Assessment Remediation--Exam 1
A nurse is writing a care plan for a newly admitted client. When formulating the diagnostic statements in the care plan, what would the nurse use?
Diagnostic reasoning Explanation: Nurses use diagnostic reasoning and critical thinking to formulate diagnostic statements. Rationale, ANA recommendations, and physical assessment skills are not part of formulating diagnostic statements. Rationale supports the nursing interventions of the nursing care plan. The American Nurses Association does not have recommendations regarding formulation of diagnostic statements for the care plan. Physical assessment skills are important in the assessment step of the nursing process, not the formulation of the diagnostic statements.
Which method should a nurse use when assessing respirations in a newborn?
Observe the respiratory effort for one full minute Explanation: A nurse should observe a newborn or infant's respiratory effort for one full minute because they have periodic irregular breathing, often accompanied by apnea lasting a few seconds. Anytime a nurse finds an irregular pulse or respiratory rate, the vital sign should be assessed for a full minute to obtain an accurate rate. The pulse should be auscultated at the 4 intercostal space because the heart lays more horizontal in the chest. One full breath is an inhalation and exhalation.
To obtain the most accurate temperature on an infant, a nurse should use which method?
Rectal Explanation: A rectal temperature is the most accurate method for obtaining a temperature on an infant. Oral temperatures are not recommended until childhood when the child can understand the concept of holding the thermometer in the mouth.
The nurse is planning to instruct a first time mother about her newborn. The nurse should plan to instruct the mother that the newborn
is an obligatory nose breather. Explanation: Newborns are obligatory nose breathers and, therefore, have significant distress when their nasal passages are obstructed.
A nurse auscultates the bowel sounds of a 1-month-old. Which of the following findings should warrant further assessment by the nurse?
Presence of marked peristaltic waves Explanation: Marked peristaltic waves almost always indicate a pathologic process such as pyloric stenosis. Normal bowel sounds occur every 10 to 30 seconds. They sound like clicks, gurgles, or growls.
A mother brings her 10-month-old infant to the health care clinic for a routine checkup. Which gross motor developmental task should the nurse expect the infant to be able to have achieved?
Pulling self to a standing position with support Explanation: Pulling up to a standing position is a gross motor skill. Pinching a raisin and transferring blocks between hands are fine motor skills. Vocalization is a cognitive and language skill.
A nurse is assessing a 1-month-old infant with a distended abdomen. Which of the following conditions would most likely explain this finding?
Pyloric stenosis Explanation: A distended abdomen may indicate pyloric stenosis. A scaphoid (boat-shaped; i.e., sunken with prominent rib cage) abdomen may result from malnutrition or dehydration. A bulge at the umbilicus suggests an umbilical hernia. Diastasis recti (separation of the abdominal muscles) is seen as a midline protrusion from the xiphoid to the umbilicus or pubis symphysis. This condition is secondary to immature abdominal muscles and usually has little significance.
The student nurse reports that the breath sounds of an infant are loud and harsh. How should the nurse best respond?
"Breath sounds in infants will be louder and harsher due to a thinner chest wall" Explanation: Breath sounds are typically louder and more bronchial in infants due to a thinner chest wall. It does not indicate a need for oxygen, nor is a sign of respiratory distress or infection.
While assessing a young infant's musculoskeletal system, the nurse anticipates that the anterior curve in the cervical region will be developed by
3 to 4 months. Explanation: By 3 to 4 months, the anterior curve in the cervical region develops from the infant raising its head when prone.
A newborn is being assessed at 1 minute after birth. A score that indicates the newborn is adapting well to the extrauterine environment is in what range?
7 to 10 Explanation: The Apgar score is one of the first newborn assessments the nurse makes. It is not used to guide resuscitation efforts but gives important clues about how well the newborn is adapting to life outside the womb. The newborn receives a score of 0 to 2 in each of 5 areas for a possible total score of 10. The score is calculated at 1 min and again at 5 min of life. Score of 7 to 10 indicates a vigorous newborn adapting well to the extrauterine environment. This makes the other options incorrect.
Which action by the nurse demonstrates the correct technique to elicit Ortolani's maneuver?
Abduct the legs and move the knees outward Explanation: The nurse should abduct the legs and move the knees outward to elicit Ortolani's maneuver. Barlow's maneuver involves adducting the legs until the thumbs of the nurse touch. Assessing the symmetry of the gluteal fold is done to look for hip dysplasia but is not a part of Ortolani's maneuver. The buttocks are spread with gloved hands to examine the anus.
The mother of a newborn tells the nurse that the infant is turning blue. Upon further assessment, the nurse finds that the 24 hour infant has blue lips, skin and nail beds. How would the nurse document these findings?
Acrocyanosis Explanation: Acrocyanosis is bluing of the extremities, and is common in newborns and resolves with increasing body temperature within 24-48 hours. Cyanosis is persistent bluing of the skin, lip and nail beds. Anemia may cause pallor or paleness. Petechiae are small red or purple spots on the skin.
A client presents to the health care facility with reports of new onset of chest pain of three days duration. Vital signs are stable and the chest pain has subsided since the client entered the exam room. Which type of assessment is most appropriate for a nurse perform for this client?
Comprehensive Explanation: This client presents with a new problem and the nurse should perform a comprehensive assessment. Chest pain is an emergent problem but the client is has stable vital signs and no chest pain so an emergency assessment is not indicated at this time. A partial or focused assessment would not allow collection of enough data to properly complete diagnose the cause of a new problem.
A young adult male nurse is assessing a teenage girl newly admitted to the pediatric unit. The nurse knows that an efficient assessment framework that provides additional modesty for the client is what?
Head to toe Explanation: The head-to-toe method is efficient and provides more modesty for clients. The body systems and functional assessment does not address the modesty issue in the question. The focused assessment is not appropriate for the newly admitted client.
A nurse is distracted during her assessment of a client and does not take as thorough or as accurate notes as usual. Her supervisor, who is familiar with the client, reads the patient's chart and questions the nurse. The supervisor should point out to the nurse that which of the following errors is most likely to occur due to the nurse's lapse?
Making incorrect nursing judgments or diagnoses Explanation: Assessment is the first and most critical phase of the nursing process. If data collection is inadequate or inaccurate, incorrect nursing judgments may be made that adversely affect the remaining phases of the nursing process. Interjection of the nurse's thoughts or feelings may lead to bias or the withholding of information but would not necessarily result from a lack of a thorough and accurate assessment of a client. Nursing judgments should rely on both objective and subjective information; thus this is not an error. Validating information that is correct makes more work for the nurse but will not be prevented by a thorough and accurate assessment of a client.
A group of students is preparing a class presentation on infant sleeping and Sudden Infant Death Syndrome. The presentation would include which of the following?
Teach parents about "Back to Sleep" Explanation: Appropriate education topics involve teaching parents the importance of not sleeping with infants and safe sleep practices for infants, who are to always be placed on their backs to sleep, with no pillows or excessively soft bedding or toys in cribs. Smoke alarms have nothing to do with sleeping and Sudden Infant Death Syndrome.
Why is the nurse always reassessing the patient for changes?
To achieve the best results Explanation: The nurse or detective is always reassessing the patient or case for changes in order to achieve the best results. Each relies on both the science and art of his or her respective profession.
What is the primary function of the health care team?
To decide the best overall care Explanation: The health care team meets to collaborate on patients and decide the best overall care. This occurs throughout the lifespan, from the inception of life until death. The health care team is a partnership. The group includes the nurse, physician, nutritionist, social worker, physical therapist, occupational therapist, speech therapist, and/or dentist. They all work together on the same team for the benefit of the patient.
A nurse is caring for three clients whose care involves complex situations and multiple responsibilities. What is the key to resolving problems for this nurse?
Critical thinking Explanation: Nurses are frequently involved in complex situations with multiple responsibilities. They are required to think through the analysis, develop alternatives, and implement the best interventions. Critical thinking is the key to resolving problems. Diagnostic reasoning is important in developing diagnostic statements, not in caring for multiple clients with complex care needs. Physical assessment is important in the building the foundation of the nursing care plan. The nursing care plan directs the care that will be provided for the individual client, but does not address the needs of caring for multiple clients.
A nurse examines a frail elderly client's mouth and finds several broken and missing teeth and irritated gums. The nurse should assess this client closely for problems associated with which body system?
Gastrointestinal Explanation: Oral health is a vital component of good nutrition. It affects the frail elderly client's ability to chew food properly and ultimately affects digestion. If the client does not eat enough or digest properly, many gastrointestinal problems may arise as well as the tendency towards malnutrition, undernutrition, or dehydration.
A nurse assesses an 8-month-old infant and observes an irregular shape to the infant's head. What assessment should the nurse perform next?
Palpate anterior fontanelle Explanation: After observing an irregular shaped head, the nurse should palpate for the anterior fontanelle because premature closure will cause the head to become irregular in shape. Then the nurse can perform further neurological assessment of the infant to assess for deficits.
When assessing a newborn post vaginal delivery, the nurse observe bluish colored hands and feet. What is the nurse's priority action?
Place the newborn under the radiant warmer. Explanation: The first action of the nurse is to place the infant under the radiant warmer.The hands and feet of the newborn may appear blue at times (acrocyanosis), which is normal, especially when the newborn is cold. With warming, skin color should return to pink. If the infant does not respond with warming techniques (placing newborn under radiant heater or adding a layer of blankets), consider a congenital heart defect in the newborn. The nurse should auscultate, not palpate, the apical pulse at the 4th intercostal space.
The nurse is performing an initial assessment of the newborn in the nursery. To assess gestational age in the newborn, what tool will she use?
The new Ballard tool Explanation: After birth, physical characteristics and neuromuscular assessment are used to evaluate gestational age. The Ballard Gestational Age Assessment Tool is commonly used in newborn nurseries. The New Ballard Scale includes extremely premature newborns and has been refined to improve accuracy in more mature newborns.
Mrs. Williams is an 89-year-old independent woman who lives alone and has severe arthritis in her hands. Over the last few months the arthritis has gotten worse and she is concerned because she can no longer clean her apartment. What question by the nurse would gain the most usable information to assist with this concern?
"Do you have family who visit you regularly?" Explanation: Asking if family visit regularly may provide a link to getting them to assist in cleaning the apartment.
When the nurse is performing a physical examination on admission of a patient to the medical unit, the patient says the doctor already did an exam. The best response by the nurse would be
"the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease." Explanation: The medical examination focus is on diagnosis and treatment of disease and the nursing examination focuses on the human response.
When making rounds, the RN should prioritize follow-up care for which client?
An oncology client with a cough but no fever. Explanation: The nurse should prioritize care for the oncology client, because immunosuppression due to chemptherapy is a concern. The immunosuppressed client can still exhibit a respiratory infection without fever. The clients require routine assessments with no immediate concerns.
A clinical instructor is teaching a nursing student group about organizing data when documenting and communicating assessment findings. The clinical instructor knows that the method being taught promotes critical thinking and clustering of similar data. The instructor is teaching about which type of assessment?
Body systems Explanation: A body systems approach is a logical tool for organizing data when documenting and communicating findings. This method promotes critical thinking and allows nurses to analyze findings as they cluster similar data. The comprehensive assessment is more encompassing in nature, including more aspects that the body systems approach. The head-to-toe assessment does not look at promoting critical thinking and clustering, rather going through a process to organize data in a logical fashion. Functional assessment is a distraction in this question.
A nurse conducts an initial comprehensive assessment for a client admitted with a fever of unknown origin. Which area of assessment is primarily the nurse's responsibility?
Collect subjective data related to overall function Explanation: The nurse is responsible for collecting subjective data related to the client's overall function. The physical therapist performs a musculoskeletal examination. A dietician may take anthropometric measurements in addition to a subjective nutritional assessment.
It is summer and an 82-year-old woman arrives at the emergency room from her home after seeing her primary care physician 2 days ago, when she had been started on an antibiotic. Today, she does not know where she is or what year it is. What could be a likely cause?
Delirium Explanation: These are not signs of normal aging and seem to be of acute onset. This makes Alzheimer's disease unlikely. Stroke and meningitis could cause these symptoms as well, but the combination of the heat and a recent infection make delirium much more likely. Though she was prescribed an antibiotic, her condition may not have improved because of bacterial resistance, non-compliance due to cost, depression, or even an underlying mild dementia. Dementia should not result in an acute mental status change, although illness may cause a worsening of dementia.
A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and the temperature of the extremities. What is the purpose of this ongoing or partial assessment?
Determine any changes from the baseline data Explanation: Ongoing or partial assessments help to determine any major changes from the baseline data. The nurse collects subjective data related to the client's overall health and conducts a comprehensive health assessment during the initial comprehensive assessment to determine baseline data. The nurse makes a rapid assessment for prompt treatment in life-threatening situations when an immediate diagnosis is needed to provide prompt treatment. Evaluation is done after an intervention to determine if the outcomes have been achieved
An older adult with a history of varicose veins presents with lower extremities that are reddish-brown and edematous. What is the nurse's best action?
Document findings and notify the healthcare provider Explanation: Stasis dermatitis is another common fi nding in older adults with a history of varicosities, phlebitis, and trauma. Lower extremities have a reddish-brown ruddy appearance and are usually edematous but are not infl amed or infected. Nurses often mistake stasis dermatitis for cellulitis, but the stasis changes do not respond to antibiotics. Stasis dermatitis may lead to leg ulcers on the lower shin area; these ulcers can become infected. Your assessment notes should include location, color and size of the area, size and depth of the ulcer (if present), presence of infl ammation or warmth, and presence and severity of edema. Pressure ulcers are staged, not stasis dermatitis. If varicose veins are a common cause leading to stasis dermatitis, then the legs should be raised rather than placed in a dependent position.
An adult client is being admitted to the hospital for a cardiac catheterization related to chest pain and shortness of breath on exertion. What kind of assessment is the admitting nurse going to perform?
Emergency Explanation: The emergency assessment involves a life-threatening or unstable situation, such as a client in an emergency department (ED) who has experienced trauma. Focused and comprehensive assessments are not used in a life-threatening situation. The cardiac catheterization alone will not be sufficient.
A nurse inspects the external genitalia of a newborn girl who was born by breech vaginal delivery. Which of the following findings should be a cause of concern?
Enlarged clitoris and fusion of the posterior labia majora Explanation: The labia majora and minora should be pink and moist. The newborn's genitalia may appear prominent because of influence of maternal hormones. Bruises and swelling may be caused by breech vaginal delivery. Pseudomenstruation (blood-tinged discharge) and smegma (cheesy, white discharge) of the sebaceous gland are also normal findings. However, an enlarged clitoris in a newborn combined with fusion of the posterior labia majora suggests ambiguous genitalia.
Which action by the nurse demonstrates the correct technique of assessing for arm recoil?
Flex the elbows up bilaterally Explanation: Flexing the elbows up bilaterally is done to test arm recoil. Flexing the thigh on top of the abdomen is used to test the popliteal angle. To assess for the square window sign, the nurse should bend the newborn's wrist towards the ventral forearm until resistance is met and the angle is measured. Lifting the arm across the chest towards the opposite shoulder until resistance is met is done to elicit the Scarf sign.
An assessment that concentrates on patterns of role performance that all humans share is called what?
Functional Explanation: A functional assessment focuses on the functional patterns that all humans share: health perception and health management, activity and exercise, nutrition and metabolism, elimination, sleep and rest, cognition and perception, self-perception and self-concept, roles and relationships, coping and stress tolerance, sexuality and reproduction, and values and beliefs.
The nursing instructor is teaching about health assessment and explains to students how to assess the roles and relationships of the client. The students know that this type of information is assessed in what type of assessment?
Functional Explanation: A functional assessment focuses on the patterns that all humans share: health perception and health management, activity and exercise, nutrition and metabolism, elimination, sleep and rest, cognition and perception, self-perception and self-concept, roles and relationships, coping and stress tolerance, sexuality and reproduction, and values and beliefs (Gordon, 1987). Therefore, options A and B are incorrect. The body systems and head to toe assessment does not address the holistic needs of the client. The roles and relationships of the client would not be included in these two types of assessment Option D is a distracter for this question.
A nurse performs, measures, and documents the findings of the initial newborn assessment. Which data should the nurse recognize as an abnormal finding in the newborn?
Head circumference is 30 cm Explanation: A head circumference of 30 cm in a newborn is an abnormal finding. The normal head circumference is 33 to 35.5 cm. The newborn usually weighs between 2500 to 4000 g. The normal length of the newborn is 44 to 55 cm and the chest circumference is 30 to 33 cm.
Which of the following statements best conveys the rationale for health promotion in a school setting?
Healthy child development is a critical health determinant because of its implications for lifelong health. Explanation: The future implications of healthy child development coupled with the fact that children spend much time at school mean that schools are crucial settings for health promotion.
The mother of a 9-month-old girl calls the clinic. She tells the nurse that her daughter has developed a rash. The nurse asks a series of questions to assess the rash. Why would it be important for the nurse to ask these questions?
Helps pinpoint possible causes Explanation: These questions help pinpoint possible causes. Many skin conditions have predictable patterns of spread, parts of the body affected, and associated symptoms, such as pruritis (itching). It is important to differentiate if the symptoms are localized versus systemic or if there might be an infectious versus an allergic origin. Therefore, options A, B, and C are incorrect, and distracters for the question.
A new mother wants to give her baby honey. The nurse tells her that it is potentially dangerous to do this. Why is this practice potentially dangerous?
Honey is a known reservoir for the botulism bacterium Explanation: Honey should not be given to infants. It is a known reservoir for the bacterium that causes botulism. The spores that the bacteria produce make a toxin that can cause infant botulism, a serious form of food poisoning. The toxin affects the infant's neurologic system and can lead to death. There is no high rate of honey allergies in infants; the baby can digest honey, and honey is not too thick for the baby to swallow.
A few nursing students revealed to a faculty advisor that they were concerned about the effects of their program demands on their personal health practices. Follow-up with other students indicated that this was a common concern among the student group. Further assessment showed that the students expressed their belief in the importance of maintaining good health practices, but that most students had discontinued weekday efforts because of their focus on school-related stress and limited economic resources. Faculty members supported the concept of integrated health programs and were prepared to develop a program as a project. To assess the need for health promotion among the group of students, which of the following assessment methods would be most useful?
Individual student interview and questionnaire Explanation: Key to any health promotion activity is a thorough assessment of the context and particular needs of the participants. This could be best determined by asking the students what would be more effective than a physical assessment, literature review, tour of the facility, or questionnaire of the faculty members.
An elderly client presents to the emergency department with reports of a productive cough of blood tinged sputum, fatigue, weight loss, and shortness of breath. The nurse recognizes that these are symptoms associated with which respiratory disease process?
Lung cancer Explanation: A recurrent cough, fatigue, weight loss, and shortness of breath are hallmarks of lung cancer, the most common cause of cancer associated deaths in the United States. COPD clients do not usually have a blood tinged cough. Hallmark symptoms of TB include weight loss and night sweats. Pneumonia in the elderly often does not manifest with the normally associated symptoms but rather with fatigue or other vague symptoms.
A nurse recognizes that a thorough and accurate assessment of a client is important to prevent what error from occurring when utilizing the nursing process?
Making incorrect nursing judgments or diagnoses Explanation: Assessment is the first and most critical phase of the nursing process. If data collection is inadequate or inaccurate incorrect nursing judgments may be made that adversely affect the remaining phases of the nursing process. Injection of the nurse's thoughts or feeling may lead to bias or the withholding of information. Nursing judgments should rely on both objective and subjective information. Validating information that is correct makes more work for the nurse but will not lead to inaccurate judgments.
A nurse assesses a newborn of African American descent and observes a bluish-pigmented area on the sacrum. The nurse recognizes this as what type of skin variation?
Mongolian spot Explanation: A bluish coloration of the skin on the sacral area is called a Mongolian spot and is common in infants of Asian, African American, Native American, and Mexican American descent. Erythema toxicum consists of tiny bumps that are firm, yellowish, or white, and surrounded by a ring of redness. The rash usually appears on the baby's face, chest, arms, and legs. Telangiectatic nevi are flat, red birthmarks, often called port wine stains. Trauma from delivery can be seen anywhere and manifest as any type of abnormality.
The nurse is doing a shift assessment on an older adult client with diabetes who has had a 2 pack/day smoking habit for 22 years. The nurse cannot palpate a dorsalis pedis pulse even with a Doppler. When reviewing previous assessment findings, they show that pulses were weakly palpable. What would be the first nursing action?
Notify the primary provider Explanation: Absent peripheral pulses are of great concern and should be noted in the record. The primary provider should be contacted if this finding is new. It is more common in a person with a long history of smoking or who has diabetes; it can seriously interfere with wound healing. The nurse would not delay to reevaluate the pulse in either 15 or 30 minutes. Asking the client how the extremity feels is appropriate but does not take precedence over notifying the primary provider.
A community health nurse is planning individualized care for a community. What does the nurse use as a framework for this plan?
Nursing process Explanation: The nursing process serves as a framework for providing individualized care not only to individuals but also to families and communities.
A nurse cares for a client with lung cancer who presents with rust colored sputum and a fever. The nurse performs frequent auscultation of the lungs sounds to determine any changes from the baseline. What type of assessment is the nurse performing?
Partial Explanation: Ongoing or partial assessments consist of obtaining data to follow up a previously diagnosed problem that may be changing from the baseline. An emergency assessment is a very rapid assessment performed in life threatening situations such as drowning, choking, or cardiac arrest. It is also used when an immediate diagnosis is needed to provide prompt treatment. These situations are those in which a person's airway, breathing, or circulation is compromised. A focused assessment gathers information specific to the problem and does not cover any other areas. Comprehensive is not necessary at this time because the client already has a documented problem.
The mother of a newborn has struggled to effectively breastfeed her daughter. The mother has received instruction from a lactation specialist on proper breastfeeding techniques, but the baby will not latch on. She has decided to bottle feed the baby at least for now. Also, when assessing the infant's musculoskeletal system, the nurse found unequal gluteal folds and limited hip abduction. Which of the following should be the priority nursing conclusion?
RC: Hip displacement Explanation: The priority conclusion is that the infant is at risk for complications related to hip displacement, as the findings of unequal gluteal folds and limited hip abduction indicate. The problem related to breastfeeding does not appear to be an issue of knowledge deficit, as the mother has received proper instruction. Also, risk for ineffective breastfeeding would be an inaccurate diagnosis, as ineffective breastfeeding has already occurred. Because the baby has switched to bottle feeding, however, and because there are no other adverse indications related to the child's weight gain or nutritional status, there is no failure to thrive or risk of complications thereof.
Which finding in a 6-month-old infant should a nurse recognize a needing further assessment?
Reflexively grasp an object Explanation: A 6 month old infant should be able to hold an object voluntarily. The grasp reflex is a primitive reflex and disappears by 3 months of age. A 6-month-old infant should be able to roll form front to back, babble spontaneously, and sit with support. Sitting unsupported occurs around 6 or 7 months of age.
A nurse observes a newborn's feet and notices that the right foot is positioned outward. What should the nurse do to further assess this finding?
Scratch along the lateral edge of the foot Explanation: A newborn's feet may retain their intrauterine position after birth and appear deformed. The nurse should scratch along the lateral edge of the affected foot to assess if the foot returns to its normal position. A neurovascular assessment should be performed if the newborn endured a traumatic delivery. A talipes varus is when the forefoot is adducted and the entire foot is inverted and this position is fixed. Unequal gluteal folds are seen with congenital hip dysplasia.
The nurse is conducting a physical assessment. The data the nurse would collect vary depending on what?
The client's acuity Explanation: Data that nurses collect during a physical assessment vary depending on a client's acuity, health history, and current symptoms. The data collected during a physical assessment do not depend on how much time the nurse has, how cooperative the client is, or the onset of the current symptoms.
While assessing a 6-week-old infant new to the clinic, the nurse notices that the infant's ears fall below the imaginary line that runs from the inner canthus of the eye to the outer canthus and ear. What might indicate to the nurse that this finding is a normal variant in this case?
The mother has low-set ears Explanation: It may be helpful to note if either parent has low-set ears. If so, then the low-set ears may be an inherited normal variant. Options B, C, and D are incorrect.
A nurse is trying to decide whether to recommend that a pregnant client be screened for HIV. Which of the following resources would best help in this decision?
U.S. Preventive Services Task Force Explanation: The U.S. Preventive Services Task Force (USPSTF) determines risk versus benefit in screenings. The Health Belief Model is based on three concepts: the existence of sufficient motivation; the belief that one is susceptible or vulnerable to a serious problem; and the belief that change following a health recommendation would be beneficial to the individual at a level of acceptable cost. The Pender Health Promotion Model proposes that individual characteristics and experiences affect behavior-specific cognitions and affect, which in turn yield the level of commitment to a plan. Healthy People 2020 is a model developed by the U.S. Department of Health and Human Services that focuses on increasing the life span and improving the quality of health for Americans.
An elderly client reports pain in the leg which is not associated with any particular activity but is lessened when the leg is elevated. The nurse recognizes that the client may have which vascular condition?
Venous insufficiency Explanation: Pain unrelated to activity indicates venous insufficiency in the client. Partial obstructed blood flow causes ulcers and increases risk of infection. Arterial insufficiency may cause insufficient or absent peripheral pulses and pain known as claudication with activity. Complete obstructed blood flow manifests itself initially as acute pain, numbness, and coolness, also known as gangrene, which leads to amputation.
A nurse assesses a newborn and finds a white, cheesy substance on the infant's skin, especially within the folds of the skin. How should the nurse document this finding?
Vernix caseosa Explanation: The white, cheesy substance seen on the skin of the infant, especially in the folds of the skin, is vernix caseosa, which is normal in the newborn. Ecchymosis is bruising of the skin. Lanugo is the fine, downy hair that disappears after 2 weeks of life. Erythema toxicum is the rash seen in the first few days after the birth.
To arrive at a nursing diagnosis or a collaborative problem, the nurse goes through the steps of analysis of data. After proposing possible nursing diagnoses, the nurse should next
check for the presence of defining characteristics. Explanation: To arrive at nursing diagnoses, collaborative problems, or referral, you must go through the steps of data analysis. This process requires diagnostic reasoning skills, often called critical thinking. The process can be divided into seven major steps: 1. Identify abnormal data and strengths. 2. Cluster the data. 3. Draw inferences and identify problems. 4. Propose possible nursing diagnoses. 5. Check for defining characteristics of those diagnoses. 6. Confirm or rule out nursing diagnoses. 7. Document conclusions.
An assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a(n)
focused or problem-oriented assessment. Explanation: A focused or problem-oriented assessment does not replace the comprehensive health assessment. It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern. A focused assessment consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem.
A nurse is assessing a 9-month-old and finds that the infant's sucking reflex is still intact. At what age does this reflex normally disappear?
10 to 12 months
Which assessment finding should the nurse document as objective data?
Body functions Explanation: Subjective data is what the client tells the nurse. Objective data is what the nurse assesses or observes when performing care of a client.
The nurse practitioner is using an otoscope to assess the ears of a 1-year-old. What would it be important for the nurse practitioner to do?
Brace the hand holding the otoscope against the infant's face Explanation: The nurse always braces the hand holding the otoscope against the infant's face, so that if the infant moves, the otoscope moves with him or her to avoid injuring the tympanic membrane. Option A is for assessing the ears of an adult. Options C and D are incorrect—the parent would hold the infant's head while the infant sits on the parent's lap.
Parents bring a 4-month-old to the clinic for a checkup. The mother tells the nurse that the infant is exclusively breast-fed. The nurse should assess the infant's need for which of the following?
Iron supplements Explanation: The AAP recommends that iron-fortified formulas be used for infants. These formulas are considered acceptable nutrition substitutes when breastfeeding is not chosen or not possible.
As a nurse becomes more proficient and comfortable in his or her role, what increases?
Knowledge base and expertise Explanation: As the nurse becomes more proficient and comfortable in his or her role, the accountability does not decrease, but the knowledge base and expertise increase to foster confidence.
A nurse should assist an elderly client to assume which position to facilitate the examination of the anus and rectum?
Left side-lying Explanation: The anus and rectum should be assessed with the client in left side-lying position for better accessibility and comfort. The lithotomy position is used for assessment of female genitalia. The standing position is used for assessment of male genitalia. The prone position does not give access to anus and rectum.
To enhance personal health practices, the most fundamental and effective approach to individual client assessment would be:
Using reputable health-education strategies to reduce risk behaviors Explanation: A central component of health promotion involves helping clients to develop personal health practices and to enhance coping skills, which are results of health education that emphasizes client knowledge for directing choices and actions. While the other given factors may hold significance for many individuals, they are not as salient as health education.
The Moro reflex is
a response to sudden stimulation or an abrupt change in position.
The nurse is assessing a newborn with the mother present. When the nurse observes an irregularly shaped red patch on the back of the newborn's neck, the nurse should explain to the mother that this is termed
stork bite.