Exam 1 Review practice questions (2,3,6,8,9,13) (PrepU/NCLEX style)

A female client is admitted to the health care facility due to reports of decreased appetite, loss of sleep, feelings of being unsafe in her own home, and inability to concentrate. She appears pale; her hair is disheveled, she is not wearing makeup, and she will not make eye contact. Based on this data, which nursing diagnosis can the nurse confirm? (prepu, 8) A. Anxiety B. Imbalanced nutrition: less than body requirements C. Impaired verbal communication D. Risk for self-directed violence

A Rationale: The major defining characteristics of anxiety are present: loss of sleep, feeling unsafe, inability to concentrate, and poor eye contact. There are no major characteristics for the nursing diagnosis of imbalanced nutrition: less than body requirements, risk for self-directed violence, or impaired verbal communication.

A nurse takes the vital signs on a new 35-year-old client: temperature 98.5° F (36.94° C), pulse 87 beats/min and regular, blood pressure 125/77 mm Hg on the right arm and 120/75 mm Hg on the left arm, and respiratory rate 16 breaths/min. What action should the nurse take? (prepu, 8) A. Document normal findings. B. Allow client to rest and then recheck the vital signs. C. Report abnormal blood pressures to health care provider. D. Assess apical pulse for 1 full minute.

A Rationale: The nurse's findings are normal. There is no need to contact the health care provider, even for the difference in blood pressure between the two arms; a blood pressure 10 mm Hg difference in arms is considered normal. Because the pulse is regular and within normal limits, there is no need to assess the apical pulse for 1 minute. There is no indication that the vital signs need to be rechecked.

During the health-history interview, which of the following components of cognitive function can the nurse quickly assess? (prepu. 6) A. Memory and attention B. Abstract thinking and perceptions C.Judgment and behavior D. Calculation and language

A Rationale: While gathering the health history, it is possible to quickly discern the client's level of alertness and orientation, mood, attention, and memory. As the history unfolds, the nurse will learn about the client's insight and judgment and any recurring or unusual thoughts or perceptions. Calculation, behavior, and abstract thinking are less likely to emerge during this phase of assessment.

Which would the nurse recognize as an example of visceral pain? Select all that apply. (prepu, 9) A. Liver pain B. Gallbladder pain C. Muscular pain D. Burn pain E. Pancreatic pain

A, B, E Explanation: Examples of visceral pain include pain associated with the liver, gallbladder, and pancreas. Pain associated with a burn is an example of cutaneous pain. Muscular pain is a type of somatic pain.

Prior to inflating the cuff to measure the client's blood pressure, the nurse has palpated the radial artery, inflated the cuff, and noted the point at which the radial pulse disappears. What is the rationale for the nurse's action? (prepu, 8) A. It confirms proper cuff size and suggests the correct rate for cuff inflation. B. It facilitates easier auscultation of the Korotkoff sounds. C. It aids the detection of arterial obstruction and aortic regurgitation. D. It prevents client discomfort and an auscultatory gap.

D Rationale: Estimating systolic pressure by palpation allows the nurse to gauge how high to inflate the cuff, thus preventing overinflation and consequent discomfort, as well as avoiding errors related to an auscultatory gap. It does not confirm proper cuff size, direct the rate of inflation, facilitate auscultation of the Korotkoff's sounds, or detect arterial obstruction or aortic regurgitation.

A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow? (prepu, 8) A. Pressure on the cuff would be painful. B. It will be difficult to pump up the bladder. C. Reading is erroneously low. D. Reading is erroneously high.

D Rationale: The bladder of the cuff should enclose at least two-thirds of the adult limb. If the cuff is too narrow, the reading could be erroneously high because the pressure is not being transmitted evenly to the artery.

A nurse has been assigned a group of clients. Which of the following clients would the nurse determine to be at highest risk for overhydration? Select all that apply. (prepu, 13) A. client with a long history of liver dysfunction B. client with renal dysfunction C. client receiving large volumes of parenteral fluids D. client who runs regularly E. client who consumes 48 oz. of fluid each day

A & B Rationale: A client receiving large volumes of parenteral fluids or who has kidney, liver, or cardiac disease is at risk for fluid overload (overhydration). Clients who drink 48 oz. of fluid each day or run regularly are at risk for dehydration, not overhydration.

An adult client who had a baby 2 weeks ago is brought to the ED because her boyfriend has noticed she has not been herself since they brought the baby home. The clients appearance is unkempt, her hair is a mess, and she appears not to have bathed for several days. What could these finding reflect? (ch. 6) A) Depression B) need for more time to recover from childbirth C) mania D) Poor nutrition

A) depression rationale: Poor hygiene may be from paranoia of water, homelessness, severe depression, or incapacitiation as a result of mental illness. Poor hygiene is not a result of mania, poor nutrition, or needing to recover form childbirth. The other options are distracters to the question

Which question is appropriate for a nurse to ask a client to assess the client's recent memory? (ch. 6) A) What did you eat for breakfast today? B) How are an orange and an apple different? C) When is your birthday? D) Why are you at the health care clinic today?

A) what did you have for breakfast? Exp: when assessing a client recent or short term memory ask the client about things and events that are happening currently. Asking the client what he or she ate for breakfast is testing recent memory. Asking the client their birth date test remote memory. Asking how an orange and an apple are different test a client ability for abstract reasoning. Asking the client the reason for today visit is used to identify the client CC.

A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply. (ch. 13) A. Broth B. Coffee C. Gelatin D. Pudding E. Vegetable juice F. Pureed vegetables

A, B, C Rationale: CLEAR! Liquids. When shining a light through, it is transparent and clear. Black coffee, yes. Coffee with milk, NOT clear!

The nurse is most likely to collect timely, specific information by asking which of the following questions? (Ch.2) A. "Would you describe what you are feeling?" B. "How are you today?" C. "What would you like to talk about?" D. "Where does it hurt?"

A. "Would you describe what you are feeling?" Rationale: This is an open-ended question that will elicit subjective data. The data collected will reflect the client's current health status and human response(s) and should generate specific information that can be used to identify actual and/or potential health problems. Options 2 and 3 are more likely to elicit general, nonspecific information. Option 4 may result in a brief, one-word response or nonverbal gesture indicating the site of the client's pain. A better approach to collect specific information might be, "Describe any pain you are having."

When assessing level of consciousness, what should a nurse do if a client does not respond appropriately to a verbal stimulus? (ch. 6) A. Repeat the command louder and in a lower tone of voice B. Gently shake the client and observe the response C. Vigorously shake the client and speak loudly D. Apply a painful stimulus and observe the client movements

A. Repeat the command louder and in a lower tone of voice rationale: when assessing the level of consciousness, the nurse should begin with the least noxious stimulus which is verbal, and then proceed to tactile , to painful. The client may just need the command to be given louder or in a lower tone of voice

The nurse decides it would be beneficial to the client to allow the client's infant granddaughter to visit before the client's scheduled heart transplant. Before implementing this intervention the nurse should collaborate with which of the following? Select all that apply. (Ch. 2) A. Client and Family B. Other nursing staff on the unit C. Security department D. Hospital administration E. This is not a collaborative intervention so no collaboration will be needed prior to implementation

A. Client and Family B. Other nursing staff on the unit Rationale: Collaboration with the client and family will encourage a sense of autonomy and active involvement in the healthcare process for the client. In this case collaboration with other nursing staff will ensure the successful implementation of the planned intervention. There is no real need for collaboration with hospital administration or the security department in this situation although the nurse should be aware of her responsibility to collaborate at those levels when the situation demands it.

The nurse is caring for a hospitalized client who received pain medication for a pain rating of 8 out of 10 on a scale of 0 to 10 (10 being the worst pain). The nurse determines the pain medication was effective when which of the following is observed? Select all that apply. (prepu, 9) A. Client is ambulating in the hallway. B. There is a slight decrease in the client's moaning and grimacing. C. Client is resting quietly. D. Client rates their pain 7 out of 10. E. Client's respiratory rate is 12.

A. Client is ambulating in the hallway C. Client is resting quietly E. Client's respiratory rate is 12 Explanation: Resting quietly, a respiratory rate of 12, and ambulating in the hallway indicate the pain medication was effective. A pain rating scale of 7 out of 10 and a slight decrease in moaning and grimacing indicate the client is still experiencing pain.

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use? (ch. 3) A.Dorsal B. Fingerpads C. Ulnar surface D. Palmar surface

A. Dorsal surface Explanation: The dorsal (back) surface of the hand is the part most sensitive to temperature and thus is the correct part to use when palpating for temperature. The fingerpads are for fine discriminations, such as for palpating for pulses, texture, size, consistency, shape, and crepitus. The ulnar or palmar surface is used to palpate for vibrations, thrills, and fremitus

The nurse notes that the client often sighs and says in a monotone voice, "I'm never going to get over this." When encouraged to participate in care, the client says, "I don't have the energy." The nurse believes these cues are suggestive of which nursing diagnoses? Select all that apply. (Ch. 2) A. Hopelessness B. Powerlessness C. Interrupted sleep pattern D. Disturbed self esteem E. Self care deficit

A. Hopelessness B. Powerlessness Rationale: Rationale: A nursing diagnosis is a clinical judgment about a response to an actual or potential health problem. This client is manifesting symptoms of both hopelessness and powerlessness. Although the client does report symptoms compatible with fatigue, there is no direct data is given that indicates the client has interrupted sleep patterns (option 3), disturbed self esteem (option 4), or self care deficit (option 5).

During which part of the client interview would it be best for the nurse to ask, "What's the weather forecast for today?" (Ch. 2) A. Introduction B. Body C. Closing D. Orientation

A. Introduction Rationale: Asking about the weather initiates the social or introductory phase of the interview and allows the nurse to begin an assessment of the client's mental status. The goal is to develop rapport with the client at the beginning of the interview. In the body the client responds to the nurse's questions. During the closing the nurse or the client terminates the interview.

A nurse reviews the findings of an admission assessment. The nurse will determine the client meets the criteria of obesity based on which of the following findings? (prepu. 13) A. The client weighs 20% more than ideal body weight (IBW). B. The client has a diagnosis of type 2 diabetes. C. The client is 5% over ideal body weight (IBW). D. The client states they have gained 10 lbs. in the last month.

A. The client weighs 20% more than ideal body weight (IBW). Explanation: When intake of nutrients exceeds a person's metabolic needs, overnutrition occurs, which is considered another form of malnutrition. If a person exceeds 10% over ideal body weight (IBW) they are considered to be overweight; whereas someone who exceeds 20% over IBW is considered to be obese. Obesity may lead to type 2 diabetes and other chronic diseases. The fact that the client gained 10 lbs. in the last month does not necessarily mean the client is obese because the client could have been underweight.

Which of these is a correctly stated outcome goal written by the nurse? (Ch. 2) A. The client will walk 2 miles daily by March 19 B. The client will understand how to give insulin by discharge C. The client will regain their former state of health by April 1 D. The client achieve desired mobility by May 7

A. The client will walk 2 miles daily by March 19 Rationale: Outcome goals should be SMART, i.e., Specific, Measurable, Appropriate, Realistic, and Timely. Option 1 is the only outcome that has a specific behavior (walks daily), with measurable performance criteria (2 miles), and a time estimate for goal attainment (by March 19).

What is the most common measurement used to determine abdominal visceral fat? (prepu, 13) A. Waist circumference. B. Body mass index. C. Triceps skinfold thickness. D. Subcutaneous fat determination.

A. Waist circumference. Explanation: Waist circumference is the most common measurement used to determine the extent of abdominal visceral fat in relation to body fat.

A client appears upset and tearful, but denies pain and refuses pain medication, because "my sibling is a drug addict and has ruined our lives." what is the priority intervention for this client? (ch. 9) A. encourage expression of fears on past experiences B. provide accurate information about use of pain meds C. explain that addiction is unlikely among acute care clients D. Seek family assistance in resolving this problem

A. encourage expression of fears on past experiences Rationale: This client has strong beliefs and emotions related to the issue of sibling addiction. First, encourage expression. This indicated to the client that the feelings are real and valid. It is also an opportunity to assess beliefs and fears. Giving facts and information is appropriate at the right time. Family involvement is important, bearing in mind that their beliefs about drug addiction may be similar to those of the client.

After assessing a 65-year-old female client who is 5 feet, 5 inches in height, which of the following findings would indicate that the client has severe malnutrition? (prepu, 13) A. weight less than 70% of ideal body weight (IBW) B. weight loss of 5 lbs. in the last month C. weight 80% of ideal body weight (IBW) D. current weight of 120 lbs.

A. weight less than 70% of ideal body weight (IBW) Explanation: An ideal body weight (IBW) of less than 70% may indicate severe malnutrition. A current weight of 80% to 90% of IBW indicates a lean client. A current weight of 120 lbs. is within normal range for a female client who is 5 feet, 5 inches in height (100 lbs. for 5 feet and 5 lbs. for each inch over 5 feet). Moderate malnutrition occurs when the client's weight is 70% to 80% of IBW.

Because BMI is calculated using only height and weight, the nurse knows that inaccurate findings would most likely occur in a client (prepu, 13) A. who is a bodybuilder. B. with osteoarthritis. C. with diabetes. D. who is 182.8 cm (6 ft) tall.

A. who is a bodybuilder. Explanation: The use of BMI alone is not diagnostic of a client's health status. Because BMI does not differentiate between fat or muscle tissue, inaccurately high or low findings can result for people who are particularly muscular or for older adults who tend to lose muscle mass.

The nurse is reviewing the principles of nociception. During which phase of nociception does the conscious awareness of a painful sensation occur? (ch. 9) a.Perception b.Modulation c. Transduction d .Transmission

ANS: A term-79 Rationale: Perception is the third phase of nociception and indicates the conscious awareness of a painful sensation. During this phase, the sensation is recognized by higher cortical structures and identified as pain.

In interviewing a client about his heart rate, the nurse asks whether he has noticed any alteration to his heartbeat. The client responds that he sometimes feels his heart race even when he has not been exerting himself physically. This alteration is known as which of the following? (prepu, 8) A. Dyspnea B. Palpitation C. Apical beats D. Pulse pressure

B Rationale: An alteration in heartbeat felt by a client is called a palpitation and can be caused by various circumstances including thyroid dysfunction, medication reaction, or alteration in fluid volume. Dyspnea is difficulty breathing. Pulse pressure is the difference between systolic and diastolic blood pressures. Apical beats are simply the beats of the heart palpated directly over the apex of the heart, on the chest.

Which of the following assessment questions is most likely to allow the nurse to assess a client's judgment? (prepu, 6) A. "What do you think is responsible for your change in mood over the last several weeks?" B. "How do you plan to meet your responsibilities at work?" C. "Do you ever feel like you're hearing or seeing something that others can't see or hear?" D. "In the past, what activities have you found help improve your mood?"

B Rationale: Asking the client to explain his or her response to financial, interpersonal, or logistical challenges can yield insight into the client's judgment. Asking the client to explain the cause of mood changes can help the clinician gauge the client's insight but not judgement, while asking about seeing and hearing things addresses perception, specifically hallucinations. Asking about previous successful coping strategies can be useful but does not assess judgment.

A client's blood pressure is affected by (prepu, 8) A. cardiac intake, elasticity of the veins, blood flow, blood cells, and blood thickness. B. cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity. C. cardiac intake, elasticity of the arteries, blood flow, blood cells, and blood thickness. D. cardiac output, distensibility of the veins, blood volume, blood velocity and viscosity.

B Rationale: Blood pressure is the pressure exerted by blood on the walls of the arteries. It is affected by cardiac output, distensibility (elasticity) of the arteries, blood volume, blood velocity, and blood viscosity (thickness).

A nurse is working with a client who appears to have some form of cognitive impairment. He has a high fever, and the nurse suspects delirium . Which assessment tool should the nurse use? (ch. 6) A) GCS B)CAM C) SLUMS exam D)CAGE questionnaire

B) CAMS Exp: CAMS-> confusion assessment method= used to distinguis form cogntive impairmentSLUMS-.cognitive impairmentCAGE-> alcoholGCS-> client response to stimuli

A patient with gout is complaining of severe, throbbing pain in the great toe. What type of pain is this patient experiencing? (ch. 9) a. Neuropathic b. Somatic c. Referred pain d. Visceral pain

B. Rationale: Somatic pain arises from bone, joint, muscle, skin, or connective tissues and is usually aching or throbbing in quality and well located.

The nurse should avoid asking the client which of the following leading questions during a client interview? (Ch. 2) A. "What medication do you take at home?" B. "You are really excited about the plastic surgery, aren't you?" C. "Were you aware I've has this same type of surgery?" D. "What would you like to talk about?"

B. "You are really excited about the plastic surgery, aren't you?" Rationale: A leading question directs the client's answer. The phrasing of the question indicates an expected answer. The client may be influenced by the nurse's expectations and may give inaccurate responses. This process can result in an error in diagnostic reasoning.

Which of the following clients will have an increased metabolic rate and require nutritional interventions? (prepu, ch.13) A. A healthy young adult who works in an office. B. A person with a serious infection and fever. C. A retired person living in a temperate climate. D. An older, sedentary adult with painful joints.

B. A person with a serious infection and fever. Explanation: Factors that increase metabolic rate include growth, infections, fever, emotional tension, extreme environmental temperatures, and elevated levels of some hormones. Aging, prolonged fasting, and sleep decrease metabolic rate.

The nurse would do which of the following activities during the diagnosing phase of the nursing process? Select all that apply. (Ch.2) A. Collect and organize client information B. Analyze data C. Identify problems, risk, and client strengths D. Develop nursing diagnoses E. Develop client goals

B. Analyze data C. Identify problems, risk, and client strengths D. Develop nursing diagnoses Rationale: The diagnosing phase of the nursing process involves data analysis, which leads to identification of problems, risks, and strengths and the development of nursing diagnoses. Collecting and organizing client data is done in the assessment phase of the nursing process. Goal setting occurs during the planning phase.

Which of the following descriptors is most appropriate to use when stating the "problem" part of a nursing diagnosis? (Ch. 2) A. Grimacing B. Anxiety C. Oxygenation saturation 93% D. Output 500 mL in 8 hours

B. Anxiety Rationale: The problem part of a nursing diagnosis should state the client's response to a life process, event, or stressor. These are categorized as nursing diagnoses. The incorrect options are cues the nurse would use to formulate the nursing diagnostic statement.

The nurse is caring for a client who is experiencing visceral pain. What is this client's most likely diagnosis? (prepu, 9) A. Myocardial infarction B. Appendicitis C. Bone fracture D. Shingles

B. Appendicitis Explanation: Visceral pain originates from abdominal organs; clients often describe this pain as crampy or gnawing.

The client reports nausea and constipation. Which of the following would be the priority nursing action? (Ch. 2) A. Collect a stool sample B. Complete an abdominal assessment C. Administer an anti-nausea medication D. Notify the physician

B. Complete an Abdominal assessment Rationale: Assessment involves the systematic collection of data about an individual upon which all subsequent phases of the nursing process are built. In response to a client's complaint, a nurse assesses a specific body system to obtain data that will help the nurse make a nursing diagnosis and plan the client's care. The other options reflect interventions, which are not timely unless there is first a complete assessment.

A client receiving abdominal surgery has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing? (ch. 13) A. Milk B. Oranges C. Bananas D. Chicken

B. Oranges Rationale: Citrus fruits and juices are especially high in vitamin C.

The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan? (Ch. 2) A. Client will be able to turn self by day 3 B. Skin will remain intact and without redness during hospital stay C. Client will state pain relieved within 30 minutes after medication D. Pressure will be prevented by repositioning client every 2 hours

B. Skin will remain intact and without redness during hospital stay Rationale: The human response/label is what needs to change (Risk for impaired skin integrity). The label suggests the outcomes. In this case, "skin will remain intact" is the desired outcome for a client at risk for impaired skin integrity. Option 1 addresses immobility. Option 3 addresses pain. Option 4 is an intervention.

Which desired outcome written by the nurse is correctly written and measurable? (Ch. 2) A. Client will have a normal bowel pattern by April 2 B. The client will lose 4 lbs. within next 2 weeks C. The nurse will provide skin care at least 3 times each day D. The client will breathe better after resting for 10 minutes

B. The client will lose 4 lbs. within next 2 weeks. Rationale: An outcome statement must describe the observable client behavior that should occur in response to the nursing interventions. It consists of a subject, action verb, conditions under which the behavior is to be performed, and the level at which the client will perform the desired behavior. Each of the incorrect options lacks one of these required elements. Option 1 is not measurable. Option 3 is a nursing goal rather than a client goal. Option 4 does not include the level at which the behavior should be performed.

A nurse is meeting for the first time a 42-year-old client whose visit to the clinic has been prompted by her chief complaint of ongoing lower back pain. Which of the following approaches to pain assessment should the nurse use when assessing the client's pain? (prepu, 9) A. The nurse should prioritize objective data to quantify and validate the client's pain. B. The nurse should use a pain assessment tool that is simple but still addresses the major parameters of pain. C. The nurse should allow the client to guide the direction and character of assessment to identify her priorities. D. The nurse should implement a pain assessment tool that is as detailed as possible.

B. The nurse should use a pain assessment tool that is simple but still addresses the major parameters of pain. Explanation: Pain assessment requires an instrument that is easy to use, clinically valid, and easy to evaluate. An instrument that is too detailed is a liability; while the nurse should be responsive to the client's priorities and identified needs, it would inappropriate to wholly delegate the character and direction of assessment to the client. Pain assessment is highly dependent on subjective data, and these findings would not be minimized or discounted.

The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet? (ch. 13) A. Vitamin A B. Vitamin B12 C. Vitamin C D. Vitamin E

B. Vitamin B12 Rationale: Vitamin B12: Vegans do not consume any animal products. Vitamin B12 is found in animal products.

It would be a priority for the nurse to provide counseling about nutrition and exercise for weight loss for which client? (prepu, 13) A. a client with a body mass index of 25 and normal HDL cholesterol B. a client with body mass index of 27 and blood pressure of 145/80 mm Hg C. a client with body mass index of 18.5 and family history of heart disease D. a client with a body mass index of 23 and high LDL cholesterol

B. a client with body mass index of 27 and blood pressure of 145/80 mm Hg Explanation: The client with a body mass index (BMI) of 27 is overweight and has hypertension. The nurse should offer strategies for weight loss to prevent the progression of cardiovascular disease. A client with a BMI of 18.5 borders on normal and underweight. Despite having a family history of heart disease, the client should be discouraged from further weight loss. Other risk factors for heart disease should be identified and treated as necessary. The client with a BMI of 23 is in the normal range; therefore, pursuing weight loss is not indicated. Further monitoring of the LDL cholesterol is warranted, however. The client with a BMI of 25 would be considered on the borderline of the overweight category; however, the HDL cholesterol is normal. Cardiovascular risk associated with the BMI is not higher in the absence of other risk factors.

A nurse assesses a newly admitted 43-year-old client and documents the vital signs as follows: temperature 98° F (36.7° C), pulse 93 beats/min regular rhythm and bounding, blood pressure 145/93 mm Hg, and respiratory rate 16 breaths/min. What is the first action of the nurse? (prepu, 8) A. Document findings as normal. B. Request a prescription from the health care provider. C. Ask the client if they are experiencing other symptoms. D. Request a prescription for an antipyretic.

C Rationale: Before notifying the health care provider, the nurse should further assess client symptoms, for example, headache or visual problems. Once all the information is obtained, the nurse would then notify the health care provider of the high blood pressure and associated symptoms and may recommend a prescription for a blood pressure medication. The client's temperature is within normal range (98° F/36.7° C), so there is no need to request an antipyretic. The nurse would not document these findings as normal because the client has an elevated blood pressure (hypertensive).

A nurse has an order to obtain orthostatic blood pressure readings on a client admitted with dehydration. The sitting blood pressure is 140/75 mm Hg. Which blood pressure reading with the client standing should the nurse recognize as orthostatic hypotension? (prepu, 8) A. 130/65 mm Hg B. 140/55 mm Hg C. 120/55 mm Hg D. 160/85 mm Hg

C Rationale: A drop in both the systolic and diastolic readings of 20 mm Hg or more from the sitting position to the standing position indicates orthostatic hypotension. A drop of less than 20 mm Hg from the sitting position is considered normal. An elevation is not called hypotension but hypertension.

The nurse is reviewing the chart of a newly admitted client and identifies the client has Marfan syndrome. What assessment finding would the nurse expect to find? (prepu, 8) A. Decreased height and skeletal malformations B.Increased fat distribution in the chest, stomach and neck C. Elongated fingers D. Elongated bones of the face and hands

C Rationale: Marfan syndrome is characterized by elongated limbs and fingers. Elongated bones of the face and hands are associated with acromegaly. Client's with Cushing's syndrome exhibit weight gain in the chest, stomach and neck. Decreased height and skeletal malformations are associated with dwarfism.

Which of the following statements is true of the role of inspection in the physical examination? (ch. 3) a) It should be performed after auscultation but before palpation and percussion b) To maximize findings, local inspection should be conducted prior to general inspection c) It is often the source of the most physical signs d) The acuity of the client will determine whether general or local inspection should be implemented in the examination.

C It is often the source of the most physical signs. Explanation: Inspection often yields the most signs during an examination. It should begin the examination, and general inspection precedes local inspection. The two are not mutually exclusive and should both be implemented in each examination.

The nurse is performing a mental health assessment on an older adult client. The nurse suspects Alzheimer disease when which of the following is observed? Select all that apply. (prepu, 6) A. challenges in planning or solving problems B. misplacing things but able to retrace steps C. occasional difficulty with word finding D. difficulty completing familiar tasks E. decreased or poor judgment

C, D, E Rationale: There are seven signs of Alzheimer disease: memory loss that disrupts daily life; challenges in planning or solving problems; difficulty completing familiar tasks at home, at work, or at leisure; confusion with time or place; new problems with words in speaking or writing; misplacing things and losing the ability to retrace steps; and decreased or poor judgment. Because the client can retrace steps and only has occasional difficulty with word finding, these are not signs and symptoms of Alzheimer disease.

A nurse is interviewing a 65-year-old client with a history of atrial fibrillation, type 2 diabetes, obesity, and congestive heart failure. The nurse determines the client is experiencing chronic neuropathic pain when the client makes which of the following statements? (prepu, 9) A. "My shoulder has been hurting off and on for the year." B. "I have had this aching pain in the right side of my stomach for a few months now." C. "The burning sensation in my feet has gotten worse over the past year." D. "I have been so depressed since my husband died that I ache all over."

C. "The burning sensation in my feet has gotten worse over the past year." Rationale: Neuropathic pain results from damage or dysfunction of any level of the nervous system, including peripheral nerves. This client has a long history of type 2 diabetes, which can cause peripheral neuropathy (burning, tingling sensation). The client has been experiencing the pain for longer than a year. Constant pain lasting more than 6 months is classified as chronic. Shoulder pain that comes and goes would be classified as nociceptic pain. Pain in the abdomen that has been ongoing for a few months would be acute visceral pain. The client statement about being depressed and aching all over indicates psychogenic pain, which occurs when psychological pain becomes physical.

A female client with a diagnosis of hypothyroidism asks the nurse why she has begun to gain body weight. Which is the best explanation the nurse can provide? (prepu, 13) A. "You could be making healthier food choices." B. "You should be exercising for longer periods of time." C. "Your metabolism is slowing down." D. "You are retaining fluid."

C. "Your metabolism is slowing down." Explanation: The pituitary gland is responsible for the release of thyroid stimulating hormone (TSH). Due to the decreased production of TSH in hypothyroidism, the metabolism slows down resulting in weight gain. Weight gain associated from hypothyroidism is not as a result of fluid retention, though this can be a secondary cause for additional weight gain. Although making healthy food choices and encouraging exercise are important to discuss with any client, these responses do not sufficiently explain this phenomenon.

A nurse is caring for several clients in an outpatient setting. Which of the following clients is most likely to experience a weight gain? (prepu, 13) A. A 27-year-old woman with pneumonia B. A 42-year-old client with irritable bowel syndrome C. A 33-year-old athlete on steroids D. A 39-year-old who has been in remission from cancer for 4 years

C. A 33-year-old athlete on steroids Explanation: A client taking steroids may gain weight.

The nurse informs the physical therapy department that the client is too weak to use a walker and needs to be transported by wheelchair. Which step of the nursing process is the nurse engaged in at this time? (Ch. 2) A. Assessment B. Planning C. Implementation D. Evaluation

C. Implementation Rationale: The nurse is responsible for coordinating the plan of care with other disciplines to ensure the client's safety. This action represents the implementation phase of the nursing process. Data gathering occurs during assessment. Goal setting occurs during planning. Determining attainment of client goals occurs as part of evaluation.

When teaching a nutrition class, what would you recommend for adults older than the age of 50? (prepu, 13) A. Increase foods rich in vitamin B12 and calcium B. Increase foods rich in vitamin B6 and saturated fats C. Increase foods rich in vitamin B6 and vitamin D D. Increase foods rich in vitamin E and folic acid

C. Increase foods rich in vitamin B12 and calcium Explanation: Be prepared to help adolescent females and women of child-bearing age increase intake of iron and folic acid. Assist adults older than 50 years to identify foods rich in vitamin B12 and calcium. Advise older adults and those with dark skin or low exposure to sunlight to increase intake of vitamin D.

How can a nurse best assess a client's dietary habits? (prepu, 13) A. Ask about how much food is eaten at an average meal B. Assess for the presence of any chronic disease processes C. Obtain a 24 hour dietary recall of all foods and fluids consumed D. Obtain a height and weight and calculate a body mass index (BMI)

C. Obtain a 24 hour dietary recall of all foods and fluids consumed. Explanation: The nurse can best assess dietary habits by asking the client about an average daily intake of food and fluids, where and when food is consumed, and if there are any conditions or diseases that may affect intake or absorption of nutrients. A height and weight may not accurately reflect dietary intake. One meal will not provide the best assessment of overall dietary habits. Reference:

The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium. The nurse should teach the client to limit intake of which food? (ch. 13) A. Apples B. Bananas C. Smoked sausage D. Steamed vegetables

C. Smoked sausage Rationale: Smoked foods are usually very high in sodium.

A nurse is collecting subjective data from a client who is reporting pain. Which of the following actions should the nurse take to determine the severity of the pain? (prepu, 9) A. Ask the client how long the pain lasts. B. Determine when the pain first started. C. Use a pain scale to measure the pain. D. Question the client about the character of the pain.

C. Use a pain scale to measure the pain. Explanation: The nurse would use a pain scale to determine the severity of the client's pain. Asking the client how long the pain lasts determines the duration of the pain. Determining when the pain first started provides the nurse with the onset of the pain. The character of the pain provides the nurse with information related to what the pain feels like, for example, gnawing or stabbing.

During an interview between a nurse and a client, the nurse and the client collaborate to identify problems and goals. This occurs during the phase of the interview termed... (prepu, 2) A. introductory B. ongoing C. working D. closure.

C. working Explanation:During the working phase, the nurse elicits the client's comments about major biographic data, reasons for seeking care, history of present health concern, past health history, family history, review of body systems for current health problems, lifestyle and health practices, and developmental level. The nurse then listens, observes cues, and uses critical thinking skills to interpret and validate information received from the client. The nurse and client collaborate to identify the client's problems and goals. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 2: Collecting Subjective Data: The Interview and Health History, pp. 13-14. Chapter 2: Collecting Subjective Data: The Interview and Health History - Page 13-14

A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use? (ch. 3) a) Tuning fork b) Reflex hammer c) Coin or key d) Tongue depressor

Coin or key Explanation: The nurse needs a coin or a key to test the client for stereognosis, which is the ability to recognize objects by touch. A reflex hammer is used to determine deep tendon reflexes. A tuning fork is used to test for vibratory sensation. A tongue depressor is used to test for the rise of the uvula and gag reflex

Assessment of the pulse amplitude is accomplished by which of the following? (prepu, 8) A. Auscultating the area of the left ventricle B. Auscultating the flow of blood through an artery C. Palpating the area of the left ventricle D. Palpating the flow of blood through an artery

D Rationale: The pulse amplitude describes the quality of the pulse in terms of its fullness and reflects the strength of left ventricular contraction. It is assessed by the feel of the blood flowing through an artery.

A nurse is performing percussion on a client's back to assess the lungs, and hears a loud, low-pitched, hollow sound, indicating normal lungs. Which of the following describes this finding?(ch.3) a) Dullness b) Tympany c) Hyper-resonance d) Resonance

D) Resonance is a loud, low-pitched, hollow sound normally percussed over an area that is part air and part solid, which is expected over normal lung fields. Hyper-resonance is a very loud, low-pitched sound that is normally heard in lungs with a lot of air such as in emphysema. Tympany is a very loud, high-pitched, drumlike sound that is heard over an air-filled structure, such as the stomach. Dullness is a medium-pitched, thudlike sound that is percussed over solid tissue such as the liver.

A nurse suspect that a client may have an alcohol problem. Which of the following assessments should the nurse use to confirm this suspicion? (ch. 6) A) CAM B)GCS C) SLUMS exam D) CAGE questionnaire

D) CAGE questionnaire Exp: The CAGE assessment is a quick questionnaire used to determine if an alcohol assessment is needed. THE SLUMS exam assesses for cognitive impairment. The glasgow coma Scale (GCS) assesses a clients response to stimuli. The confusion assessment method (CAM) is used to assess for confusion.

A nurse wants to assess a client orientation. The nurse recognizes that which orientation usually lost first when the client is confused? (ch.6) A) location B) place C) Person D) Time

D) Time rationale : Orientation to time is usually lost first and orientation to person is lost last. Place is the middle. Location is the same as place

The nurse needs to assess the visual perceptual and constructional ability of a client. Which of the following assessments should the nurse use? (ch. 6) A) Ask the client to pick up a pencil with the left hand, move it to the right, and then hand it to her B) Perform the SLUMS exam C) Ask the client todays date D) Have the client draw the face of a clock

D) have the client draw the face of a clock Exp: Having the client draw the face of a clock is one way to assess visual perceptual constructional ability. The SLUMS exam test cognitive function. Giving directions to to the client to perform a series of tasks, such as picking up and manipulating a pencil, is an assessment of concentration. Asking the client todays date is an assessment of orientation

The nurse is teaching a client who has iron deficiency anemia about foods she should include in her diet. The nurse determines that the client understands the dietary modifications if she selects which items from her menu? (ch. 13) A. Nuts and milk B. Coffee and tea C. Cooked rolled oats and fish D. Oranges and dark green leafy vegetables

D. Rationale: Dark green leafy vegetables are a good source of iron and oranges are a good source of vitamin C, which enhances iron absorption

An individual is considered obese when his or her BMI is: (prepu, 13) A. Less than 24 B. Greater than 40 C. 25-29 D. 30-39

D. 30-39 Explanation: Those persons with a BMI of 30 to 39 are considered obese. Persons with a ABMI of less than 24 are risk for problems associated with poor nutritional status. A BMI of 25 to 29 are considered overweight. Those with a BMI of greater than 40 are considered extremely obese.

A nurse assesses an older adult client who lives alone and is unable to drive a vehicle. Which of the following assessment areas of the nutritional history will most likely impact the client's nutritional status? (prepu, 13) A. Finances B. Food preparation C. Food preferences D. Accessibility

D. Accessibility Explanation: The older adult client who is unable to drive will have limited access to a range of foods that will promote nutritional health. The correct option is accessibility. Food preparation seeks to determine who does the cooking for the client and the way in which the foods are prepared. Finances refers to having access to sufficient funds to purchase foods that support nutritional health. Food preferences are personal for each client and refer to likes or dislikes. In addition, the client may report foods they find harmful or beneficial and cultural or religious preferences in this assessment area.

A nurse recognizes that a client may be at risk for malnutrition when which lifestyle behavior is present? (prepu, 13) A. Diabetes mellitus B. Excessive exercise C. Single parenthood D. Chronic dieting

D. Chronic dieting Explanation: Chronic dieting, especially with fad diets, can predispose an individual to malnutrition because the amount of needed nutrients is often lacking in an effort to lose weight quickly. Single parenthood is not a risk factor for malnutrition unless the parent is unable to gain access to shopping or suffers form a lower socioeconomic status. Diabetes mellitus is a chronic disease, not a lifestyle behavior. Excessive exercising may lead to weight loss but not malnutrition.

The nurse would write which of the following outcome statements for a client starting an exercise program? (Ch. 2) A. Client will walk quickly three times a day B. Client will be able to walk a mile C. Client will have no alteration in breathing during the walk D. Client will progress to walking a 20-minute mile in one month

D. Client will progress to walking a 20-minute mile in one month Rationale: Outcome statements must be written in behavioral terms and identify specific, measurable client behaviors. They are stated in terms of the client with an action verb that, under identified conditions, will achieve the desired behavior. They should also be realistic and achievable.

A 4-year-old boy is brought to the emergency department by his mother. She says he points to his stomach and says, It hurts so bad. Which pain assessment tool would be the best choice when assessing this childs pain? (ch. 9) a.Descriptor Scale b.Numeric rating scale c. Brief Pain Inventory d. Faces Pain Scale

D. FACES Pain Scale Rationale: Rating scales can be introduced at the age of 4 or 5 years. The FPS-R is designed for use by children and asks the child to choose a face that shows how much hurt (or pain) you have now. Young children should not be asked to rate pain by using numbers.

A client with chronic pain reports to you, the charge nurse, that the nurse have not been responding to requests for pain medication. What is your initial action? (ch. 9) A.Check the MARs and nurses' notes for the past several days. B. Ask the nurse educator to give an in-service about pain management. C. Perform a complete pain assessment and history on the client. D. Have a conference with the nurses responsible for the care of this client

D. Have a conference with the nurses responsible for the care of this client Rationale: As charge nurse, you must assess for the performance and attitude of the staff in relation to this client. After gathering data from the nurses, additional information from the records and the client can be obtained as necessary. The educator may be of assistance if knowledge deficit or need for performance improvement is the problem.

The rehabilitation nurse wishes to make the following entry into a client's plan of care: "Client will reestablish a pattern of daily bowel movements without straining within two months." The nurse would write this statement under which section of the plan of care? (Ch. 2) A. Nursing diagnosis/problem list B. Nursing orders C. Short-term goals D. Long-term goals

D. Long-term goals Rationale: Long-term goals describe changes in client behavior expected over a time frame greater than one week. They are usually designed to restore normal functioning in a problem area and are helpful to other healthcare workers who care for the client, often in a variety of settings.

A nurse explains to a student that the nursing process is a dynamic process. Which of the following actions by the nurse best demonstrates this concept during the work shift? (Ch. 2) A. Nurse and client agree upon health care goals for the client B. Nurse reviews the client's history on the medical record C. Nurse explains to the client the purpose of each administered medication D. Nurse rapidly reset priorities for client care based on a change in the client's condition

D. Nurse rapidly reset priorities for client care based on a change in the client's condition Rationale: The nursing process is characterized by unique properties that enable it to respond to the changing health status of the client. Options 1, 2, and 3 are appropriate nursing care measures, but do not demonstrate the dynamic nature of the nursing process.

While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment? (Ch. 2) A. Help client into the chair but more quickly B. Document client's vital signs taken just prior to moving the client C. Help client back to bed immediately D. Observe client's skin color and take another set of vital signs

D. Observe client's skin color and take another set of vital signs Rationale: Assessment is ongoing throughout the nurse-client relationship. During re-assessment, the nurse collects additional data to help evaluate the status of problems or identify new problems. Options 1, 2, and 3 are interventions.

A nurse is teaching a class on diet and nutrition to a group of mothers who are breast-feeding their infants. What would the nurse tell the group is the emphasis of nutritional guidelines? (prepu, 13) A. Increased intake of meats B. Decreased intake of grains C. Weight loss D. Variety

D. Variety Explanation: Emphasis of nutritional guidelines is on variety; increased intake of vegetables, fruits, lentils, and grains, particularly from plant sources; and meeting individual nutritional needs while avoiding either deficiencies or excesses in nutrient intake.

A client has a 10-year history of being treated for hypertension. Where should the nurse document this information? (prepu, 2) A. health B. review of systems .C. health maintenance D. past medical history

D. past medical history Explanation: An adult medical illness is documented as part of the past medical history. Health patterns identify the client's personal/social history and daily living routines that may influence health and illness. The review of systems focuses on the presence or absence of common symptoms related to each major body system. Health maintenance is a part of the past medical history and identifies actions taken to improve or maintain health. Reference:Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 2: Collecting Subjective Data: The Interview and Health History, p. 21.Chapter 2: Collecting Subjective Data: The Interview and Health History - Page 21

A client reports pain in the knee. The knee is warm, swollen, and red and the client describes the pain as aching and gnawing. The nurse determines the client is experiencing which of the following types of nociceptive pain? (prepu, 9) A. phantom B. referred C. neuropathic D. somatic

D. somatic Explanation: The client is experiencing somatic pain, pain that occurs when stimuli in the tissues (skin, muscles, joints, skeleton, connective tissue) are activated. Neuropathic pain results when there is damage or dysfunction to the nervous system. Referred pain occurs when pain is in a body region that is distant from the actual source of the painful stimulus, such as pain in the jaw and shoulder when a person is experiencing a myocardial infarction. Phantom pain occurs when there is pain in a part of the body that has been removed, such as when a client reports pain in the right foot after a right above-the-knee amputation.

A client is admitted with right lower abdominal pain with rebound tenderness. The nurse suspects appendicitis and documents this type of pain as which of the following? (prepu, 9) A. referred B. somatic C. phantom D. visceral

D. visceral Explanation: Because the pain is due to inflammation of the appendix (an organ), it would be documented as visceral pain. Phantom pain occurs when a client reports pain from a removed body part. Somatic pain occurs when stimuli in the tissues (skin, muscles, joints, skeleton, connective tissue) are activated. Referred pain is the sensation of pain in a body region distant from the actual source of the painful stimulus.

A nurse is preparing to perform intubation on a client. Which pieces of equipment are needed to prevent the transmission of infectious agents during this procedure? Select all that apply. (ch. 3) A. Face shield B. Gown C. Gloves D. Nasopharyngeal airway E. Stethoscope

Face shield• Gloves• Gown Correct Explanation: The specific personal protective equipment needed to prevent the transmission of infectious agents varies depending on the procedure to be performed. For example, performing venipuncture requires only gloves, but intubation requires gloves, gown, and face shield, mask, or goggles. A nasopharyngeal airway may be needed for intubation, but its purpose is not to prevent transmission of infectious agents. A stethoscope would not be needed for this procedure.

The nurse is assessing a client with unexplained lesions noted on the client's back. The nurse is going to palpate the area of the lesions. What type of palpation should the nurse use? (ch. 3) a) Moderate b)Deep c) Intermediate d) Light

Light Explanation: Light palpation is appropriate for the assessment of surface characteristics, such as texture, surface lesions or lumps, or inflamed areas of skin. Moderate palpation should be used to assess the size, shape, and consistency of abdominal organs. Pressure is firm enough to depress approximately 1 to 2 cm in depth. During deep palpation, the nurse uses a pressure to palpate 2 to 4 cm in depth. Intermediate palpation is a distracter for this question.

A nurse, new to the hospital, is attending orientation with the nurse educator. The educator is discussing the use of deep palpation when assessing a patient. The nurse should be aware of what risk when using this assessment technique? (ch. 3) a) Risk for chronic pain b) Risk for infection c) Risk for injury d) Risk for impaired skin integrity

Risk for injury Explanation: With deep palpation, you might say, "I'm going to touch you and push down more deeply than before. Let me know if you feel pain or want me to stop." As palpation proceeds, continue conversation, asking the patient about pain, presenting symptoms, or contributing factors while observing for nonverbal signs of tenderness or discomfort.

The nurse is admitting a client to the surgical unit. The nurse should begin the general survey at which point in the admission process? (ch. 3) a) As soon as any visitors have left the room b) After the physical examination is completed c)Upon meeting the client and family members d) When the demographic data has been documented

Upon meeting the client and family members Explanation: The general survey begins immediately when meeting the client and continues throughout the assessment.

Which Glasgow Coma Score indicates the client is in a deep coma? (prepu, 6) a.3 b.8 c.14 d.15

a. 3 Explanation:A Glasgow Coma Scale score indicates the client is in a deep coma. All other scores indicate some impairment with a score of 15 being no impairment.Reference:Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 6: Assessing Mental Status and Substance Abuse, p. 85.Chapter 6: Assessing Mental Status and Substance Abuse - Page 85

When doing a pain assessment for a patient who has been admitted with metastatic breast cancer, which question asked by the nurse will give the most information about the patient's pain? (ch. 9) a. "How long have you had this pain?" b. "How would you describe your pain?" c. "How much medication do you take for the pain?" d."How many times a day do you medicate for pain?"

b. "How would you describe your pain?" Rationale: Because pain is a multidimensional experience, asking a question that addresses the patient's experience with the pain is likely to elicit more information than the more specific information asked in the other three responses. All of these questions are appropriate, but the response beginning "How would you describe your pain?" is the best initial question.

How would the nursing instructor explain the goal of guided questioning to his or her students? (prepu, 2) A. Providing the most plausible answer to the client B. Facilitating the client's fullest communication C. Developing a basis for accurate health promotion activities D. Creating an opportunity for the early generation of a plan

b. Facilitating the client's fullest communication Explanation:The main goal of guided questioning is to facilitate the client's fullest communication. The early generation of a plan is not a paramount goal and it is incorrect to suggest particular answers to the client.Reference:Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 2: Collecting Subjective Data: The Interview and Health History, pp. 14-16.Chapter 2: Collecting Subjective Data: The Interview and Health History - Page 14-16

A 29-year-old woman comes to the office. During history taking, the nurse notices that the client is speaking very quickly and jumping from topic to topic so rapidly that it is difficult to follow her. The nurse can find some connections between ideas, but it is difficult. Which word best describes this thought process? (prepu, 6) a.Derailment b. Flight of ideas c. Circumstantiality d. Incoherence

b. Flight of ideas Explanation:This represents flight of ideas, because the ideas are connected in some logical way. Derailment, or loosening of associations, has more disconnection within clauses. Circumstantiality is characterized by the client speaking "around" the subject and using excessive detail, though thoughts are meaningfully connected. Incoherence lacks meaningful connection and often has odd grammar or word use.Reference:Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018.

A nurse is interviewing a 16-year-old girl regarding her health history. When inquiring about her chief complaint, the girl lowers her voice and says, "I've been with a guy recently, and I'm worried that I might have caught something from him." The nurse responds by saying, "So, you're concerned that you may have a sexually transmitted infection?" Which verbal communication technique is the nurse using here? (prepu, 2) A. Open-ended B. Rephrasing C. Laundry list D. Well-placed phrase

b. Rephrasing Explanation:Rephrasing information the client has provided is an effective way to communicate during the interview. This technique helps to clarify information the client has stated; it also enables the nurse and the client to reflect on what was said. Open-ended questions are used to elicit the client's feelings and perceptions, and typically begin with the words "how" or "what." The laundry list approach involves providing the client with a choice of words describing symptoms, conditions, or feelings, which reduces the likelihood of the client's perceiving or providing an expected answer. The nurse can encourage client verbalization by using well-placed phrases such as "uh-huh," "yes," or "I agree."Reference:Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 2: Collecting Subjective Data: The Interview and Health History, p. 16.

A nurse has completed assessment of a client and is now validating the information gathered and reviewing goals with the client. Which phase of the interview process is this? (prepu, 2) A. Introductory B. Summary c.Analysis D. Working

b. Summary Explanation:During the summary and closing, the nurse summarizes information obtained during the working phase and validates problems and goals with the client. In the introductory phase, the nurse meets the client and explains the purpose of the interview, discusses what type of questions will be asked, explains reasons for taking notes, and assures the client that confidential information will remain confidential. Analysis is not a phase of the interview process. The working phase is when data collection occurs.Reference:Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 2: Collecting Subjective Data: The Interview and Health History, p. 14.Chapter 2: Collecting Subjective Data: The Interview and Health History - Page 14

During an admission interview, the nurse asks the patient, "Do you have discomfort or soreness?" What is the objective of this question? (ch. 9) a. To identify the quality of b. To identify the severity of pain c. To identify the duration of pain d. To identify the intensity of pain

b. To identify the severity of pain Rationale: During the interview, the nurse uses a variety of words such as discomfort or soreness to identify severity of pain. These types of questions help to assess pain in patients who report pain only when it is severe.

During an assessment the client says "I've been having bad pain in my left leg for a week." In which section should the nurse document this information? (prepu, 2) A. health patterns B. chief of complaint C. review of systems D. history of present illness

b. chief complaint Explanation:The chief complaint is the reason for the person seeking care. Health patterns focuses on the client's social history. The review of systems is where the presence or absence of common symptoms related to each major body system are reviewed and documented. The history of present illness describes how each symptom developed. It includes the client's thoughts and feelings about the illness, relevant parts of the review of systems, and medications, allergies, and lifestyle habits that impact the present illness. Reference:Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 2: Collecting Subjective Data: The Interview and Health History, pp. 19-21.Chapter 2: Collecting Subjective Data: The Interview and Health History - Page 19-21

For which of the following assessments would the nurse plan to use deep palpation? (Select all that apply.) (ch. 3) a) Texture of a mole b) Pulsation of abdominal aorta c) Shape of abdominal mass d) Size of liver e) Macular rash

c) Shape of abdominal mass d) Size of liver b) Pulsation of abdominal aorta Explanation: Deep palpation is used to assess the size, shape, and consistency of abdominal organs. Light palpation is used to assess surface characteristics, such as a macular rash and texture of a mole.

For which patient should the nurse wear gloves to provide care? Select all that apply. (ch. 3) a) The patient who self-administer heparin b)The patient continent of urine c) The patient requiring oropharyngeal suctioning d) The patient with Clostridium difficile e) The patient with vancomycin-resistant enterococci

c) The patient requiring oropharyngeal suctioning d) The patient with Clostridium difficile e) The patient with vancomycin-resistant enterococci Explanation: The nurse wears gloves when contact with any body secretions and fluids is possible. The nurse wears gloves to provide care for patients with infections of Clostridium difficile or vancomycin-resistant enterococci and patients requiring oropharyngeal suctioning. Gloves are not necessary when caring for a continent patient or a patient who self-administer heparin.

During a health history, a client reports drinking bloody Mary's several mornings a week before going to work. In which part of the CAGE questionnaire should the nurse document this information? (prepu, ch. 6) a.Annoyance b.Eye-openers c. Cutting down d. Guilty feelings

c. Eye-openers Explanation:The client drinking alcohol in the morning would be applicable to the area on eye-openers specifically the question "Have you ever taken a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover? This information is not applicable to the other areas of the CAGE questionnaire, specifically, annoyance, cutting down, or guilty feelings.Reference:Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 6: Assessing Mental Status and Substance Abuse.

A client opens the eyes and answers questions however falls back asleep within seconds. How should the nurse document this assessment finding? (prepu, 6) a. Coma b. Stupor c.Lethargy d. Obtunded

c. Lethargy Explanation:Opening the eyes, answering questions, and falling back asleep describes lethargy. Being completely unresponsive to all stimuli with the eyes closed describes a coma. Being awakened with vigorous or painful stimuli describes stupor. Opening the eyes to loud voices, responding slowly with confusion, and being unaware of the environment describes obtunded.Reference:Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 6: Assessing Mental Status and Substance Abuse, p. 96.Chapter 6: Assessing Mental Status and Substance Abuse - Page 96

The nurse is admitting a client to the unit for surgery the next morning. The nurse notes that the client speaks at an accelerated pace and jumps from topic to topic, none of which progresses to sensible conversation. What would the nurse document about this client? (prepu, 6) a.Patient demonstrates confabulation b. Patient is depressed c. Patient demonstrates flight of ideas d. Patient demonstrates schizophrenia

c. Patient demonstrates flight of ideas Explanation:Flight of ideas is an almost continuous flow of accelerated speech in which a person changes abruptly from topic to topic. Changes are usually based on understandable associations, plays on words, or distracting stimuli, but the ideas do not progress to sensible conversation.Reference:Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 6: Assessing Mental Status and Substance Abuse, p. 87.Chapter 6: Assessing Mental Status and Substance Abuse - Page 87

After using the SLUMS tool to test a client's mental status, the nurse calculates a score of 12. The nurse should make... (prepu, 6) a .the nursing diagnosis: Disturbed thought processes related to substance abuse. b. the nursing diagnosis: Ineffective decision making related to loss of memory. c .a referral to the primary health care provided for further evaluation. d. a referral for the family and client to seek mental health counseling.

c. a referral to the primary health care provided for further evaluation. Explanation:A score of 12 on the SLUMS tool indicates dementia. The client needs further evaluation.Reference:Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 6: Assessing Mental Status and Substance Abuse, p. 90.Chapter 6: Assessing Mental Status and Substance Abuse - Page 90

During palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing: (ch.3) a)moderate palpation b) light palpation c) very deep palpation d) deep palpation.

d) deep palpation Explanation: Deep palpation depresses the surface between 2.5 and 5 cm (1 and 2 inches). This allows you to feel very deep organs or structures that are covered by thick muscle.

Light palpation is most appropriate to assess the: (ch.3) a) appendix b) bladder c) liver d) inflamed areas of skin

d) inflamed areas of skin Explanation: Light palpation is appropriate for the assessment of surface characteristics, such as texture, surface lesions or lumps, or inflamed areas of skin

A nurse is beginning the physical examination of an elderly man with chronic obstructive pulmonary disease. In which order should the nurse implement the four physical assessment techniques with this client? (ch. 3) A. Auscultation, percussion, palpation, inspection B. Percussion, palpation, inspection, auscultation C. Palpation, inspection, auscultation, percussion D. Inspection, palpation, percussion, auscultation

d. Inspection, palpation, percussion, auscultation Explanation:Four basic techniques must be mastered before you can perform a thorough and complete assessment of the client. These techniques are inspection, palpation, percussion, and auscultation. Inspection precedes palpation, percussion, and auscultation because the latter techniques can potentially alter the appearance of what is being inspected.Reference:Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 3: Collecting Objective Data: The Physical Examination, p. 37.Chapter 3: Collecting Objective Data: The Physical Examination - Page 37

A patient with carpal tunnel syndrome reports having a tingling and burning sensation in the thumb, middle, and index fingers. What does the nurse interpret from these symptoms? (ch. 9) a. The patient has referred pain. b. The patient has cutaneous pain. c. The patient has nociceptive pain. d. The patient has neuropathic pain.

d. The patient has neuropathic pain Rationale: The patient has neuropathic pain.RationaleThe presence of a tingling, burning sensation in the thumb, middle, and index fingers indicates that the patient has neuropathic pain

A patient who has chronic musculoskeletal pain tells the nurse, "I feel depressed because I ache too much to play golf." The patient says the pain is usually at a level 7 (0 to 10 scale). Which patient goal has the highest priority when the nurse is developing the treatment plan? (ch. 9) a. The patient will exhibit fewer signs of depression b. The patient will say that the aching has decreased c. The patient will state that pain is at a level 2 of 10 d. The patient will be able to play 1 to 2 rounds of golf.

d. The patient will be able to play 1 to 2 rounds of golf. Rationale: For chronic pain, patients are encouraged to set functional goals such as being able to perform daily activities and hobbies. The patient has identified playing golf as the desired activity, so a pain level of 2 of 10 or a decrease in aching would be less useful in evaluating successful treatment. The nurse also should assess for depression, but the patient has identified the depression as being due to the inability to play golf, so the goal of being able to play 1 or 2 rounds of golf is the most appropriate.

While interviewing a client, the nurse asks, "What happens when you have low blood glucose?" This type of response to the client is used for what purpose? (prepu, 2) A. To summarize the conversation B. To restate what the client has said C. To promote objectivity D. To clarify

d. To clarify Explanation:Another way to clarify is to ask, "What happens when you get low blood sugar?" Such questions prompt clients to identify other symptoms or give more information so that you can better understand the situation. Reference:Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 2: Collecting Subjective Data: The Interview and Health History, p. 16.Chapter 2: Collecting Subjective Data: The Interview and Health History - Page 16

A patient who uses a fentanyl (Duragesic) patch for chronic cancer pain complains to the nurse of the rapid onset of pain at a level 9 (0 to 10 scale) and requests "something for pain that will work quickly." The nurse will document this as: (ch. 9) a. somatic pain b. referred pain c. neuropathic pain d.breakthrough pain.

d.breakthrough pain Rationale: Pain that occurs beyond the chronic pain already being treated by appropriate analgesics is termed breakthrough pain. Neuropathic pain is caused by damage to peripheral nerves or the central nervous system (CNS). Somatic pain is localized and arises from bone, joint, muscle, skin, or connective tissue. Referred pain is pain that is localized in uninjured tissue.