct Answer: 3, 4, 5, 2, 1 Rationale 1: Has no apparent bearing on clients symptoms Rationale 2: Indicates an issue worth observing Rationale 3: Indicates an objective cardiac symptom Rationale 4: Indicates a subjective symptom Rationale 5: Indicates a possible cause of the clients symptoms

The nurse is going to assess the apical-radial pulse of a client with a cardiovascular disorder. Which rationale did the RN use to make this decision? 1. A forceful radial pulse is much too difficult to count correctly. 2. Both arteriole and venous sounds were heard simultaneously. 3. The pulse was bounding and easily obliterated. 4. The thrust of blood from the heart is too feeble for the wave to be felt at the peripheral pulse site.

Correct Answer: 4 Rationale 1: A forceful radial pulse would be ideal for assessing a clients peripheral pulse. Rationale 2: Arteriole and venous sounds would be detected when using the Doppler, but there is no indication for Doppler use given this situation. Rationale 3: A bounding pulse is not easily obliterated. Rationale 4: Knowing there is a history of a cardiovascular disorder would alert the RN to the importance of the utmost accuracy for the clients pulse assessment. The apical-radial pulse is used to assess this type of client due to the feebleness of the wave of blood flow felt at the peripheral sites.

A client is being treated for congestive heart failure. Which physical finding would lead the RN to believe the clients condition has not improved? 1. Temperature of 98.6F (37C) 2. Moderate amount of clear thin mucus 3. Pulse oximetry reading of 96% 4. Wheezing of breath sounds in all lobes

Correct Answer: 4 Rationale 1: A temperature reading of 98.6F is a normal finding and not an indication of heart failure. Rationale 2: A moderate amount of clear mucus is a normal finding and not an indication of heart failure. Rationale 3: A pulse oximetry reading of 96% is a normal finding and not an indication of heart failure. Rationale 4: Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which are characteristic of congestive heart failure.

As the RN is suctioning a client, the pulse oximetry reading drops to 83%. What should the nurse do? 1. Allow the client to take some extra deep breaths. 2. Continue to suction but only intermittently. 3. Keep the catheter in place and wait a few minutes. 4. Stop suctioning and give supplemental oxygen.

Correct Answer: 4 Rationale 1: Allowing the client to take a few deep breaths will help but not quickly enough to compensate for the hypoxia experienced. Rationale 2: Continuing to suction continuously or intermittently will only decrease the saturation levels more. Rationale 3: Leaving the catheter in place obstructs air flow, thus compromising an already poor situation. Rationale 4: Not only does suctioning remove secretions, but it also removes the clients air. By stopping suctioning, the RN stops removing both. This allows the client to recoup from the procedure, and giving oxygen will also increase the saturation ability back to a normal range.

A client has a heart rate of 170 beats per minute. For what will the nurse assess next in this client? 1. Increased cardiac output 2. Increased preload 3. Decreased afterload 4. Decreased cardiac output

Correct Answer: 4 Rationale 1: Cardiac output equals stroke volume x heart rate. Because this client has a sustained rapid heart rate, the ventricles are most likely not having sufficient time to relax and refill between contractions, so the stroke volume will decrease. Rationale 2: Preload refers to the degree to which muscle fibers in the ventricle are stretched at the end of the relaxation period. Rationale 3: Afterload is reflective of systemic vascular resistance. Rationale 4: Cardiac output equals stroke volume x heart rate. Because this client has a sustained rapid heart rate, the ventricles are most likely not having sufficient time to relax and refill between contractions, so the stroke volume will decrease. At the rate of 170, the compensatory increase in heart rate is no longer helpful in increasing cardiac output. This leads to a decrease in cardiac output.

The nurse is caring for a client following a cerebrovascular accident (stroke). The client is able to comprehend what is being said to him; however, he is unable to respond by speech or writing. What type of aphasia should the nurse realize this patient is demonstrating? 1. Auditory aphasia 2. Acoustic aphasia 3. Sensory aphasia 4. Expressive aphasia

Correct Answer: 4 Rationale 1: Clients with auditory aphasia have lost the ability to understand the symbolic content associated with sounds. Rationale 2: This is the same as auditory aphasia. Rationale 3: Sensory or receptive aphasia is the loss of the ability to comprehend written or spoken words. Rationale 4: Motor or expressive aphasia involves loss of the power to express oneself by writing, making signs, or speaking. Clients may find that even though they can recall words, they have lost the ability to combine speech sounds into words.

During an assessment interview, the client states that an elective surgical procedure will not be done because it does not fit into the clients life goals. Into which of Gordons functional health patterns should the nurse identify this clients comment? 1. Cognitive/perceptual pattern 2. Coping/stress-tolerance pattern 3. Health-perception/health-management pattern 4. Value/belief pattern

Correct Answer: 4 Rationale 1: Cognitive perceptual patterns describe sensory-perceptual and cognitive patterns. Rationale 2: Coping/stress-tolerance patterns describe the clients general coping pattern and the effectiveness of the patterns in terms of stress tolerance. Rationale 3: Health-perception/health-management pattern describes the clients perceived pattern of health and well-being and how health is managed. Rationale 4: The value/belief pattern describes the patterns of values, beliefs (including spiritual), and goals that guide the clients choices or decisions. The client in this situation has decided against a surgical procedure because it doesnt coincide with the clients beliefs and goals.

Which determinant of blood pressure would explain a clients blood pressure reading of 120/100? 1. Blood viscosity 2. Blood volume 3. Pumping action of the heart 4. Peripheral vascular resistance

Correct Answer: 4 Rationale 1: Determinants of blood pressure such as blood viscosity mainly affect the systolic reading portion of the blood pressure. Rationale 2: Determinants of blood pressure such as blood volume mainly affect the systolic reading portion of the blood pressure. Rationale 3: Determinants of blood pressure such as pumping action of the heart mainly affect the systolic reading portion of the blood pressure. Rationale 4: Peripheral vascular resistance especially affects diastolic blood pressure readings. A reading of 120/100 would be indicative of peripheral vascular resistance.

The nurse documents: Client avoids eye contact and gives only vague, nonspecific answers to direct questioning by the professional staff. Is quite animated (laughs aloud, smiles, uses hand gestures) in conversation with spouse. Which method of data collection does this documentation demonstrate? 1. Examining 2. Interviewing 3. Listening 4. Observing

Correct Answer: 4 Rationale 1: Examining is the major method used in the physical health assessment. Rationale 2: Interviewing is used mainly while taking the nursing health history. Rationale 3: Listening is only one part of observing. Rationale 4: Observation is a conscious, deliberate skill that is developed through effort and with an organized approach. Observation occurs whenever the nurse is in contact with the client or support persons.

Kozier & Erbs Fundamentals of Nursing, 10/E Chapter 29 Question 1 An older client has an oral temperature reading of 97.2 degrees F. The nurse realizes that this clients low temperature could be due to which observation? 1. The anxiety level of the client has increased. 2. Hormones have fluctuated in this client. 3. Muscle activity has increased during the clients therapy session. 4. Loss of subcutaneous fat is noted.

Correct Answer: 4 Rationale 1: If a client is anxious or stressed, this response stimulates the sympathetic nervous system. This in turn increases the production of epinephrine and norepinephrine, which increases metabolic and heat production, causing the temperature to rise. Rationale 2: Women experience more hormonal fluctuations than men, and this is usually true with the secretion of progesterone at the time of ovulation. Because this client is older, hormone fluctuations and ovulation will not impact the temperature. Rationale 3: Exercise, which represents hard work or strenuous activity, increases body temperature. That is not the case with this client. No reference has been made to a therapy session, and the temperature is decreased. Rationale 4: This client is older and research shows that older people are at risk for hypothermia. When one ages, subcutaneous fat is lost.

The client has a history of recurrent transient ischemic attack (TIA). Based upon this history the nurse should be most concerned about the clients potential to develop 1. renal failure. 2. gangrene. 3. myocardial infarction. 4. stroke.

Correct Answer: 4 Rationale 1: Renal failure would result from atherosclerotic changes in the renal artery. Rationale 2: Gangrene may occur if atherosclerosis reduces blood flow to the extremities. Rationale 3: Myocardial infarction results from atherosclerosis of the coronary arteries. Rationale 4: Transient ischemic attacks may result from atherosclerosis of the cerebral vessels. Continued development of this atherosclerosis may result in stroke.

The 50-year-old who is postmenopausal asks the nurse about the use of estrogen replacement therapy to protect the heart. How should the nurse respond? 1. This therapy is well proven to protect the heart in postmenopausal women. 2. Estrogen replacement therapy is helpful to reduce the sleep disturbances and hot flashes associated with menopause, but does not protect the heart. 3. Estrogen replacement therapy has been proven to have no effect on any postmenopausal symptoms and is not protective of the heart. 4. The use of estrogen replacement therapy is complex and requires a thoughtful review of the balance between possible benefits and possible risks.

Correct Answer: 4 Rationale 1: Research on estrogen replacement therapy is ongoing. Currently, it is thought that there may be some benefit in reducing cardiac risk. Rationale 2: Research on estrogen replacement therapy is ongoing. Currently, it is thought that there may be some benefit in reducing cardiac risk. Rationale 3: Research on estrogen replacement therapy is ongoing. Currently, it is thought that there may be some benefit in reducing cardiac risk. Rationale 4: There is some concern about the risk of administering this therapy and the development of other health problems such as cancers. The choice to use this therapy should be made only after careful consideration of these benefits and risks.

A new client has been admitted to the care area. How soon should the nurse plan to complete a physical assessment on this patient? 1. 1 hour 2. 12 hours 3. 48 hours 4. 24 hours

Correct Answer: 4 Rationale 1: The Joint Commission requires that each client have an initial assessment consisting of a history and physical performed and documented within a specific time period, but not 1 hour. Rationale 2: The Joint Commission requires that each client have an initial assessment consisting of a history and physical performed and documented within a specific time period, but not 12 hours. Rationale 3: The Joint Commission requires that each client have an initial assessment consisting of a history and physical performed and documented within a specific time period, but not 48 hours. Rationale 4: The Joint Commission requires that each client have an initial assessment consisting of a history and physical performed and documented within 24 hours of admission as an inpatient.

While assessing the dorsalis pedis pulse of a client, the nurse determines that the pulse is absent. However, the extremity is warm and pink with nail beds blanching at 2 to 3 seconds of capillary refilling time. How would the nurse explain these findings? 1. A change in the clients health status has occurred. 2. The client has thrown a blood clot in that extremity. 3. The RNs watch has stopped working. 4. Too much pressure was applied over the pulse site.

Correct Answer: 4 Rationale 1: The information provided gives no indication that any health change has occurred. Rationale 2: The assessment data given (warm, pink, etc.) are not symptoms of a blood clot. Rationale 3: There is no data given in regard to equipment malfunction, such as the nurses watch. Rationale 4: Too firm of pressure on a pulse site will obliterate that pulse because assessing the dorsalis pedis pulse requires one to apply some pressure over the dorsalis pedis artery, making contact with the cones in the foot.

The nurse is assessing a newly admitted client for the presence of impaired peripheral arterial circulation. Which finding would be significant to this condition? 1. Ruddy skin color over legs 2. Bounding pedal pulses 3. Hot spots on the feet and legs 4. Decreased hair on the legs

Correct Answer: 4 Rationale 1: The skin color of the legs is more likely to be pale. Rationale 2: The pulses will be weak. Rationale 3: The feet and legs will be cool to the touch. Rationale 4: When peripheral arterial blood flow is reduced, the amount of oxygen to support hair growth is decreased and there is a reduction of hair distribution on the legs.

The nurse is preparing the morning assignments. Which assessment could the nurse delegate to unlicensed assistive personnel? 1. Neurological assessment 2. Musculoskeletal assessment 3. Vital signs assessment 4. Female genital assessment

Correct Answer: 3 Rationale 1: The UAP cannot perform a neurological assessment. Rationale 2: The UAP cannot perform a musculoskeletal assessment. Rationale 3: The nursing assistant can only assess vital signs. Rationale 4: The UAP cannot perform a female genital assessment.

The nurse has just completed an admission interview with a new client. Which nursing statement indicates that the interview is in the closing phase? 1. Im going to set up your physical assessment now. Do you have any questions? 2. Tell me more about how you feel. 3. Could you give examples of what types of other treatments youve had? 4. Is there anything youre worried about?

Correct Answer: 1 Rationale 1: Closing the interview is important for maintaining the rapport and trust between the client and nurse as well as to facilitate future interactions. The closing should contain an offer for questions, conclusions, plans for the next meeting, and a summary to verify accuracy. Rationale 2: This would be part of the body of the interview/questions designed to gather the most information about the situation. Rationale 3: This would be part of the body of the interview/questions designed to gather the most information about the situation. Rationale 4: This would be part of the body of the interview/questions designed to gather the most information about the situation.

The nurse is assessing the vital signs of a 5-year-old client. Should the nurse measure this childs blood pressure? 1. Yes, blood pressure is measured for all children over the age of 3 years. 2. No, blood pressure measurements are not required until age 13. 3. Only if the child complains of headache or has an elevated pulse rate. 4. Yes, but the measurement must be taken in the childs thigh.

Correct Answer: 1 Rationale 1: Blood pressure measurements should be included for all children over the age of 3 years. Rationale 2: Blood pressure measurements should be included for all children over the age of 3 years. Rationale 3: Blood pressure measurements should be included for all children over the age of 3 years. Rationale 4: The blood pressure is measured with a child-size cuff and can be taken in any extremity.

A client exhibits confusion, decreased capillary refill time, low oxygen saturation readings, and decreased renal output. What NANDA nursing diagnosis problem statement should the nurse choose for this client? 1. Ineffective Tissue Perfusion 2. Decreased Cardiac Output 3. Activity Intolerance 4. Risk for Injury

Correct Answer: 1 Rationale 1: Ineffective Tissue Perfusion is the diagnosis assigned when there is a decrease in oxygenation from failure to nourish tissues at the capillary level. Rationale 2: Decreased Cardiac Output is the diagnosis assigned when there is inadequate blood pumped by the heart to meet the demands of the body. Rationale 3: Activity Intolerance is the diagnosis assigned when the client does not have the energy for daily activities. Rationale 4: Risk for Injury is the diagnosis assigned when the client has an increased chance of being injured.

A client asks the nurse to please close the door when entering or exiting the room because the noise is more than the client is used to because he lives alone. The nurse identifies the reason for this clients response to sensory stimuli as being due to which factor? 1. Lifestyle 2. Developmental stage 3. Culture 4. Illness

Correct Answer: 1 Rationale 1: Lifestyle influences the quality and quantity of stimulation to which an individual is accustomed. A client who lives alone is exposed to fewer, less diverse stimuli. Rationale 2: There is no information to support that the clients response to sensory stimuli is because of developmental stage. Rationale 3: There is no information to support that the clients response to sensory stimuli is because of culture. Rationale 4: There is no information to support that the clients response to sensory stimuli is because of illness.

A client asks why sequential compression devices have been prescribed. How should the nurse respond to the client? 1. They stimulate the blood return that would occur with walking. 2. They prevent lymph drainage buildup in the tissues. 3. They exercise the muscles of the leg. 4. They are used instead of walking out of bed.

Correct Answer: 1 Rationale 1: Sequential compression devices simulate the blood flow that results from walking. Rationale 2: Sequential compression devices do not prevent lymph drainage buildup in the tissues. Rationale 3: Sequential compression devices do not exercise the muscles of the leg. Rationale 4: Sequential compression devices are not used instead of walking out of bed.

The nurse is providing education for the parents of a 7-month-old child who has just been diagnosed with a hearing loss. What guidance should the nurse provide? 1. Expect that the child will be enrolled in a special hearing intervention program immediately. 2. Keep your child in a quiet environment until additional testing is done. 3. Interventions to support hearing are not useful until the child is at least 9 months old. 4. Hearing loss is not serious until 1 year of age.

Correct Answer: 1 Rationale 1: The Centers for Disease Control and Prevention (CDC) expects that all infants identified with hearing loss will receive early intervention services prior to age 36 months. Rationale 2: The child should be stimulated with color, smells, body positions, and textures to develop compensatory mechanisms for the hearing loss. Rationale 3: The Centers for Disease Control and Prevention (CDC) expects that all infants identified with hearing loss will receive early intervention services prior to age 36 months. Rationale 4: Hearing loss is serious from birth.

The nurse is concerned that a client is experiencing sensory deprivation. What did the nurse assess to make this clinical decision? Standard Text: Select all that apply. 1. Excessive sleeping 2. Confusion at night 3. Anger over minor issues 4. Easily distracted 5. Sitting quietly reading a book

Correct Answer: 1, 2, 3, 4 Rationale 1: A clinical manifestation of sensory deprivation is excessive sleeping. Rationale 2: A clinical manifestation of sensory deprivation is nocturnal confusion. Rationale 3: A clinical manifestation of sensory deprivation is annoyance over small matters. Rationale 4: A clinical manifestation of sensory deprivation is a decreased attention span. Rationale 5: Sitting quietly reading a book is not a clinical manifestation of sensory deprivation.

A client is experiencing acute confusion. What nursing actions would be appropriate for this client? Standard Text: Select all that apply. 1. Eliminate unnecessary noise. 2. Keep eyeglasses within reach. 3. Place a calendar in the room, and identify each day. 4. Keep the room well lit during waking hours. 5. Provide dark glasses.

Correct Answer: 1, 2, 3, 4 Rationale 1: Eliminating unnecessary noise would help the client who is experiencing acute confusion. Rationale 2: Keeping eyeglasses within reach would help the client who is experiencing acute confusion. Rationale 3: Placing a calendar in the room and identifying each day would help the client who is experiencing acute confusion. Rationale 4: Keeping the room well lit during waking hours would help the client who is experiencing acute confusion. Rationale 5: Providing dark glasses would help the client who is experiencing sensory overload.

The nurse documents that a client is fully conscious. What did the nurse assess in this client? Standard Text: Select all that apply. 1. Client responded to verbal stimuli. 2. Client responded to written words. 3. Client oriented to time, place, and person. 4. Client demonstrated poor memory. 5. Client alert.

Correct Answer: 1, 2, 3, 5 Rationale 1: A characteristic of being fully conscious is responding to verbal stimuli. Rationale 2: A characteristic of being fully conscious is responding to written words. Rationale 3: A characteristic of being fully conscious is being oriented to time, place, and person. Rationale 4: Demonstrating poor memory is a characteristic of being confused. Rationale 5: A characteristic of being fully conscious is being alert.

The nurse is preparing to apply sequential compression devices to a client. In which order should the nurse apply these devices? Standard Text: Click and drag the options below to move them up or down. 1. Place in the dorsal recumbent or semi-Fowlers position. 2. Place a sleeve under each leg with the opening at the knee. 3. Wrap the sleeve securely around the leg, securing the Velcro tabs. 4. Turn on the control unit and adjust the alarms and pressures as needed. 5. Connect the sleeves to the control unit and adjust the pressure as needed.

Correct Answer: 1, 2, 3, 5, 4 Rationale 1: When applying sequential compression devices, the nurse should first place the client in the dorsal recumbent or semi-Fowlers position. Rationale 2: The second step is to place a sleeve under each leg with the opening at the knee. Rationale 3: The third step is to wrap the sleeve securely around the leg, securing the Velcro tabs. Rationale 4: The fifth step is to turn on the control unit and adjust the alarms and pressures as needed. Rationale 5: The fourth step is to connect the sleeves to the control unit and adjust the pressure as needed.

The nurse is concerned that a hospitalized client is experiencing sensory overload. What did the nurse assess to come to this conclusion? Standard Text: Select all that apply. 1. Sleeplessness 2. Anxiety 3. Apathy 4. Racing thoughts 5. Somatic complaints

Correct Answer: 1, 2, 4 Rationale 1: Sleeplessness is an indication of sensory overload. Rationale 2: Anxiety is an indication of sensory overload. Rationale 3: Apathy is associated with sensory deprivation. Rationale 4: Racing thoughts are an indication of sensory overload. Rationale 5: Somatic complaints are an indication of sensory deprivation.

Which recent change, reported by a clients family, would indicate that the clients hearing ability is decreasing? Standard Text: Select all that apply. 1. Inability to follow directions 2. Mood swings 3. Decreased appetite 4. Complaints of dizziness 5. Answering questions incorrectly

Correct Answer: 1, 2, 4, 5 Rationale 1: The client who has difficulty hearing might have an inability to follow directions because the directions were not heard. Rationale 2: The client who has difficulty hearing might have mood swings because of the stress of not hearing well. Rationale 3: Decrease in appetite is not generally associated with hearing loss. Rationale 4: The client who has difficulty hearing might have complaints of dizziness associated with inner ear disturbances. Rationale 5: The client who has difficulty hearing might answer questions incorrectly because a question was not heard or was misinterpreted.

A client is experiencing changes in taste. What can the nurse do to improve this clients gustatory sense? Standard Text: Select all that apply. 1. Suggest eating each food separately. 2. Offer foods with a variety of flavors. 3. Recommend eating foods that are cold. 4. Promote sips of water between eating different foods. 5. Encourage the client to consume foods of different textures.

Correct Answer: 1, 2, 4, 5 Rationale 1: To improve the sense of taste, the nurse should encourage the client to eat each food separately. Rationale 2: To improve the sense of taste, the nurse should encourage the client to eat foods with a variety of flavors. Rationale 3: Eating cold foods will not improve the clients sense of taste. Rationale 4: To improve the sense of taste, the nurse should encourage the client to take sips of water between eating different foods.

The nurse is caring for a client who has difficulty hearing conversation. What intervention should the nurse implement? 1. Use short phrases. 2. Overarticulate words. 3. Vary the volume of the voice. 4. Face the client during conversation.

Correct Answer: 4 Rationale 1: The nurse should use longer phrases that more completely explain concepts. Rationale 2: Overarticulation of words makes them difficult to lip-read. Rationale 3: The volume of the voice should be consistent. Rationale 4: The best intervention is to face the client during conversation so that the client can employ any lip-reading skills.

A client is diagnosed with anemia. What will the nurse most likely assess in this client as evidence of an alteration in cardiovascular functioning? Standard Text: Select all that apply. 1. Chronic fatigue 2. Lower-extremity edema 3. Pallor 4. Shortness of breath 5. Hypotension

Correct Answer: 1, 3, 4, 5 Rationale 1: A lack of red blood cells to transport oxygen to tissues can lead to chronic fatigue. Rationale 2: A lack of red blood cells does not cause lower-extremity edema. Rationale 3: A lack of red blood cells within tissues can cause skin pallor. Rationale 4: A lack of red blood cells to transport oxygen to tissues can cause shortness of breath. Rationale 5: A lack of red blood cells to transport oxygen to tissues can cause hypotension.

The nurse suspects a client will develop sensory overload. What characteristics did the nurse observe in the client? Standard Text: Select all that apply. 1. Ongoing pain 2. Confusion at night 3. Inability to sleep 4. Easily angered 5. Worrying about upcoming diagnostic tests

Correct Answer: 1, 3, 5 Rationale 1: Pain can contribute to sensory overload. Rationale 2: Nocturnal confusion is a manifestation of sensory deprivation. Rationale 3: Sleeplessness can contribute to sensory overload. Rationale 4: Being easily annoyed is a manifestation of sensory deprivation. Rationale 5: Worry can contribute to sensory overload.

A client diagnosed with congestive heart failure has been treated for many years with intravenous furosemide (Lasix). What sensory impairment should the nurse assess in this client? 1. Loss of ability to taste 2. Hearing loss 3. Vision loss 4. Loss of ability to smell

Correct Answer: 2 Rationale 1: Furosemide (Lasix) does not affect the ability to taste. Rationale 2: Furosemide (Lasix) can be ototoxic if taken over long periods of time. The nurse would monitor for hearing loss. Rationale 3: Furosemide (Lasix) does not affect vision. Rationale 4: Furosemide (Lasix) does not affect the ability to smell.

The nurse finds a client pulseless and breathless. The clients skin is pale and cool, but not cyanotic. Because of this finding, what should the nurse suspect? 1. Respiratory arrest occurred prior to cardiac arrest. 2. Cardiac arrest occurred prior to respiratory arrest. 3. The client cannot be resuscitated. 4. Arrest was caused by airway obstruction.

Correct Answer: 2 Rationale 1: In the absence of cyanosis, the logical sequence of events would be cardiac arrest followed by respiratory arrest. Rationale 2: In the absence of cyanosis, the logical sequence of events would be cardiac arrest followed by respiratory arrest. Rationale 3: Unless the client has do-not-resuscitate orders, a code should be called. Rationale 4: There is no indication that the arrest was caused by airway obstruction or that the client cannot be resuscitated.

The nurse suspects that the client has a hearing disorder; however, the client denies not being able to hear. What initial assessment technique should the nurse employ? 1. Schedule a Weber and Rinne test. 2. Observe the clients interaction with significant others. 3. Use an otoscope to visualize the inner ear. 4. Confront the client with the nurses suspicion.

Correct Answer: 2 Rationale 1: The Weber and Rinne test may be a part of assessment, but will not yield as much information as the simple observation. Rationale 2: The most telling of these options would be to observe the clients interactions with significant others. The nurse should assess for frequent requests to repeat, inattention to conversation, turning one ear to the conversation, and lip-reading. Rationale 3: Use of an otoscope may be a part of assessment, but will not yield as much information as the simple observation. Rationale 4: The client has already denied a hearing problem, so confronting the client with the nurses suspicion will probably only serve to alienate the client from the nurse.

The nurse is planning care for a client who is experiencing dementia. What essential concept should the nurse consider for this planning? 1. Background noise such as music will keep this client calm. 2. Activities should be scheduled at the same time each day. 3. Pain mediation will increase dementia. 4. It is important to talk with the client throughout procedures.

Correct Answer: 2 Rationale 1: The client typically is better oriented when it is quiet. Rationale 2: The client with dementia benefits from a routine schedule of activities. Rationale 3: Pain should be controlled. Rationale 4: Procedures should be explained in direct, clearly understandable terms, but the nurse should avoid chatter.

After an assessment, the nurse determines that a clients sequential compression devices need to be removed. What should the nurse document about this clients status in the medical record? 1. Client ambulating without assistance. 2. Client complains of numbness, tingling, and leg pain with the sequential compression devices. 3. Client requested devices to be removed. 4. Client to wear sequential compression devices during sleep.

Correct Answer: 2 Rationale 1: The devices should be worn as prescribed. Rationale 2: The nurse should remove the devices if the client complains of numbness, tingling, or leg pain. Rationale 3: The devices should be worn as prescribed. Rationale 4: The devices should be worn as prescribed.

A client is hospitalized for treatment of a new disorder. While admitted, the client receives no telephone calls or visitors. The nurse should assess which aspect of the clients sensory-perception function? 1. Risk for sensory overload 2. Social support network 3. Mental status 4. Environment

Correct Answer: 2 Rationale 1: The lack of telephone calls or visitors will not be assessed through assessing the clients risk for sensory overload. Rationale 2: The degree of isolation a person feels is significantly influenced by the quality and quantity of support from family members and friends. The nurse should assess the clients living arrangements, visitors, and any signs indicating social deprivation, such as withdrawal from contact with others to avoid embarrassment or dependence on others, negative self-image, reports of lack of meaningful communication with others, and absence of opportunities to discuss fears or concerns that facilitate coping mechanisms. Rationale 3: The lack of telephone calls or visitors will not be assessed through a mental status assessment. Rationale 4: The lack of telephone calls or visitors will not be assessed through an environmental assessment.

A client has a long history of hypertension and has developed heart failure. The nurse should anticipate giving medications for which purpose? 1. To increase preload 2. To decrease afterload 3. To decrease contractility 4. To decrease cardiac output

Correct Answer: 2 Rationale 1: There is no reason to provide medication to increase preload. Rationale 2: The client likely has developed heart failure secondary to the hypertension, which is an increase in afterload. The nurse would anticipate giving medication to decrease afterload. Rationale 3: There is no reason to decrease this clients contractility. Rationale 4: There is no reason to provide medications to decrease this clients cardiac output.

The nurse is assisting a visually impaired client with ambulation. How should the nurse proceed with this intervention? 1. Walk slightly behind the client. 2. Walk 1 foot in front of the client. 3. Walk on the right side of the client. 4. Walk on the left side of the client.

Correct Answer: 2 Rationale 1: Walking behind the client would be unsafe. Rationale 2: The nurse should walk about 1 foot in front of the client, offering the client an arm. Rationale 3: The side the nurse walks on will depend upon the preference of the client. Rationale 4: The side the nurse walks on will depend upon the preference of the client.

The nurse is assessing a client for possible sensory deprivation. What findings would indicate the client is at risk for developing this sensory disorder? Standard Text: Select all that apply. 1. Client has severe pain. 2. Client has impaired vision. 3. Client is unable to ambulate. 4. Client is on medication that alters sensory perception. 5. Client has no family in the immediate area.

Correct Answer: 2, 3, 4, 5 Rationale 1: Severe pain increases a clients risk for sensory overload. Rationale 2: Impaired vision increases a clients risk for developing sensory deprivation. Rationale 3: Mobility restrictions increase a clients risk for developing sensory deprivation. Rationale 4: Medications that affect the central nervous system increase a clients risk for developing sensory deprivation. Rationale 5: Limited social contact with family and friends increases a clients risk for developing sensory deprivation.

The nurse is concerned that a client is not aware of being in the hospital. For what aspects of the sensory process should the nurse assess the client? Standard Text: Select all that apply. 1. Speech 2. Stimuli 3. Receptor 4. Perception 5. Impulse conduction

Correct Answer: 2, 3, 4, 5 Rationale 1: Speech is not an aspect of the sensory process. Rationale 2: For an individual to be aware of the surroundings, four aspects of the sensory process must be present. One of these aspects is a stimulus, which is an agent or act that stimulates a nerve receptor. Rationale 3: For an individual to be aware of the surroundings, four aspects of the sensory process must be present. One of these is a receptor, which is the ability to convert the stimulus to a nerve impulse. Rationale 4: For an individual to be aware of the surroundings, four aspects of the sensory process must be present. One of these is perception, which is the awareness and interpretation of the stimuli in the brain. Rationale 5: For an individual to be aware of the surroundings, four aspects of the sensory process must be present. One of these is impulse conduction, which means the impulse travels along the nerve pathways to either the spinal cord or directly to the brain.

The nurse is documenting the use of sequential compression devices in a clients medical record. What should be included in this documentation? Standard Text: Select all that apply. 1. Calf circumference 2. Skin integrity 3. Peripheral vascular status 4. Neurovascular status 5. Control unit settings

Correct Answer: 2, 3, 4, 5 Rationale 1: The nurse does not need to document the clients calf circumference unless it is warranted for another health problem. Rationale 2: The nurse should document the clients skin integrity. Rationale 3: The nurse should document the clients peripheral vascular status. Rationale 4: The nurse should document the clients neurovascular status. Rationale 5: The nurse should document the control units settings.

The family of a client in the hospital is concerned about the constant noise in the care area. Which health care professionals have the greatest control over the level of sensory input in the hospital? 1. Physicians 2. Administrators 3. Nurses 4. Planners

Correct Answer: 3 Rationale 1: Physicians are not at the bedside as much as nurses. Rationale 2: Administrators are not at the bedside as much as nurses. Rationale 3: Nurses have the greatest amount of control over the level of sensory input in the hospital. Nurses can decrease sensory overload by controlling lights, noise, odors, and pain. Nurses can also increase sensory input by stimulating the client as appropriate. Rationale 4: Planners are not at the bedside as much as nurses.

A client is on strict bed rest following hip surgery. What nursing intervention would support vascular health? 1. Place pillows under the unaffected knee for support. 2. Position the bed to flex the knees at least 20 degrees. 3. Have the client alternately flex and extend the feet several times a day. 4. Keep the client in a prone position for at least 20 minutes twice a day.

Correct Answer: 3 Rationale 1: Placing pillows under the knees supports the development of clotting. Rationale 2: Positioning the bed so that the knees are in more than 15 degrees of flexion supports the development of clotting. Rationale 3: Alternating flexion and extension of the feet will help keep clots from forming in the extremities. Active contraction and relaxation of the calf muscles is also used for this purpose. Rationale 4: The client would not be placed in the prone (on abdomen) position.

The odor from a hospitalized clients draining wound permeates the room and is very overwhelming and distracting to the client and the staff. What intervention would be most helpful? 1. Spray the room routinely with a floral room spray. 2. Instill a vinegar solution into the wound. 3. Keep the wound dressing dry and clean. 4. Burn a candle in the room.

Correct Answer: 3 Rationale 1: Spraying the room with a floral spray will add to the sensory overload. Rationale 2: Vinegar is not instilled into wounds. Rationale 3: The best way to keep odors controlled is to keep the wound dressing dry and clean. Rationale 4: Burning a candle will add to the sensory overload, and burning candles are not safe in the hospital environment.

The nurse determines that UAP can apply sequential compression devices to a client when what is observed? 1. The devices are left off for 1 hour after morning care. 2. The alarm is turned off. 3. The tubing is not kinked. 4. Ankle pressure is set at 100 mm Hg.

Correct Answer: 3 Rationale 1: The client should wear the devices as much as possible. Rationale 2: The alarm should be activated. Rationale 3: The tubing should not be kinked. Rationale 4: Ankle pressure should be set at 35 to 55 mm Hg.

The nurse is identifying outcome criteria for a client with a nursing diagnosis of Disturbed Sensory Perception, Auditory. What would indicate that interventions to address this diagnosis have been successful? 1. Client places hearing aid on beside table when not in use. 2. Client does not respond appropriately to questions. 3. Client demonstrates use and care of hearing aid. 4. Client demonstrates difficulty with problem solving.

Correct Answer: 3 Rationale 1: The clients placing the hearing aid on a bedside table when not in use would indicate that interventions were not successful. Rationale 2: The clients responding inappropriately to questions would indicate that interventions were not successful. Rationale 3: Outcome criteria that indicate interventions to address Disturbed Sensory Perception, Auditory have been successful would include the clients demonstrating use and care of the hearing aid. Rationale 4: The clients demonstrating difficulty with problem solving is an indication of sensory overload.

An older client has become very confused since being hospitalized earlier in the week. Prior to this illness, the client exhibited clear thought processing and was able to maintain an independent lifestyle. How should the nurse document this mental state? 1. As reversible confusion 2. As sundown syndrome 3. As delirium 4. As dementia

Correct Answer: 3 Rationale 1: The nurse has no way of knowing if this clients confusion is reversible. Rationale 2: There is not enough information to determine if the client is experiencing sundown syndrome. Rationale 3: Delirium is acute confusion caused by illness, medication, or a change in environment and is the appropriate documentation for this client. Rationale 4: Dementia is chronic confusion with symptoms that are gradual in onset and are irreversible.

Kozier & Erbs Fundamentals of Nursing, 10/E Chapter 38 Question 1 During review of admission data, the nurse learns that the new client has impairment of kinesthetic sensation. Which nursing intervention should be planned for this client? 1. Use the clock face as a format for describing the position of food on meal trays. 2. Provide all teaching materials in very large font. 3. Ensure that the client has assistance when ambulating. 4. Use only nonirritating soaps for bathing.

Correct Answer: 3 Rationale 1: This would be appropriate for the client with an alteration in vision. Rationale 2: This would be appropriate for the client with an alteration in vision. Rationale 3: Kinesthetic sensation refers to the awareness of the position and movement of body parts. The client with impairment of this sensation may be prone to injury by falling and should be assisted when ambulating. Rationale 4: This intervention would be appropriate for a client having a tactile or skin disorder.

A client has been treated for diabetes mellitus since childhood. Currently, the clients blood glucose reading is 180 mg/dl. For which sensory disturbance should the nurse assess in this client? 1. Loss of ability to taste 2. Hearing loss 3. Vision loss 4. Loss of ability to smell

Correct Answer: 3 Rationale 1: Uncontrolled diabetes mellitus does not affect the ability to taste. Rationale 2: Uncontrolled diabetes mellitus does not affect hearing. Rationale 3: Uncontrolled diabetes mellitus is a leading cause of blindness in the United States. Rationale 4: Uncontrolled diabetes mellitus does not affect the ability to smell.

The nurse seeing a client stop breathing realizes that there is how much time before the onset of permanent damage? 1. 3 minutes 2. 2 minutes 3. 4 to 6 minutes 4. 20 to 40 minutes

Correct Answer: 3 ( 4 to 6 minutes) Rationale 1: Extensive damage occurs after 4 to 6 minutes. Rationale 2: Extensive damage occurs after 4 to 6 minutes. Rationale 3: After 4 to 6 minutes, the lack of oxygen supply to the brain causes permanent and extensive damage. Rationale 4: The person is clinically dead 20 to 40 minutes after the heart stops beating.

A client can be aroused only with extreme or repeated stimuli. How should the nurse document this clients behavior? 1. Somnolent 2. Disoriented 3. Comatose 4. Semicomatose

Correct Answer: 4 Rationale 1: The somnolent client is very drowsy, but will respond to stimuli. Rationale 2: A disoriented client is alert, but not oriented to time, place, or person. Rationale 3: The comatose client is not arousable. Rationale 4: Because this client can be aroused with extreme stimuli or repeated stimuli, the correct description is semicomatose.

A client with a terminal illness without an advance directive stops breathing, and does not have a heartbeat. What should the nurse do? 1. Call a slow code. 2. Call a partial code. 3. Call the physician. 4. Call a code.

Correct Answer: 4 Rationale 1: Both legally and ethically, there is no such thing as a slow code. Rationale 2: Both legally and ethically, there is no such thing as a partial code. Rationale 3: The nurse should start CPR, and not stop to phone the physician. Rationale 4: If there is no do-not-resuscitate order, all clients who arrest will have resuscitation efforts begun.

The client who has the medical diagnosis of Alzheimers disease is confused and has difficulty interpreting environmental stimuli. Which nursing diagnosis problem statement most accurately describes this clients situation? 1. Acute Confusion 2. Altered Role Performance 3. Disturbed Sensory Perception 4. Disturbed Thought Processes

Correct Answer: 4 Rationale 1: Clients with Alzheimers disease are more likely to exhibit chronic confusion. Rationale 2: There is no evidence to support Altered Role Performance. Rationale 3: Disturbed Sensory Perception is more useful with the client who has difficulty related to sensory input (perception). Rationale 4: Because this client has dementia, which interferes with the ability to interpret stimuli, the correct diagnosis problem statement is Disturbed Thought Processes.

The nurse is identifying diagnoses appropriate for a client recovering from cataract surgery who lives alone. Which diagnosis would be the priority for this client? 1. Social Isolation 2. Risk for Impaired Skin Integrity 3. Disturbed Sensory Perception 4. Risk for Injury

Correct Answer: 4 Rationale 1: Social Isolation would be appropriate for the client with long-term vision changes but not one with an acute change as in cataract surgery. Rationale 2: Risk for Impaired Skin Integrity is used to describe clients who have altered tactile sensation. Rationale 3: Disturbed Sensory Perception is used to describe clients whose perception has been altered by physiological factors such as pain, sleep deprivation, immobility, disease states such as CVA, or brain trauma. Rationale 4: Because the client lives alone and is recovering from cataract surgery, the clients risk for injury is great.

The nurse is planning morning care for a client who has sequential compression devices in place. How should the nurse instruct the UAP who will be giving the bath? 1. Come get me when it is time to remove the devices, because that must be done by a nurse. 2. You may remove the devices, but standards require that only a nurse put them back on the client. 3. You may leave the devices off until the clients legs air dry. 4. Put the devices on as quickly as possible after the bath.

Correct Answer: 4 Rationale 1: The UAP is able to perform this activity. Rationale 2: The UAP can reapply the devices. Rationale 3: The UAP should dry the clients legs and reapply the devices. Rationale 4: The nurse should remind the UAP that the devices are being used to support circulation and should be off the client for as short a period of time as possible. The UAP who knows the correct removal and application process may remove and apply these devices.

Which condition would lead the RN to choose the dorsalis pedis pulse as the site for further assessing the clients status? 1. Altered level of consciousness 2. Decreased urine output 3. Irregular radial pulse 4. Toes cool to touch

Correct Answer: 4 Rationale 1: To assess an altered level of consciousness, the nurse would most likely assess the clients apical pulse. Rationale 2: To assess for decreased urine output, the nurse would most likely assess the apical pulse. Rationale 3: For an irregular radial pulse, the nurse would most likely assess the apical pulse. Rationale 4: The dorsalis pedis pulse site is in the foot, so this is the ideal site to assess the pulse for toes that are cool to touch.