EAQ practice questions

Which client is exhibiting Biot's respiration?

Abnormally shallow for two breaths followed by apnea

What patient is most at risk for developing breast cancer?

Age 60, family history, no children, age of onset of menopause 50 (later age)

What infant has an abnormal weight

Age: 5 months weight at birth: 3.3kg current weight: 8.5kg Average weight of newborn: 3.2-3.4kg infant doubles weight by 4-5 months infant triples weight around 1 year

When assessing the muscle functionality of a client, the nurse assigns an F (fair) grade in the Lovett scale. What described the functionality of the patient?

Full range of motion with gravity

While performing a neck assessment, the nurse finds the client has enlarged lymph nodes, a history of intravenous drug use, and bisexual activity. what diagnosis is suspected?

HIV

what statements indicate effective learning on body mass index?

I should lose at least half a pound to a pound each week I'll make sure to eat foods meeting my daily nutritional requirement I should stay away from unhealthy foods between meals and after dinner

what statements indicate effective learnings about measures to promote health?

I will assess my own pulse after exercising I will follow my hypertension treatment plan consistently I will perform a self assessment of my heart rate using the carotid pulse

Which statements indicate an understanding of teaching about head lice?

I will clean my comb in ammonia water I should use a dilute vinegar solution to loosen the nits I should use a shampoo treatment once every 24hrs

After teaching a male client about sexual health and STI's what demonstrates effective learning?

I will consult my primary care provided when there is a rash or ulcer on my genitalia

What statement indicates need for further teaching on breast health?

I will increase my daily meat consumption should be reduced, can lead to obesity, risk factor for breast cancer

what is the correct order of abdominal assessment?

I will inspect the surface motion of the abdomen I will note the position of the umbilicus I will assess for bowel mobility by auscultation I will palpate to assess for any abdominal tenderness

What statements demonstrate effective learning about precautions taken for a physical exam?

I would examine the client in noise free areas I would wear eye shields while examining a client with excessive drainage

Which client is suspected of having hypertension?

Increased cardiac output, increased peripheral resistance, increased hematocrit

Which assessment indicate Cheyne-Stokes respiration?

Irregular, alternating apnea and hyperventilation

what statements indicate a risk of breast cancer?

My first child was born when I was 32 I noticed a slight discharge from a nipple I consume 2-4 glasses of alcohol a day Early onset of menarche

when assessing an older client as they walk into exam room, what finding is abnormal

The client is wearing an excessive amount of cologne may indicate alteration in self-perception

A diminished barely palpable pulse strenght

1+

The sequence of events occurring during a fever in order include:

1. Immune system response is triggered 2. The set point of the hypothalamus is raised 3. Body temperature is increased 4. Pyrogens are destroyed 5. Heat loss responses are initiated

which client is suffering from remittent fever?

103, 101, 104, 102 when body temp spikes and falls, without return to normal temp

If the bp of patient is 140/90 and the cuff is too wide. what is the reading

130/80 mmHg results in false low readings

If the bp of patient is 140/90 and you deflated the cuff too slowly. what is the reading

140/100 mmHg results in false high diastolic

If the bp of patient is 140/90 and the cuff is too narrow or too short or wrapped loosely or unevenly. what is the reading

150/100 mmHg results in high false readings

If the bp of patient is 140/90 and you deflated the cuff too rapidly. what is the reading

150/100 mmHg will result in false low systolic and false high diastolic

What respiratory rate is expected for a 2 year old child?

30 breaths/min

Which rectal temperature would the nurse anticipate for a client reporting chills and has a fever?

38.5C (101.3 F) normal temp for older adults orally" 36-36.6C normal temp for older adults rectal: 36.6-37.2C

normal respiratory rate in newborns

40 breaths/min

what patient is at high risk for a rise in blood pressure

40 yr old client, 40 bpm, increased stroke volume when heart rate is decreased and stroke volume increased the bp rises

normal respiratory rate in infants

50 breaths/min

What temperatures indicate moderate hypothermia?

88F (31.1C) 92F (33.3C)

What is true about falls risk assessments?

We will assess every admission to the unit We will implement a valid falls risk assessment tool We will apply yellow wrist bands to high risk clients We will update the admission fall assessment routinely through discharge

When do you provide a mask to a client?

a moist productive cough

Rhonchi breath sounds

abnormal breath sounds heard over large airways of the lungs low pitch caused by movement of secretions, usually clear with coughing

which finding would necessitate holding the feedings and meds via gastronomy tube and notifying the health care provider?

absence of bowel sounds presence of abdominal distencion residual capacity exceeding 300mL positive guaiac test of abdominal contents seepage of feeding around tracheostomy

What are psychologic symptoms of sleep deprivation?

agitation and hyperactivity confusion and disorientation increased sensitivity to pain

Which priority assessment would be included when providing care for a client who is experiencing depression?

appetite, activity and emotional status

When assessing a client reporting shortness of breath, what activity best ensures that the nurse obtains accurate and complete data to prevent a diagnostic error

assess the client's lungs

What condition is the result of changes in the integrity of arterial walls and small blood vessels

atherosclerosis

What drug causes pupillary dilation?

atropine

Where do you assess the turgor of an older adult?

back of the forearm on the sternal area

For which assessment situation would the nurse use an alcohol based hand sanitizer for hand hygiene?

before and after palpating a pulse appropriate for when hands are not visibly soiled

When assessing a patient for malnutrition, the nurse would monitor for an increase of liver enzymes and a decrease in which water soluble vitamins?

biotin. niacin, folic acid, riboflavin, vitamin C

what physical assessment of the skin indicates a client is deals with alcohol abuse?

burns on the skin

The white patchy plaques on the mucosa of a patient's oral cavity represents which infection?

candida albicans

What factor elevates a patient's oxygen saturation?

carbon monoxide

A patient is unconscious experiencing severe bleeding due to a motor vehicle accident and in hypovolemic shock. Which site do you obtain the pulse rate?

carotid and femoral

what pulses do you check if a patient is in physiologic shock?

carotid or femoral pulse

Which finidng is an early sign of dehydration for an older adult>

change in mental status

What order do you do a lesion assessment

collect information about the color, size, shape, type, grouping, distribution observe for any odor, amount, consistency measure the size of the lesion in cm using a ruler measure each lesion for height, width, depth

what patient is at risk for heart disease

color assessed: bluish location: nail beds, lips, mouth, skin

Which clinical indicator would the nurse expect a client with hyperkalemia to exhibit?

confusion, weakness, dysarrthymias

what site do you assess for pallor?

conjuctiva

What assessment requires additional evaluation for a client with a closed chest tube drainage system connected to suction?

constant bubbling in the water seal chamber indicative of an air leak

Which condition would be suspected when a client who underwent a physical exam two days ago reports itching?

contact dermatitis

Auscultation of soft, crackling bubbling breath sounds more obvious in respiration?

crackles

When assessing a client, the child is unable to focus on an object with both eyes simultaneously. what findings conform strabismus diagnosis>

crossed appearance of eyes impaired extraocular muscles

when assessing a client with diabetes the nurse finds the hands and feet are dry due to infection. what is the rationale for the dryness

cutting nails after soaking them for 10 minutes in warm water should not be performed on diabetic clients

false high diastolic reading

deflating cuff too slowly

what physical assessment of the skin is associated with chronic abuse of sedative hypnotics?

diaphoresis

What factors would be assessed for a client reporting constipation?

diet. fluid intake, date of last bowel movement, use of laxatives, use of opioid pain medications

Which type of interview would the nurse utilize when admitting a client to a clinic?

directive

when the nurse completes a thorough assessment to identify the reason for a client's anxiety. what critical thinking attitude is involved?

discipline

What position is used for abdominal assessment?

dorsal recumbent position (lying on your back, knees up)

lordosis

excessive inward curvature of the lumbar part of the spine

Which finding would prompt the use of a protective gown?

excessive wound drainage

When assessing a 17 yr old client. Which findings alerts the nurse to explore substance abuse with the adolescent?

failing grades blood spots on clothing absenteeism from school long sleeved shirts in warm weather

when assessing a patient blood pressure, obtained with an unsupported left arm, what reading error is expected?

false high reading

When assessing a client with hepatitis A, with which substance does the nurse need to be careful to prevent transmission of the disease?

fecal matter

A patient with chest pain, shortness of breath, weakness, and vomiting is admitted. the nurse suspects acute coronary syndrome (ACS). At which site would the nurse check the pulse rate?

femoral

which pulse do you assess for peripheral artery disease?

femoral

What part of the patient's body would be assessed to conform a diagnosis of frostbite?

fingers and ear lobes

To prevent an adverse outcome while providing care for a client experiencing diarrhea, which data would be closely monitored?

fluid and electrolyte balance

The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia?

flushed face increased pulse rate

A strength of a pulse of 3+ refers to

full

When the defining characteristics of a patient's assessment data apply to more than one diagnosis, which action would the nurse take?

gather more information identify related factors review all defining characteristics

What is true about s3 sounds?

heard in clients with heart failure abnormal in adults over 31 years of age normal in children and young adults common and normal in last stages of pregnancy (NOT ALL STAGES)

Cardiac output equation

heart rate x stroke volume

An older adult with a history of giddiness, excessive thirst, and nausea. During the assessment the temperature is 105F(40.6C) orally. what condition is suspected?

heat stroke

Which condition is the nurse trying to prevent when teaching a patient undergoing diuretic therapy to avoid working in the garden on hot summer days?

heatstroke

What drug causes pupillary constriction?

heroin, morphine, pilocarpine

what is a priority in a care plan when caring for a dying patient?

hygiene and comfort

What physical change would the nurse observe in a client with malnutrition

hypotension, dry dull hair, abdominal edema, delayed wound healing, and depletion of muscle mass

Which breathing pattern would a client experiencing hypercarbia exhibit?

hypoventilation

for which clinical indicator would the nurse question a prescription for gastric lavage?

increased serum bicarbonate level

What condition is suspected when a client's respiratory rate increases and the respirations are abnormally deep and regular?

kassmaul's respiration

what term refers to concavely curved nails?

koilonychia

What refers to the exaggerated posterior curvature of a client's thoracic spine?

kyphosis

What position is used for murmur assessment?

lateral recumbent position (lying on the side)

What site do you assess to confirm cyanosis?

lips (and nail beds)

What clinical indicator is most commonly used to determine whether the client has a fluid deficit when reporting vomiting and diarreha for days?

loss of body weight

Osteoporosis

loss of bone mass and deterioration of bone tissues

What actions do you take when a patient is receiving total parenteral nutrition (TPN)

monitor for hydration monitor for weight daily monitor vital signs every 4 hrs discard any solution after 24 hrs check the expiration data of the solution before administration

what findings is associated with hypokalemia?

muscle weakness

bronchial breath sounds

normal, full inspiration and expiration, with expiration being louder

vesicular breath sounds

normal, quiet, soft and inspiration sounds that are short and almost silent on expiration

what client would the nurse anticipate needing a referral to a support group for people with vision loss?

obstruction of central vision may indicate macular degeneration causing permanent blindness

Which client would be treated last?

older adult male with a laceration to the danger

for which age group would there be the occurrence of chronic illness to be highest?

older adults

What food is recommended to increase potassium intake?

oranges

what term refers to inflammation of the skin at the base of the nail?

paronychia

After pelvic surgery the majority of pulmonary emboli begin as deep vein thrombosis in which area

pelvis and thighs

Maslow hierarchy of human needs

physiological, safety, love, esteem, self-actualization

the RN measure the BP as 130/80 mmHg. when the UAP measured it the BP was 120/90. What explains the difference?

poor fitting of the cuff deflating the cuff too quickly Causes false low systolic & false high diastolic

A client who relocated to a new city is unable to continue the practice of exercising. What stage of the transtheoretical model is the patient experiencing?

pre contemplation

Stages of Health Behavior change within the transtheoretical model of change

precontemplation, contemplation, preparation, action, maintenance stage

when interpreting findings from a pain assessment, which factors would the nurse consider the most significant influences on a client's perception of pain?

previous experience and cultural values

What position is used to assess hip joint extension and buttocks

prone position (lying on your front)

What physiologic symptoms are associated with sleep deprivation?

ptosis and blurred vision decreased auditory alertness

what physical assessment of the skin indicates a client is addicted to phencyclidine?

red and dry skin

bradypnea

regular and abnormally slow

Tachypnea

regular but abnormally rapid

false high systolic

repeating assessments too quickly

A patient diagnosed with COPD. Which vital signs indicate a positive outcome?

respiratory rate, blood pressure, oxygen saturation

What site do you assess to confirm jaundice?

sclera and mucus membrane

Which sites would be safer and less expensive for temperature measurement of a human?

skin and axilla

What finidings are expected to the aging process of an older adult male?

slowed neurological responses forgetfulness about recent events reduced ability to maintain an erection

when asked about spanking as a disciplinary technique. what response would you use?

spanking is strongly suggestive of negative role behavior

What location would the nurse take when performing a romberg test on a client?

standing to the side of the client

false low diastolic reading

stethoscope applied too firmly

What equipment piece would the nurse make sure was sterile while providing care?

suction catheter

What position is used for heart, abdomen, extremities, and pulses assessment?

supine position (lying on your back)

What questions o you ask when obtaining a health history?

tell me about your food habits do you use alcohol or tobacco have you ever experienced any allergic reactions

what is correct when assessing body temperature

the axilla is recommended to measure body temp in unconscious clients the tympanic membrane is a preferred site of measuring body temperature in infants the temporal artery is a preferred site to measure rapid changes in core temperature.

what diagnosis made by the nurse is helpful in providing the right nursing interventions for the client?

the nurse identifies the client is not aware of perineal care and has impaired skin integrity

why would the nurse ask the student to check the apical pulse after assessing the radial pulse?

the patient may have a dysrhythmia

What does a remittent fever pattern look like?

the patient's fever spikes and falls without return to normal temperature levels

If a patient has a 7mm indurated area at the injection site of tb. what is the result

the result indicated you are infected with the tuberculosis organism

Why do you assess the brachial pulse?

to evaluate blood pressure

Why do you assess the radial pulse?

to evaluate heart rate

what pulse site is used to perform the allen test

ulnar or radial

What body systems do you assess in the left lateral recumbent position for women?

vagina and rectum

what physical assessment of the skin is associated with cocaine abuse?

vasculitis

What action would prevent aspiration when administering medications through a nasogastric tube?

verify placement of the nasogastric tube

When auscultating high pitched, creaking, accentuated breath sounds on expiration, what is the term?

wheezes

When should you use gloves?

An open sore or abrasions on the skin

What action would increase the effectiveness of the teaching session about self injection insulin?

Assess the client's barriers to learning self injection techniques

An adolescent taken to the ED after stepping on a nail. The nurse asks if the patient has had a tetanus immunization. They respond that all immunizations are up to date. A few days later the patient is admitted with a diagnosis of tetanus. What is the nurse's responsibility in this situation?

Assessment by the nurse was incomplete and as a result the treatment was insufficient

What patient has the lowest neurological function?

Opens eyes on pain, flaccid motor response, incomprehensible sounds

Which pain assessment data would the nurse include when obtaining a health history from a newly admitted client who has chronic pain?

Pain history, including location, intensity, and quality of pain Pain pattern, including precipitating and alleviating factors

What is an initial sign of hypocalcemia?

Parenthesias

what is an involuntary physiologic response that the nurse would use to monitor development in a client experiencing pain>

Perspiring

Which assessment item needs to be documented on a client with restraints?

Pulse near restrained area Temperature of the restrained area Skin integrity surrounding the restraint Behavior leading to the need for restraint

Why do you assess the ulnar pulse?

To evaluate arterial insufficiency

While assessing a client's skin the nurse notices it is dry. what is the probable cause?

Use of hard soap Frequent bathing