Custom: NUR 204 ATI Health Promotion Ch. 16-31

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

Explain to the client what is about to happen

A nurse is reviewing the medical records of four older adult clients. The nurse should plan to administer the herpes zoster vaccine to which of the following?

A client who takes omeprazole for peptic ulcer disease

A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

"I watch television until I fall asleep"

A nurse is conducting a health promotion class for clients and their children about sun protection. The nurse should identify which of the following client responses as an indication that the teaching was effective?

"I will avoid sitting in the sun between 10 a.m. and 3 p.m

A nurse in a clinic teaching a group of clients about preventing low back pain and injury. Which of the following statements should the nurse identify as an indication that the client requires further clarification?

"I'll sit with my knees lower than my hips"

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

"What brought you to the hospital?"

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? (SATA)

- Excessive laxative use - Ignoring the urge to defecate - Inadequate fluid intake

A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion? (SATA)

- More difficulty seeing due to a greater sensitivity to glare - Decrease cough reflex -Decreased bladder capacity -Dehydration of intervertebral discs

A nurse is teaching a group of older adults about health tests and screenings. Which of the following information should the nurse include? (SATA)

-"You should have a single dose of the shingles vaccine at age 60" -"You should have a the pneumococcal vaccine at age 65 and then every 10" -"You should have visual acuity screening every year"

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

A systolic murmur

A nurse is teaching an adult client who has a low literacy level about self-administration of a subcutaneous medication. Which of the following strategies should the nurse use to promote the client's understanding?

Ask the client to demonstrate the skill

A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve II?

Ask the client to read a Snellen chart

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

Assess the apical pulse for a full minute

A nurse is preparing to teach a client who has a low literacy level. Which of the following methods should the nurse plan to include?

Have short teaching sessions

A nurse in an outpatient clinic is assessing a middle adult client as part of a routine physical examination. The client's BP is 142/88mmHg, his body mass index (BMI) is 31, and he is a current smoker. The nurse should identify that this client has multiple risk factors for which of the following disorders?

Cardiovascular disease

A nurse is assisting with the admission of a client to an inpatient unit. Which of the following sources of information should the nurse rely on for accurate information about the client?

Client concerns

The family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling. Which of the following factors should the nurse identify as a likely explanation for the client's behavior?

Confusion

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Conjunctivae

A nurse is caring for a client in the emergency department who, 2 hr earlier, severed the tip of a finger in an accident. During the assessment, the nurse detects a strong smell of alcohol from the client's breath. For which of the following findings should the nurse assess first?

Date of the client's last tetanus immunization

A nurse is preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following changes should the nurse plan to include?

Decreased muscle mass

A nurse is developing a teaching plan for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following actions should the nurse plan to take first?

Determine what the client knows about managing diabetes

A nurse is completing a client assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse?

Ecchymosis

A nurse is presenting information to the public about preventative measures to reduce the risk for contracting West Nile virus. Which of the following instructions should the nurse include?

Encourage the use of mosquito repellent

A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. To focus on effective learning with this client, which of the following interventions should the nurse use?

Explore the client's feelings about dietary modifications

A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. Which of the following of Erikson's developmental stages should the nurse consider in the planning?

Industry vs. Inferiority

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

Inspect

A nurse is instructing the clients in the community about relationship development. The nurse should explain that, according to Erikson, establishing relationships with commitment is a primary task of which of the following stages of psychosocial development?

Intimacy vs. Isolation

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

Kyphosis

A nurse is obtaining a medical history from a client who is requesting the herpes zoster (HZV) vaccine. The nurse should identify which of the following findings as a contraindication for receiving this vaccine.

Long-term use of prednisone for COPD

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?

Nausea

A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?

Pain

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

Palpates the abdomen prior to performing auscultation

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

Performing monthly breast self-examinations

A nurse working in a community health center is preparing a flow sheet detailing essential screenings according to age group. At which developmental level stage on the chart should the nurse add scoliosis screening?

Pre-adolescent/Adolescent

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

Prior to percussing the abdomen

A nurse is caring for a client who has contact dermatitis of the neck and upper chest. Which of the following is an expected finding?

Report of exposure to a skin irritant

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

The left second intercostal space

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

Third square from the top

A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse

Third square on the right

A nurse is providing discharge teaching about intermittent self-catheterization for a client who has benign prostatic hyperplasia. Which of the following instructions should the nurse include?

Use soap and water to wash the catheter after each use

A nurse is assessing an older adult client who is sedentary plan a new exercise regimen. Which of the following activities should the nurse recommend?

Walking

A nurse is talking with a client who is beginning a program of moderate exercise. The client asks the nurse why warm-up exercises are necessary. Which of the following responses should the nurse make?

Warm-up exercises reduce the risk of injury