health assessment exam 1 &2 prep u ?

A nurse is explaining to a new client that the office uses electronic health records (EHRs) for all clients. The client says that at his last office, they used electronic medical records (EMRs). He asks whether these are the same thing. The nurse explains that they are different. Which of the following is a characteristic that is true of an EMR?

A record supplied by a physician in which diagnoses and prescribed treatments are recorded

When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles?

Attempting to roll the structure up and down and side to side While lymph nodes may be rolled both up and down and side to side, muscles will not move in this manner. The other cited techniques do not differentiate between lymph nodes and muscles.

The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is the preceptor talking about?

Head-to-toe

A nurse admits a client to the health care facility. The nurse gathers data about the client's social history and wants to make this information available to the social worker. Which initial assessment documentation form is best for the nurse to use?

Integrated Cued Checklist

Which is an example of auscultation? Select all that apply.

The nurse notes gurgling sounds over the individual's abdomen. The nurse notes crackling over the individual's thorax. The nurse notes a rhythmic lub-dub over the patient's anterior thorax.

A nurse has just discussed with a client the quality, severity, and location of the client's back pain. Which of the following is an appropriate guideline for the nurse to follow when documenting these findings?

Use phrases instead of sentences to record data.

During the physical examination of a client, a nurse notes that a client's trachea has been pushed toward the right side. The nurse recognizes that the pathophysiologic cause for this finding is related to what disease process?

Atelectasis Atelectasis can cause the trachea to be pushed to one side from its midline position.

The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. What can the nurse focus on while doing discharge teaching?

Encourage the use of safety equipment Nurses encourage use of appropriate safety equipment to reduce risk of head or neck trauma.

When an agency has policies that require nurses to write focus notes, the nursing documentation can include what?

Family concerns

What is the most common type of hyperthyroidism?

Graves' disease Graves' disease, the most common type of hyperthyroidism, is autoimmune and may also be genetic.

When documenting the findings from a physical examination of the head and neck, what will the nurse include when describing the client's head?

Hair color When describing a client's head, the nurse should include 2 categories of findings, the client's hair color and the presence or absence of abnormalities of the skull.

A nurse begins the eye examination on a client who presents to the health care clinic for a routine examination. What is the correct action by the nurse to perform the test for near visual acuity?

Have the client hold the Jaeger card 14 inches from the face and read with one eye at a time

When conducting a generalized assessment of a new client, what would the nurse focus upon when inspecting the neck?

Limitations in movement During inspection of the neck, the nurse observes for lesions and limitations in movement. The nurse cannot assess strain, vertebral injury, or lymph node enlargement by inspection.

During your physical examination o

Look for a source such as infection in the area that it drains Knowledge of the lymphatic system is important to a sound clinical habit: whenever a malignant or inflammatory lesion is observed, look for involvement of the regional lymph nodes that drain it; whenever a node is enlarged or tender, look for a source such as infection in the area that it drains.

A nurse is distracted during her assessment of a client and does not take as thorough or as accurate notes as usual. Her supervisor, who is familiar with the client, reads the patient's chart and questions the nurse. The supervisor should point out to the nurse that which of the following errors is most likely to occur due to the nurse's lapse?

Making incorrect nursing judgments or diagnoses

A client comes to the trauma unit in respiratory distress following a motor vehicle accident. On examination, the nurse notices that the trachea is deviated from the midline. What does this finding indicate?

Tension pneumothorax Palpation of the thyroid gland reveals important landmarks of the trachea. Such landmarks are noted when assessing for tracheal deviation, which accompanies a potentially life-threatening condition called tension pneumothorax.

The healthcare provider states that the client's blood count with differential demonstrates a shift to the left. The nurse expects to see which lab result when reviewing the differential?

Bands greater than 10%

Waist circumference guidelines may not be accurate for adult clients who are shorter than 152.4 cm (5 ft) in height. This restriction is also a concern for which other anthropometric measurement?

Body mass index (BMI).

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?

CAM

Question 10 See full question 17s The nurse assesses a heart rate of 110 beats per minute (bpm), cool clammy skin, and blood pressure 88/58 mm Hg. Which heading should the nurse use to cluster this data?

Low fluid volume

A nurse is instructing a client on the importance of protein in the diet. Which of the following should the nurse mention as functions of proteins in the body? Select all that apply.

Making hormones such as insulin Acting as enzymes for chemical reactions such as digestion Helping transport oxygen and lipids through the circulatory system

A young adult spends time alone and has difficulty talking with others. What should this behavior indicate to the nurse about the client's developmental level?

May turn to addictive behaviors

A patient has sustained burns over 50% of the body. When planning care for this patient, the nurse will include interventions to address which alteration in the skin's barrier function? (Select all that apply.)

Mechanical or chemical injuries Penetration by microorganisms Loss of water and electrolytes

During the health-history interview, which of the following components of cognitive function can the nurse quickly assess?

Memory and attention

A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms?

Migraine headache Migraine headaches are usually located around the eyes, temples, cheeks, and forehead. They are often accompanied by nausea and vomiting

A construction worker in his mid-40s suffered a severe laceration on his leg while on the job site. Soon after he arrives at the emergency room, a nurse assesses his pain. The client states that pain, although severe, has lessened since the accident first occurred. The nurse knows that the pain message likely has been inhibited by release of endorphins and other neurotransmitters. Which physiological process does this represent?

Modulation

You are using the Braden Scale to measure risk factors for pressure sores. What risk factors will you assess? Select all that apply.

Moisture Activity Nutrition

A nurse is performing a head and neck assessment on a client. Which area should the nurse inspect for facial symmetry?

Nasolabial folds The nasolabial folds are ideal places to check facial features for symmetry. Inspection of the temporomandibular joint cannot elicit facial symmetry.

The nurse asks the client to perform the action pictured. What is the nurse assessing?

Near vision

Which assessment form provides a nurse with the ability to compare nursing data across clinical populations, settings, geographical areas, & time?

Nursing minimum data set

A nurse is caring for an older adult who reports that he is becoming "forgetful." The nurse explains that some parts of memory decrease with aging, and some do not. What would the nurse identify happens with aging to the type of memory that corresponds with the retrieval of facts, vocabulary, and general knowledge?

Decreases minimally

A nurse assesses a client with acute small-bowel obstruction who reports intermittent pain. He only noticed symptoms of this condition earlier today. Which questions are appropriate for the nurse to ask when assessing the client's pain? Select all that apply.

Describe the pain. Where is the pain located? When did the pain start?

The nurse reviews growth and development theories in preparation for completing an assessment with an adolescent client. What should the nurse recall about Sigmund Freud's theory when conducting this assessment?

Developed the first formal theory of personality

How does the nurse use critical thinking when accurately assessing vital signs?

Developing nursing diagnoses

Which of the following are cues that a person may have dementia? Select all that apply.

Disorientation Looking to a family member to answer questions directed to the client Repeatedly failing to follow instructions

The nurse is reviewing the patient's medical record. Which component of the medical record would provide the nurse the broadest overview of the health care team members' perspective of the patient's status?

Progress notes

The nursing instructor informs the students that they should obtain a North American Nursing Diagnosis Association reference book. What would the purpose of obtaining this reference be? (Select all that apply)

Helps select valid diagnosis. Determine when and when not to use each nursing diagnostic category. Helps to rule out invalid diagnosis.

During an assessment interview, a young male client makes the following statement; "I need something more than friends and family to give me meaning and purpose in life". The nurse should focus on which step in the clinical reasoning process?

Interpret the findings in terms of probable process

The nurse observes a 3-year-old child crying when an ice cream cone melts into a puddle. Which characteristic of Piaget's preoperational stage is this child demonstrating?

Limited transformation

The nurse is caring for a Jewish adolescent who is anxious to enter adulthood. The nurse suggests which activity to achieve adulthood status?

Living independently

The nurse notes that a client hesitates when responding to questions. With which part of the mental health assessment is this client having difficulty?

attention

When documenting assessment data, the nurse should avoid which phrases because of their lack of description? Select all that apply.

"Client presented as well developed." "Client is of average height and well nourished." "Client appears to be in no apparent physical distress."

A nursing student is explaining to a roommate the relationship between diagnostic reasoning and critical thinking. Which of the following is the correct statement for the nursing student to make?

"Diagnostic reasoning is a form of critical thinking used to interpret data correctly."

Which statement by a client about the skin needs validation by the collection of objective data by the nurse?

"My feet hurt and are always cold to the touch"

Which statement represents a clanging speech pattern?

"Peas are good. Trees are wood. I'd leave if I could."

Which statement by a nurse concerning the various methods used to measure temperature indicates the need for additional education?

"When monitoring the same client, an axillary temperature is usually higher by a degree than an oral temperature."

The client has been admitted for depression. What should the nurse include in the admission mental status assessment? Select all that apply.

A recent loss New physiological impairment History of a stroke

A nurse observes the presence of hirsutism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process?

Cushing's disease

A nurse is helping a sedentary 20-year-old female determine her dietary needs. Which of the following would be her estimated calorie needs per day?

1,800-2,000

A client opens the eyes upon request, uses inappropriate words when talking, and withdraws from painful stimuli. What should the nurse calculate this client's Glasgow Coma Scale score to be?

10

A patient had ingested hot coffee immediately after having an oral temperature reading obtained of 101°F. The health care provider is asking for the temperature measurement to be repeated using a tympanic membrane thermometer. What temperature will the nurse most likely obtain using this different measurement route?

102.4°F

A nurse has just assessed a client using the St. Louis University Mental Status (SLUMS) exam. From his health record, the nurse sees that the client graduated from high school. Which of the following scores would indicate mild cognitive impairment in this client?

25

A nurse is measuring an adult female client's mid-arm circumference (MAC) as part of her overall assessment of the client's nutritional status. Which of the following is the standard reference for the MAC for an adult female?

28.5 cm

The nurse is estimating potential adult height of a female child. The father's height is 69 inches and the mother's height is 68 inches. What is the child's potential adult height in inches?

66

The nurse is caring for four clients on the short-stay unit. Which client would cause the nurse greatest concern?

A 7-year-old client with a sinus dysrhythmia

Which of the following statements best describes Sigmund Freud's view of human behavior?

A person is generally not aware of the underlying reasons for his behavior.

The nurse is documenting the findings from a mental status examination. After noting the patient's appearance and behavior, what should the nurse document next?

Ability to articulate verbally

Common or concerning symptoms to inquire about in the general survey and vital signs include all of the following except: Weight Level of consciousness Adventitious lung sounds Fever

Adventitious lung sounds

While conducting an interview with a psychiatric-mental health client, the nurse is observing the client's facial expressions and nonverbal cues. What are these physical manifestations known as?

Affect

A client in a long term care facility has lost 5 lbs of body weight in the past month. Which of the following actions should the nurse take to determine the cause of the weight loss?

Analyze the client's intake record.

The nurse suspects that a middle-aged client is experiencing common stressors. What information did the nurse collect to come to this conclusion? Select all that apply.

Applying for a promotion at work Scheduling time to help aging parents Feeling sad at the death of a beloved grandparent Encouraging adolescent children to become more independent

A nurse is preparing to examine a client from Southeast Asia who has been experiencing chronic headaches. Which of the following should the nurse do in light of this client's cultural background?

Ask permission before palpating the head and neck Take care to consider cultural norms for touch when assessing the head. Some cultures (e.g., Southeast Asian) prohibit touching the head or touching the feet before touching the head. There is no need to avoid asking the client to remove clothes for the examination; removing clothing is not a particular concern related to this client's culture nor is it necessary for examination of the head and neck. Clients of certain conservative religious backgrounds may object to being assessed by a nurse of the opposite sex, but there is not enough information in this scenario to warrant such a concern.

A patient has arrived to the clinic for a routine physical examination. Prior to assessing the patient's blood pressure, what should the nurse do?

Ask the patient to sit quietly in a chair for 5 minutes.

A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action should the nurse perform next?

Assess the client's blood pressure. Onset of headache after the age of 50 paired with the statement the client has made here is considered a "red flag." The nurse should suspect this is a secondary headache or arising from another condition.

The nurse prepares to conduct a mental health assessment with an older client. What should the nurse do first before beginning this assessment?

Assess vision and hearing

The plan of care (POC) identifies problems, intended outcomes, and necessary interventions to meet those intended outcomes. What provides the basis for the POC?

Assessment data in the medical record

A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first?

Auscultate with the bell over the lateral lobes If a nurse palpates an enlargement of the thyroid, auscultation should be performed with the bell of the stethoscope to assess for the presence of a bruit. A bruit is a soft, swishing sound produced because of an increase in blood flow through the thyroid arteries. The nurse should also ask the client about past history of thyroid problems, the findings must be documented, then the health care provider notified once assessment is complete to obtain further orders.

A novice nurse is struggling with making accurate nursing diagnoses. The supervisor, a much more experienced nurse, counsels the novice on what characteristics help nurses make better diagnoses. Which of the following should the supervisor mention? Select all that apply.

Awareness of when exceptions apply to rules A focus on the big picture Years of experience Seeing shades of gray when making decisions

How does the client's medical record affect financial reimbursement?

Insurance companies audit client records to ensure that billing is accurate

The nurse is reviewing the patient's medical record. Which of the following does the nurse recognize as accurate documentation? (Select all that apply.)

Bowel sounds are hyperactive in all 4 quadrants. Coarse rhonchi noted throughout lung fields Left dorsalis pedis pulse weaker than right.

The nurse practitioner auscultates both lobes of a client's enlarged thyroid gland. Identification of what sound would tend to confirm a diagnosis of a toxic goiter?

Bruit

One of the goals of nursing is to provide care that is safe to clients. What is the best way for nurses to realize this goal?

By continual communication with all members of the health care team

A hospital is changing the format for documentation in an attempt to decrease the amount of time the nurses are spending on charting. The new type of charting will require that the nurses document the significant findings as a narrative note in a shorthand method using well-defined standards of practice. Which of the following best defines this type of charting?

Charting by exception

A nurse proposes a nursing diagnosis for a client based on subjective and objective data. What step should the nurse perform before the diagnosis can be confirmed or ruled out?

Check for the presence of major and minor defining characteristics

A physician has asked a nurse to use written forms of communication to share the client's health status with other medical personnel. Which of the following is an example of a written form of communication that the nurse should use?

Checklists

Which technique demonstrates the proper positioning of the client's arm by a nurse when measuring a blood pressure? Client standing with arm outstretched and at the level of the heart Client sitting with arm slightly flexed and even with the heart Client's arm above the level of the heart and resting on a bedside table Client's arm bent at the elbow and resting on the thigh

Client sitting with arm slightly flexed and even with the heart

Which step in the diagnostic reasoning process does the nurse look at the identified abnormal findings and strengths for cues that are related?

Cluster Data

A nurse is busy analyzing data collected for an elderly Indian client with Alzheimer's disease who is in the hospital for pneumonia. The nurse originally had "demonstrates dementia" and "does not respond when spoken to" grouped together as symptoms of Alzheimer's. Later, however, the nurse learned that the client is also hearing impaired, which better explains the fact that the client does not respond when spoken to. Which error did the nurse commit in this case?

Clustering together unrelated cues

What should the nurse do prior to analyzing data collected on a patient with Addison's disease? (Select all that apply)

Collect and organize assessment data. Validate data. Document data.

What will be the nurse's initial role when conducting a health assessment with a client reporting abdominal pain?

Collecting data regarding the nature of the pain

The nurse is assessing a patient with a history of Korsakoff syndrome. What would the nurse expect this patient might demonstrate?

Confabulation

When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics?

Consistency, delineation, mobility, tenderness

A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition?

Corrective lenses

The nurse notes unilateral facial drooping and reports the finding immediately to the healthcare provider. The client is diagnosed with Bell palsy. The nurse should include assessment of which affected cranial nerve in the client's head and neck assessment?

Cranial nerve VII Facial asymmetry may indicate inflammation of cranial nerve VII with Bell palsy.

The student nurse asks the instructor, "What is the difference between the data analysis and the diagnostic phase?" What is the best response by the instructor?

Data analysis is also referred to as the diagnostic phase because the end result is the identification of the nursing diagnosis."

Which strategy reduces documentation errors? Select all that apply.

Document patient information immediately. Designate a person to document during emergencies. Organize patient data logically, using a timed sequence.

A nurse has completed her physical examination of a client and is recording her findings. Which of the following should she do while documenting? Select all that apply.

Document the findings in a private area, where no other clients can read the nurse's notes Write entries objectively without making premature judgments or diagnoses

A nurse has performed a head and neck assessment of an adult patient and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action?

Document this as an expected assessment finding

A nurse needs to assess the temperature of a client with high fever. Which of the following sites will most closely reflect core body temperature of the client? Ear Mouth Rectum Axilla

Ear

While playing, a preschool age child figures out how to use a toy for another purpose. Which structure of the personality is this child demonstrating?

Ego

The paramedics are called to a gym to see an individual who has been exercising and developed pain in the upper right quadrant of the abdomen. The initial vital sign reading indicates a pulse of 175 beats per minute. This pulse would be considered what? (Mark all that apply.)

Elevated due to pain Elevated due to anxiety Elevated due to activity

While assessing the eye of an adult client, the nurse observes an inward turning of the client's left eye. The nurse should document the client's

Esotropia is an inward turn of the eye.

Revising the plan as needed occurs in what part of the nursing process?

Evaluation

Nurses use the FLACC scale to assess pain in children ages 2 months to 7 years. This scale uses which of the following indicators? (Select all that apply.)

Facial expression Leg movements Activity Cry Ability to console patient

Primary headaches are more worrisome than secondary headaches.

False

A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider?

Fixed to underlying tissue Normally lymph nodes are round and soft, less than 1 cm in size, mobile from side to side, soft in consistency, and nontender. A fixed lymph node may be seen in metastatic disease.

The nurse suspects that a client is experiencing normal age-related changes in mental functioning. What assessment finding caused the nurse to come to this conclusion?

Forgot the word to describe indigestion

During a mental health assessment, how can the nurse obtain subjective data? Select all that apply.(Select all that apply.)

From the client From the client's family From an overheard conversation the client has with someone else

A nurse is assessing a client's pain level while taking his blood pressure. Which of the following are signs of pain that the nurse should look for in the assessment? Select all that apply.

Grimacing Holding a shoulder Shallow, rapid breathing

A nurse has completed the assessment phase of the nursing process with a client and is now moving into the data analysis phase. Which of the following are essential components that the nurse will address in this phase? Select all that apply.

Grouping and organizing data Clustering data to make inferences Generating possible hypotheses

Which of the following findings from a nutritional history most likely indicate the client is showing signs of an eating disorder? (Select all that apply.)

Has body mass index of 16 Discusses feeling fat in clothes

A nurse performs an admission assessment and notices that a client's speech is slow and the client has difficulty answering some of the questions. How can the nurse differentiate the cause of the client's slow speech?

Have the client read a few sentences out loud

A nurse is collecting both subjective and objective data in assessment of a client's mental health. Which of the following are examples of subjective data? Select all that apply.

History of hospitalization for a mental health problem History of Alzheimer's disease in a family member Use of recreational drugs Onset of memory lapses

What structure is found midline in the tracheal area just beneath the mandible?

Hyoid bone

The nurse is formulating a wellness diagnosis for a patient ready for discharge from the hospital. In order to do this, what must the nurse identify?

Identified strengths

You are the office nurse admitting a new patient to the clinic. You have gained your patient's trust, gathered a detailed history, and finished your portion of the physical examination. What is your next step in caring for this patient?

Identify the patient's problems

The nurse is deciding if an older client's moral behavior is normal or abnormal. What should the nurse consider before making this decision?

If the client is harming self or others

Shortly after a client departs the office following a routine physical, the nurse notices in her chart that the client has gained 10 lb in the past year and is now overweight. Although the client is generally healthy, the nurse realizes that if this trend continues, the overweight will begin to affect the client's health. The nurse makes a note to discuss it with the client at the next visit. Which nursing diagnosis would be most appropriate for this client?

Imbalanced nutrition: more than body requirements

The nurse gathers the follow data: complaint of headache and sore throat, redness noted on pharynx with white exudates on tonsils, minimal cough, temperature 100.6°F orally. It was noted that the patient had another sore throat 2 weeks ago. The most appropriate nursing diagnosis for this data would be

Impaired comfort related to headache and sore throat pain

The client states her husband died a few months ago and she has not been the same since. Which nursing diagnosis is most appropriate?

Ineffective coping

The preschool teacher tells the parents their child is playing well with others and frequently shares his toys. The nurse recognizes the preschool is demonstrating what stage of Erikson?

Initiative

A middle-aged client reports difficulty in reading. Which action by the nurse is appropriate to test near visual acuity using a Jaeger reading card?

Instruct the client hold the chart 14 inches from the eyes

The nursing assistant obtains vital signs and reports a blood pressure of 180/95 to the nurse. What is the nurse's best action? Ask the nursing assistant to check for symptoms of hypertension. Document the blood pressure as an expected finding. Notify the healthcare provider immediately. Instruct the nursing assistant to obtain a manual blood pressure.

Instruct the nursing assistant to obtain a manual blood pressure.

A nurse has begun a new job at a mental health facility. The supervisor is explaining to the nurse the features included in the definition of a mental disorder, according to the DSM-5. Which of the following should the supervisor mention to the nurse? Select all that apply.

Is a behavioral or psychological syndrome or pattern that occurs in an individual Reflects an underlying psychobiologic dysfunction Results in clinically significant distress or disability

A nurse is assessing a 40-year-old client in terms of his psychosexual, psychosocial, cognitive, and moral development using both subjective and objective data. Which of the following are examples of objective data collected by the nurse? Select all that apply.

Is capable of repressing anxious thoughts Demonstrates generativity Is capable of readjusting and modifying goals as necessary Appears to rely on internalized principles of self when making moral decisions

How does computerized documentation enhance communication? (Select all that apply.)

It is legible and time dated It permits multiple simultaneous users It increases compliance

The nurse overhears a parent explain a Bible story that the young child heard in a Sunday school class. According to Kohlberg, what is the goal of moral judgment?

Justice

Which of the following assessment findings most likely constitutes a secondary skin lesion

Keloid formation at the site of an old incision

A nurse obtains a client's blood pressure (BP) on admission in both arms: right arm BP is 130/75 mm Hg and left arm BP is 140/80 mm Hg. Which arm should the nurse use for subsequent blood pressure reading? Left arm Right arm Dominant arm Both arms

Left arm

A nurse reviews the documentation of the nurse on the previous shift and finds that the client was obtunded. The nurse anticipates that the client will respond to stimulation in what manner?

Opens eyes to a loud voice and answers with confusion

A nurse finds a radial pulse that is weak and thready. What action should the nurse take next?

Palpate the carotid arteries

A patient with abdominal pain is admitted from the emergency department. After having a gastrointestinal consultation and numerous tests, the results have been recorded on the patient's chart. The nurse knows to look at what part of the patient's medical record to check the current medical diagnosis?

Progress notes

A client complains of recurring headaches that are worse when first waking in the morning and with coughing or sneezing. What would be the nurse's most appropriate action?

Perform a focused assessment

The nurse is using the Visual Analog Scale to assess pain of an adult patient. The nurse instructs the patient to:

Place a mark on a 100-mm line with "no pain" at one end and "worst possible pain" at the other

A college student presents with a sore throat, fever, and fatigue for several days. Exudates are on her enlarged tonsils. A careful lymphatic examination reveals some scattered small mobile lymph nodes just behind her sternocleidomastoid muscles bilaterally. What group of nodes is this?

Posterior cervical The group of nodes posterior to the sternocleidomastoid muscle is the posterior cervical chain. These are common in mononucleosis.

The nurse observes a middle-aged colleague fully extending her arm to read the label on a vial of medication. Which of the following age-related changes is the nurse likely to have observed?

Presbyopia Prebyopia denotes an age-related deficit in close vision. It is less likely that cataracts, macular degeneration, or loss of convergence underlie the colleague's visual changes

A client reports severe pain in the posterior region of the neck and difficulty turning the head to the right. What additional information should the nurse collect?

Previous injuries to the head and neck Previous head or neck injuries may cause limitations in movement and chronic pain. Change in sleeping habits is too vague to be correct. The other two options may produce pain but not necessarily limit functioning.

The nurse is preparing to perform a head and neck assessment of an adult client who has immigrated to the United States from Cambodia. The nurse should first

ask the client if touching the head is permissible.

You are teaching a health class. What would you tell older adults is necessary when they are exposed to heat stress or when they perform sustained vigorous physical activity?

Purposeful drinking

A nurse in a dermatology clinic cares for an adolescent patient with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this patient?

Pustular acne

An older adult comes to the clinic reporting pain in the right lower quadrant. When assessing the client's pain, what elements would the nurse include? (Mark all that apply.)

Quality Intensity Quality

When assessing a client's pulse, the nurse should be alert to which of the following characteristics?

Rate, rhythm, amplitude and contour, and elasticity.

The nurse is formulating a nursing diagnosis for a patient that has had complete closure of an open abdominal wound. What would be an appropriate nursing diagnosis for this patient?

Readiness for enhanced skin integrity

A nurse obtains a height measurement on an elderly client and notes that the height has decreased from 5 years ago. What is an appropriate action by the nurse?

Record this measurement in the client chart and alert the health care provider

When educating a patient about the risks of malignant melanoma, what would you know to include? (Mark all that apply.)

Red or light hair Freckles Immunosuppression

When assessing level of consciousness, what should a nurse do if a client does not respond appropriately to a verbal stimulus?

Repeat the command louder and in a lower tone of voice

The nurse notes which of the following vital sign findings as an abnormal finding in an 88-year-old client?

Respiratory rate of 22 breaths/minute.

When delegating tasks, the RN adheres to the Five Rights of Delegation principle which includes which rights? (Select all that apply.)

Right task Right circumstances Right person Right directions

What intervention will the nurse implement initially for a client who has reported experiencing unexplained, severe neck pain for more than 2 months?

Screen for possible depression.

For which of the following assessments would the nurse plan to use deep palpation? (Select all that apply.)

Shape of abdominal mass Size of liver Pulsation of abdominal aorta

A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true?

She can see at 20 feet what a normal person could see at 100 feet.

The nurse is assessing a 79-year-old man who experienced an ischemic CVA 7 weeks prior and has a consequent loss of mobility. Because the client spends so much time immobilized, the nurse recognizes the importance of screening for pressure ulcers. Which of the following assessment findings would signal to the nurse an early sign of skin breakdown?

Skin that feels boggy on palpation Boggy skin consistency indicates a stage 1 pressure ulcer. Eschar and skin loss to the dermis would be noted in a more severe pressure ulcer; excessive sweating may constitute a risk factor but is not necessarily a sign of skin breakdown.

When assessing a patient with Graves disease, how would you expect the thyroid gland to be?

Soft in Graves disease; firm in Hashimoto thyroiditis, malignancy. Benign and malignant nodules, tenderness in thyroiditis.

What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia?

Spooning Spoon nails are indicative of iron deficiency anemia.

When a nurse works in a health care agency that charts by exception (CBE), the nurse knows that the client assessment is structured by what?

Standardized norms

The nurse has confirmed a diagnosis of Body Image Distrubance related to changes in physical appearance. What would the next step in the diagnostic reasoning process be?

Step Seven--Document Conclusions

A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches?

Stiff neck Limitation of neck mobility may be from muscle tension/strain or cervical vertebral joint dysfunction.

A young adult wants to lose weight and have a rhinoplasty to improve physical appearance. What additional issues should the nurse assess that may affect this client's self-concept? Select all that apply.

Style Fitness Sexuality

The nurse notes that an older client is grieving the loss of a dear friend as intensely as the death of a spouse a few months ago. What should this observation indicate to the nurse?

Subsequent losses are not less painful

In light of the low incidence of suicide, nurses are encouraged to perform what type of screening?

Targeted

Erikson theorizes that the school-aged child faces the task of industry vs. inferiority. What is the danger in this stage of development?

The child will not be able to learn to use adult tools

The Joint Commission mandates that nurses assess and reassess a client's pain level. A nurse's healthcare facility mandates pain reassessment at 30 minutes for any drug given intravenously. This mandate is based on what?

The time it takes a pain medication to decrease pain intensity

A nurse is recording some vital signs in a 12-year-old girl's chart when the girl asks why the nurse is writing all that information down. Which of the following should the nurse mention to this client as reasons for documenting assessment findings? Select all that apply.

To prevent delays in carrying out the plan of care To determine the educational needs of the client

A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance?

To provide a record of the actual events

A nurse is caring for a client whose injured cells are releasing chemicals such as substance P, prostaglandins, bradykinin, histamine, and glutamate. Which phase of pain is the client experiencing?

Transduction

Which of the following sites results in measuring a patient's core body temperature? Tympanic Oral Sublingual Axillary

Tympanic

A nurse begins a comprehensive physical examination on a client and notes that the client has a large amount of adipose tissue around the waistline. The nurse recognizes that this client should be assessed for an increased risk of which diseases? Select all that apply.

Type II diabetes mellitus Hypertension Stroke

What is the most important focus area for the integumentary system?

UV radiation exposure

A client shows the school nurse a rash that has developed on the back of her left hand. The school nurse assesses the rash as a depigmented macular area. What might the nurse suspect?

Vitiligo In vitiligo, depigmented macules appear on the face, hands, feet, extensor surfaces, and other regions and may coalesce into extensive areas that lack melanin. The brown pigment is normal skin color; the pale areas are vitiligo. The condition may be hereditary. These changes may be distressing to the patient.

The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the following drawbacks?

Vulnerability to legal liability since the nurse's safe, routine care is not recorded.

A middle-aged adult learned how to use a computer at the age of 30. What does this indicate about the client's developmental level?

Well-developed formal operations

The nurse notes that an older client speaks rapidly and uses words that make no sense or communicate any clear meaning. When documenting this finding, the nurse should use which term to describe this client's speech?

Wernicke's aphasia

Which of the following questions would be most helpful in beginning an initial assessment interview for a patient who has just been admitted to a psychiatric inpatient unit?

What brings you into the hospital today?"

A client seeks medical attention for the skin lesion shown. What should the nurse document as this type of lesion?

Wheal A wheal is an elevated mass with transient borders that is often irregular. A papule is an elevated, palpable, solid mass, with a circumscribed border and less than 0.5 cm in size. A pustule is a pus-filled vesicle or bulla. An erosion is a loss of superficial epidermis that does not extend to the dermis.

The nurse is performing a physical examination and notes an enlarged left supraclavicular lymph node. The nurse understands that this could be indicative of

a metastasis

After using the SLUMS tool to test a client's mental status, the nurse calculates a score of 12. The nurse should make

a referral to the primary health care provided for further evaluation.

The nurse understands that, after clustering data and drawing inferences, if the problem is something a nurse could manage independently the next step would be which of the following?

analyzing the data

The CAGE assessment is used by the nurse to determine if further assessment is needed. The nurse may assess that it is highly likely the client has a problem and would seek additional assessments if the client

answered "yes" to three of the four CAGE questions.

The patient has difficulty when the nurse asks him to say "No ifs, ands, or buts." The nurse understands that this may indicate a form of

aphasia

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the

areola of the breast. The apocrine glands are associated with hair follicles in the axillae, perineum, and areola of the breast. Apocrine glands are small and non-functional until puberty at which time they are activated and secrete a milky sweat.

While assessing an adult client's feet for fungal disease using a Wood light, the nurse documents the presence of a fungus when the fluorescence is

blue.

The nursing student has learned that diagnostic reasoning has several pitfalls. The second set of pitfalls usually occurs during the analysis phase and involves which of the following?

cues that are clustered yet unrelated

The person who has attained Kohlberg's Conventional level of moral development is best described as

desiring to avoid disapproval from others and be considered a respectful, helpful person.

An assessment form commonly used in long-term care facilities is the nursing minimum data set. One primary advantage to this type of assessment form is that it

establishes comparability of nursing data across clinical populations.

What is a characteristic symptom of Graves hyperthyroidism?

exophthalmos the eyeball protrudes forward. When bilateral, it suggests the infiltrative ophthalmopathy of Graves hyperthyroidism.

The nurse is caring for an adult client who tells the nurse "For weeks now, I've been so tired. I just can't get to sleep at night because of all the noise in my neighborhood." An actual nursing diagnosis for this client is

fatigue related to excessive noise levels as manifested by the client's statements of chronic

The nurse is caring for an adult client who tells the nurse "For weeks now, I've been so tired. I just can't get to sleep at night because of all the noise in my neighborhood." An actual nursing diagnosis for this client is

fatigue related to excessive noise levels as manifested by the client's statements of chronic fatigue.

Which nursing intervention does a client who is in the obtunded level of consciousness require most?

frequent reorientation

The nurse is planning to assess a client's near vision. Which technique should be used?

have the client read newspaper print held 14 inches from the eyes

A 20-year-old client visits the outpatient center and tells the nurse that he has been experiencing sudden generalized hair loss. After determining that the client has not received radiation or chemotherapy, the nurse should further assess the client for signs and symptoms of

hypothyroidism.

The nurse divides collected data into subjective and objective categories. What should the nurse do next in the critical thinking process?

identify abnormal data and strengths

The nurse is reviewing the laboratory report for a client with poorly controlled diabetes. This action falls within which step of clinical reasoning?

identifying abnormal or positive findings

Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV

intact, firm skin with redness ulceration involving the dermis full-thickness skin loss necrosis with damage to underlying muscle

When the client reports a problem associated with the drainage of tears from the left eye, the nurse would focus the eye assessment on which eye structure?

lacrimal puncta The lacrimal gland lies mostly within the bony orbit, above and lateral to the eyeball. The tear fluid spreads across the eye and drains medially through two tiny holes called lacrimal puncta. The nurse can easily find a punctum atop the small elevation of the lower lid medially. The tears then pass into the lacrimal sac and into the nose through the nasolacrimal duct.

A patient complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent

macular degeneration

As the nurse palpates the lymph nodes of the neck, hard and fixed nodes are noted in the supra-clavicular region. This finding is consistent with which condition?

malignancy Hard or fixed nodes, particularly in the supra-clavicular region of the neck, suggest a malignancy. This could even be a possible metastasis of a thoracic or abdominal malignancy. Although inflamed or enlarged nodes may be tender on palpation, the node should still be mobile.

The nurse assesses a client with noisy breathing including a gasping sound with respiration. The nurse notes tracheal deviation from the usual midline position. Which conditions should the nurse assess for further? Select all that apply.

mediastinal mass atelectasis pneumothorax goiter

A patient with diabetes is admitted to the medical unit for the fifth time in 6 months because of elevated blood glucose level. The nurse caring for the patient immediately states, "I knew she would be back. It was just a matter of time. She is so noncompliant." This is an example of which of the following?

not hypothesizing several diagnoses

Squamous cell carcinoma is associated with

overall amount of sun exposure. Squamous cell carcinoma is most common on body sites with very heavy sun exposure.

Before the nurse analyzes the data collected, the nurse should

perform the steps of the assessment process accurately.

The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess first?

preauricular The lymph nodes in front of the ear, or preauricular, are usually palpated first. The submental nodes are under the chin.

The nurse suspects that a client has Cushing's syndrome. What assessment finding did the nurse use to make this clinical determination?

red cheeks The increased adrenal cortisol production of Cushing syndrome produces a round or "moon" face with red cheeks.

A mother brings her 4-year-old daughter to the clinic and reports that the child has developed a rash that she is constantly scratching on her abdomen. On examination, the nurse finds that the rash is serpiginous. The nurse would know that the rash is most probably caused by

scabies A serpiginous rash is snaking. This type of rash can be caused by scabies.

During an examination, the patient has incomprehensible, illogic speech that changes abruptly from one topic to another. The nurse should refer this patient for further evaluation of

schizophrenia

The nursing instructor realizes that the nursing student understands all the criteria necessary for developing expertise when making clinical professional judgments by identifying the following as being a barrier to diagnostic reasoning.

seeing things as only right or wrong

The nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that

squamous cell carcinomas are most common on body sites with heavy sun exposure.

Connecting the skin to underlying structures is/are the

subcutaneous tissue. Subcutaneous tissue, which contains varying amounts of fat, connects the skin to underlying structures.

An adult male client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. The nurse should further assess the client for

symptoms of stress. Patchy hair loss may accompany infections, stress, hairstyles that put stress on hair roots, and some types of chemotherapy.

While assessing the head and neck of an adult client, the client tells the nurse that she has been experiencing sharp shooting facial pains that last from 10 to 20 seconds but are occurring more frequently. The nurse should refer the client for possible

trigeminal neuralgia. Trigeminal neuralgia (tic douloureux) is manifested by sharp, shooting, piercing facial pains that last from seconds to minutes. Pain occurs over the divisions of the fifth trigeminal cranial nerve (the ophthalmic, maxillary, and mandibular areas

An older client visits the clinic accompanied by his daughter. The daughter tells the nurse that her father has been experiencing severe headaches that usually begin in the morning and become worse when he coughs. The client tells the nurse that he feels dizzy when he has the headaches. The nurse refers the client for further evaluation because these symptoms are characteristic of a

tumor-related headache. Tumor-related headaches have no prodromal stage; may be aggravated by coughing, sneezing, or sudden movements of the head.

The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's

vesicles.

The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's

vesicles. Vesicles are circumscribed elevated, palpable masses containing serous fluid. Vesicles are less than 0.5 cm. Examples of vesicles include herpes simplex/zoster, varicella (chickenpox), poison ivy, and second-degree burn.

During a physical examination of the head and neck, a client reports frequently feeling cold. What additional questions should the nurse ask for more information about the client's symptoms? (Select all that apply.)

"Do you dress more warmly than other people? "Do you use more blankets that others at home? "Do you perspire less than others?"

While the nurse is obtaining a client's health history regarding the head and neck,the client tells the nurse about having a lump in the neck. In order to assess for associated manifestations of this problem, which of the following questions should the nurse ask next?

"Do you have difficulty swallowing? To assess manifestations associated with the lump in the neck, the nurse would ask if the patient has difficulty swallowing. Asking how long the client has experienced discomfort from the lump is associated with duration. Asking when the patient first noticed the lump assesses the onset of the lump. Asking if there is there more than one lump assesses the location of the lump.

A female client describes headache symptoms that seem to indicate a migraine. Which of the following questions during the client interview would, if answered in the positive, tend to confirm the nurse's suspicion?

"Does the headache occur regularly with your menstrual cycle?"

Which statement by an adolescent female client admitted for excessive weight loss and dehydration requires validation by the nurse?

"I am very happy with my life right now"

The nurse manager reviews documentation completed by a graduate nurse. Which entry should the manager question? Select all that apply

Appetite good Right foot swollen Vital signs normal

A nurse has just finished assessing a client. Which of the following are objective data that the nurse would likely have gathered?

A description of a large bruise on the client's thigh The client's weight The presence of a lump in the client's breast discovered on palpation

Upon examination of the head and neck of a client, a nurse notes that the submandibular nodes are tender and enlarged. The nurse should assess the client for further findings related to what condition?

Acute infection

The nurse is performing visual acuity testing on an older adult who has fallen and fractured their femur. What finding would be considered normal for this client? (Select all that apply.)

Arcus senilis Small cataract Decreased central vision

What are nurses able to detect through the health assessment?

Areas in need of health adjustments

A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action should the nurse perform next?

Assess the client's blood pressure. Onset of headache after the age of 50 paired with the statement the client has made here is considered a "red flag." The nurse should suspect this is a secondary headache or arising from another condition. Markedly elevated blood pressure could be indicative of imminent danger to the client's life. Assessment of the blood pressure should be the nurse's first action.

The nurse is palpating a client's cervical vertebrae. Which vertebra can be easily palpated when the neck is flexed and should help the nurse locate the other vertebrae?

C7 The cervical vertebrae (C1 through C7) are located in the posterior neck and support the cranium. The vertebra prominens is C7, which can easily be palpated when the neck is flexed. Using C7 as a landmark will help you to locate other vertebrae.

A nurse has completed assessing a client and now must validate the collected data. What are the steps that the nurse should follow? Select all that apply.

Decide whether the data require validation. Determine ways to validate the data. Identify areas where data are missing.

The nurse is performing a shift assessment on a client who just received a central line. Which finding should the nurse report as a complication of central line placement?

Decreased breath sounds unilaterally

The nurse is assessing a client's parathyroid gland. Which is the most likely finding the nurse will encounter with hyperparathyroidism?

Decreased serum calcium level on review of labwork.

A nurse has performed a head and neck assessment of an adult patient and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action?

Document this as an expected assessment finding It is not unusual for the thyroid lobes to be non-palpable using the posterior approach.

What activity is known to aggravate a tension headache?

Driving Factors that aggravate or provoke: sustained muscle tension, as in driving or typing.

A nurse experiences difficulty auscultating the heart sounds of a client. What should the nurse do to enhance the sounds of the heart tones? Select all that apply.

Eliminate distracting noises from the environment Readjust the ear pieces to ensure a snug fit Angle the binurals towards the nose

The hospital where a nurse works is converting from a paper-based documentation system to a computer-based one. The nurse recognizes that which of the following are advantages of computer-based over paper-based systems? Select all that apply.

Elimination of redundant data collection by other health care team members Increased likelihood that clients will receive life-saving treatment Potential lowered risk of hospital-acquired infections Ability to link the client's health record to other documents

A client's lab results reveal thyroid stimulating hormone level of 7.0 mU/L; Free T4 0.5 ng/dl; Total T3 60 ng/dl; and Total T4 3mdmg/dl. Based on these lab results what symptoms should the nurse expect the client to reveal?

Fatigue, cold intolerance, and constipation. The client's lab values are consistent with hypothyroidism. Fatigue, cold intolerance, constipation, depression, anorexia, dry skin, brittle and coarse hair, menstrual irregularities, and weight gain are all symptoms of hypothyroidism

On palpation, the nurse notes that a client's thyroid gland is diffusely enlarged. Which of the following health problems would the nurse want to rule out?

Graves' disease Graves' disease is associated with a diffusely enlarged thyroid. This finding is not normally consistent with neoplasm, hypothyroidism, or nephritic syndrome.

When assessing the head and neck, the nurse should realize that variations in skull or neck shape or size relate most to what?

Height and weight

A client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of post-operative care teaching?

I must take thyroid hormone replacement medication for the rest of my life After thyroidectomy, clients must be treated with exogenous thyroid hormone for the rest of their lives. Thyroid hormones are usually taken by mouth on a daily basis.

Impaired dilation of the eye is evaluated with an assessment of which cranial nerve (CN)?

III (oculomotor)

While the nurse is assessing a client for an unrelated health concern, the client experiences a sudden, severe headache with no known cause. He also complains of dizziness and trouble seeing out of one eye. What associated condition should the nurse suspect in this client? You Selected:

Impending stroke A sudden, severe headache with no known cause may be a sign of impending stroke, particularly if accompanied by sudden trouble seeing in one or both eyes or sudden trouble walking, dizziness, and loss of balance or coordination. Only impending stroke is associated with all of these symptoms.

You should use the bell of the stethoscope when auscultating what type of sounds?

Low-frequency sounds

Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse?

Open the mouth While performing the assessment of the temporomandibular joint, the nurse should ask the client to open the mouth. This gives an easy access to the joint. Telling the client to sit upright and not move helps in performing the overall examination; however, it does not contribute to the examination of the temporomandibular joint. Telling the client to perform a chewing action is not appropriate.

A client complains of pain, numbness, and tingling in the upper extremities for several weeks before coming to the clinic for evaluation. What is the nurse's best action?

Suggest referral to orthopedic spine specialist. Pain, numbness, or tingling may indicate compression of spinal root nerves, requiring further evaluation, preferably by a spine specialist. Limited range of motion with pain is most indicative of arthritis, not spinal nerve root compression. Neck exercises do not relieve nerve compression; the client needs further evaluation first. Signs of head injury include changes in level of consciousness and orientation and behavior changes.

A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis?

Tension This is a description of a typical tension headache.

A nurse is performing indirect percussion of the lungs on a young woman with pneumonia. Which of the following is the correct hand placement for this technique?

The middle finger of one hand is placed on the body surface and the other middle finger strikes.

Which is an example of inspection? Select all that apply.

The nurse notes a fine rash covering the individual's thorax. The nurse notes symmetry of the individual's thorax. The nurse detects foul odor of the urine.

The nurse is assessing a client complaining of swelling in the neck. While palpating the neck, the nurse finds a 2-cm lump that is fixed and hard. Why does this finding require emergency investigation?

This could be a sign of cancer Lymphatics larger than 1 cm, fixed, irregular, or hard or rubbery require emergency investigation. Such signs raise the possibility of cancer. The signs and symptoms cited in the scenario do not indicate pneumothorax, embolus, or parotid stone.

A nurse caring for a client at a health care facility has to maintain a medical record for the client. Which of the following is a use of the medical record?

To investigate the quality of care in the agency

A teenager is brought to the clinic for a sports physical examination. The client states plans to play goalie on the community soccer team. What is the most important teaching opportunity presented for this client?

Use of safety equipment The nurse should assess with each client the use of safety equipment when playing sports. Proper eye protection can prevent many sports-related eye injuries

A nurse is examining the eyes of a 7-year-old boy. The boy asks the nurse, "What's inside my eyeball?" The nurse explains that the biggest space inside the eyeball contains a clear, gelatinous substance that light passes through. Which of the following is the technical name for this gelatinous substance?

Vitreous humor Vitreous humor is the clear and gelatinous substance that fills the vitreous chamber, the largest chamber of the eye, which is located in the area behind the lens to the retina

The nurse is preparing to assess a client's thyroid gland using the posterior approach. What direction should the nurse provide regarding the client's head?

flex the neck forward When assessing the thyroid gland from the posterior approach the client should flex the neck forward to relax the neck muscles. Tilting the head back would be used if assessing the thyroid gland using the anterior approach. Turning the head to the right or left shoulder would be done later in order to further assess the individual thyroid gland lobes.

An adult client tells the nurse that her peripheral vision is not what it used to be and she has a blind spot in her left eye. The nurse should refer the client for evaluation of possible

glaucoma. A scotoma is a blind spot that is surrounded by either normal or slightly diminished peripheral vision. It may be from glaucoma.