Assessment

During assessment of a client admitted for cardiomyopathy, the nurse notes the following symptoms: dyspnea on exertion, fatigue, fluid retention, and nausea. The initial appropriate nursing diagnosis is which of the following?

Decreased cardiac output A primary nursing diagnosis for cardiomyopathy is decreased cardiac output related to structural disorders caused by cardiomyopathy or to dysrhythmia from the disease process and medical treatments. Dyspnea on exertion, fatigue, and fluid retention are related to poor cardiac output.

The client has just had an invasive procedure to assess the respiratory system. What does the nurse know should be assessed on this client?

Respiratory distress After invasive procedures, the nurse must carefully check for signs of respiratory distress and blood-streaked sputum.

A nurse is caring for a client with schizophrenia. Which outcome requires revising the client's care plan?

The client spends more time alone. The client with schizophrenia is commonly socially isolated and withdrawn; therefore, having the client spend more time alone wouldn't be a desirable outcome.

The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what?

Urine retention Voiding frequent, small amounts of urine indicates retention of urine with elimination of overflow. The nurse should assess the volume of first voided urine to determine adequacy of output. If the client fails to void within 8 hours of surgery, the nurse should consult with the physician regarding instituting intermittent catheterization until voluntary voiding returns and is not required in this case.

A client with extreme weakness, pallor, weak peripheral pulses, and disorientation is admitted to the emergency department. The client's partner reports that the client has been "spitting up blood." A Mallory-Weiss tear is suspected, and the nurse begins taking a client history from the client's partner. The question by the nurse that demonstrates the nurse's understanding of Mallory-Weiss tearing is

"Has your partner had recent forceful vomiting?" A Mallory-Weiss tear is associated with massive bleeding after a tear occurs in the mucous membrane at the junction of the esophagus and stomach. There is a strong relationship between forceful vomiting and a Mallory-Weiss tear.

The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying?

Circulatory hypoxia Given this patient's vital signs, he appears to be in shock. Circulatory hypoxia is hypoxia resulting from inadequate capillary circulation. It may be caused by decreased cardiac output, local vascular obstruction, low-flow states such as shock, or cardiac arrest.

The clinic nurse caring for a client with a cardiovascular disorder is performing an assessment of the client's pulse. Which of the following steps is involved in determining the pulse deficit?

Count the heart rate at the apex. The nurse determines the pulse deficit by counting the heart rate through auscultation at the apex while a second nurse simultaneously palpates and counts the radial pulse for a full minute. The difference, if any, is the pulse deficit.

The nurse is admitting a patient to the cardiac care unit with complaints of dyspnea on exertion and fatigue. The patient's electrocardiogram (ECG) shows dysrhythmias associated with left ventricular hypertrophy. What diagnostic tool would be the most helpful in diagnosing cardiomyopathy?

Echocardiogram The echocardiogram is one of the most helpful diagnostic tools because the structure and function of the ventricles can be observed easily.

The nurse working in the labor and delivery unit prepares to test for which condition as a part normal newborn screening?

Phenylketonuria Testing for phenylketonuria is part of normal newborn screening. Prenatal screening includes testing for Down syndrome

Which refers to the decrease in lens flexibility that occurs with age, resulting in the near point of focus getting farther away?

Presbyopia Presbyopia usually begins in the fifth decade of life, when reading glasses are required to magnify objects.

Which of the following musculoskeletal injuries is manifested by acromioclavicular joint pain?

Rotator cuff tears Key assessment findings related to rotator cuff tears include acromioclavicular joint pain, limited range of motion, and muscle weakness

A nurse revises the care plan for a client who has difficulty dealing with a crying neonate. Which strategy should the new care plan implement early in this mother's hospital stay?

assessment of the mother's coping strengths and weaknesses and the presence or absence of support systems Assessment of the mother's coping strengths and weaknesses and the presence or absence of support systems is an important aspect in the implementation process. Assessment will also help the nurse identify situations that the mother perceives as stressors.

While performing continuous electronic monitoring of a client in labor, the nurse should document which information about uterine contractions?

duration, frequency, and intensity

Which observation by the nurse would indicate that a client is unable to tolerate a continuation of a tube feeding?

formula in the client's mouth during the feeding, and increased cough Formula in the mouth and cough are indicators of aspiration.

A client with rheumatoid arthritis has been on aspirin therapy for an extended time. Which assessment is the most important for the nurse to obtain?

hearing Prolonged use of aspirin and other salicylates sometimes causes bilateral hearing loss of 30 to 40 decibels. Usually, this adverse effect resolves within 2 weeks after the therapy is discontinued.

The nurse is monitoring a client postoperatively after a permanent pacemaker insertion. Which finding would be most concerning to the nurse?

heart rate of 48 beats/minute The client experiencing bradycardia would be the most serious report postoperatively because it likely indicates pacemaker malfunction.

The nurse is performing a focused assessment on a client's gastrointestinal system. Which assessment is an expected finding?

high pitched gurgling noises in four abdominal quadrants High-pitched gurgles heard in four abdominal quadrants are a normal finding.

A physician orders a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance?

hypokalemia A loop diuretic removes water and, along with it, sodium and potassium. This may result in hypokalemia, hypovolemia, and hyponatremia.

A client with schizophrenia displays a lack of interest in activities, reduced affect, and poor ability to perform activities of daily living. What term would be used to describe this clustering of symptoms?

negative symptoms Schizophrenic clients commonly display positive and negative symptoms. Negative symptoms are characterized by the absence of typically displayed emotional responses.

Which finding is an early indicator of bladder cancer?

painless hematuria Initially, as cancer cells destroy normal bladder tissue, bleeding occurs and causes painless hematuria. (Pain is a late symptom of bladder cancer.)

A nurse is assessing a client with multiple myeloma. The nurse should keep in mind that clients with multiple myeloma are at risk for

pathologic bone fractures. Clients with multiple myeloma are at risk for pathologic bone fractures secondary to diffuse osteoporosis and osteolytic lesions.

A nurse is changing a client's surgical incision dressing on post-op day three. For which observation would the nurse take immediate action?

small amount of creamy yellow drainage Yellow, creamy drainage describes purulent dischage and suggests infection; the nurse must report this finding to the healthcare provider immediately and obtain a culture as ordered.

A physician orders a bland, full-liquid diet for a client. Which response, if made by the client, would indicate to the nurse that the client has understood the nurse's dietary teaching?

"Today I can have apple juice, chicken broth, and vanilla ice cream."

Two nursing students are role-playing a client assessment situation. One of the students is acting as the nurse, and the other student is acting as the client. The task is to focus on assessing the client's lifestyle. Which question would be most appropriate for the student acting as the nurse to ask?

"What do you usually do for fun?" Assessing a client's lifestyle involves questions related to behaviors such as sleep patterns, exercise, nutrition, and recreation, as well as personal habits such as smoking and the use of ilicit drugs, alcohol, and caffeine.

A client admitted to the hospital has unstable angina and receives routine applications of nitroglycerin paste. Which assessment findings would prompt the nurse to withhold the next dose? Select all that apply.

- systolic blood pressure below 90 mmHg - heart rate less than 60 bpm When the client's systolic blood pressure is below 90 mmHg, the nurse should hold the dose because this indicates hypotension. Additionally, if the heart rate is below 60 bpm, the medication should be held because of hypotension. Nitroglycerin is known to cause headaches and dizziness because it dilates both arterial and venous beds.

The parent of an 11-month-old infant reports to the nurse that the infant sleeps much less than other children. The parent asks the nurse whether the infant is getting sufficient sleep. What should be the nurse's initial response?

Ask the parent for more information about the infant's sleep patterns. The nurse needs more information about the infant's sleep patterns to rule out potential problems before determining whether the infant is getting enough sleep.

Caregivers of an infant with a feeding button style gastrostomy tube mention to the nurse there is leaking present. What action should the nurse take?

Assess if the leakage is coming from valve failure or from the peristomal area. The nurse should assess the source of the leakage because intervention will vary depending on the cause. Leakage should not be treated as normal until interventions have failed to remedy the source of the leaking.

A nurse places electrodes on a collapsed individual who was visiting a hospitalized family member. The monitor exhibits the following. Which interventions would the nurse do first?

Assess the client's airway, breathing, and circulation. The rhythm the client is experiencing is ventricular tachycardia (VT). Although all of the options listed are appropriate for someone with stable VT, it is not yet known whether the client's VT is stable, unstable, or pulseless.

If concern exists about fluid accumulation in a client's lungs, what area of the lungs will the nurse focus on during assessment?

Bilateral lower lobes Crackles are secondary to fluid in the alveoli and create a soft, discontinuous popping sound. Because fluid creates these adventitious sounds, the principle of gravity will remind the nurse to focus the assessment on the lower portion of the thorax or the lower lobes of the lungs.

The public health nurse is participating in a health fair, and she interviews a woman with a history of hypertension who is currently smoking one pack of cigarettes per day. She has had no manifestations of coronary artery disease (CAD) but a recent low-density lipoprotein (LDL) level of 154 mg/dL was found. Based on her assessment, the nurse would expect that this patient would be treated in what way?

Diet therapy and smoking cessation Diet therapy is indicated for a patient without CAD who has two or more risk factors (hypertension and cigarette smoking) and an LDL level equal to or greater than 130 mg/dL.

A nurse needs to obtain an accurate blood pressure on a client. Which action is most important for the nurse to take to ensure an accurate reading?

Palpate the brachial artery and then place the arrow on the cuff over the palpated artery. The arrow on the cuff should be placed over the area where the brachial artery has been palpated. This is the most important step in obtaining an accurate blood pressure.

Which of the following would a nurse least likely assess in a client experiencing anxiety?

Positive self-talk Anxiety would be manifested by negative self-talk, sleeping difficulties, irritability, and muscle tension.

The nurse is caring for a client diagnosed with asthma. While performing the shift assessment, the nurse auscultates breath sounds including sibilant wheezes, which are continuous musical sounds. What characteristics describe sibilant wheezes?

They can be heard during inspiration and expiration. Sibilant or hissing or whistling wheezes are continuous musical sounds that can be heard during inspiration and expiration. They result from air passing through narrowed or partially obstructed air passages and are heard in clients with increased secretions. T

At an outpatient clinic, a medical assistant interviews a client and documents the findings. "Client very anxious because new black mole with shades of brown noted on upper outer right thigh. Asymmetrical in shape with an irregular border" The staff nurse reads the progress note and begins planning client care based on which nursing diagnosis?

fear related to potential diagnosis of malignant melanoma Documentation reveals that the client is anxious about the symptoms. These symptoms most closely resemble malignant melanoma. Therefore, fear related to potential diagnosis of malignant melanoma is the most appropriate nursing diagnosis.

A nurse is caring for a client who reports consuming 12 alcoholic beverages per day. For which symptoms will the nurse monitor related to this information?

seizures and hallucinations A client who reports consuming 12 alcoholic beverages per day would be monitored for symptoms of acute alcohol withdrawal. Symptoms of acute alcohol withdrawal include seizures and hallucinations

A client has been experiencing abdominal cramps, diarrhea, and concentrated urine for the past 2 days. Which signs would be included in a focused assessment?

signs of dehydration, including loss of weight; poor tissue turgor; and dry, cracked mucous membranes When a client has abdominal cramps and diarrhea, there is a loss of extra fluids from the body. Through a focused assessment, the nurse should assess for a fluid volume deficit. This would be indicated by signs of dehydration and weight loss.

The general adaptation syndrome (GAS) is a nonspecific physiologic response to a stressor. Which stage is not a part of the process?

stress awareness stage The general adaptation syndrome can cycle many times through the alarm and resistance stages before reaching the exhaustion stage. The process occurs through the neuroendocrine and autonomic nervous systems.

The nurse has just administered ketamine to a client for a moderate sedation procedure. What assessment findings does the nurse apply as evidence of an adverse reaction to ketamine?

hallucinations and agitation Hallucinations and agitation would be common adverse effects of ketamine, for which the nurse should monitor.

The nurse is assessing a client with pneumonia. The nurse auscultates high-pitched popping sounds during inspiration. How will this finding be documented?

fine crackles Crackles result from air moving through airways that contain fluid. Audible during both inspiration and expiration, crackles are discrete sounds that vary in pitch and intensity. Fine crackles are soft and high-pitched.

When evaluating a pregnant client's fundal height, the nurse should measure in which way?

from the symphysis pubis notch to the highest level of the fundus To measure fundal height, the nurse should stretch a measuring tape over the client's enlarged abdomen and measure from the symphysis pubis notch to the highest level of the fundus, determined by palpation.