Learning System: Quiz by Category

during a physical exam of a client, the nurse suspects strabismus. which of the ff. test should the nurse use to collect additional data?

Corneal light reflex - the corneal light reflex requires the nurse to shine a penlight at the client's eyes and visualize whether the light shines on the same spot bilaterally. this test will indicate the alignment of the client's eyes as well as any deviation inward or outward. w/ strabismus, the eyes will not align when the client focuses

a nurse is supervising a newly licensed nurse who is suctioning a client's tracheostomy. which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

administering high-flow oxygen prior to the procedure - the nurse should instruct the newly licensed nurse to administer 3 to 4 breaths of 100% oxygen via a resuscitation bag before suctioning to the client to reduce the risk of hypoxia

a nurse in an urgent-care center is caring for a 15-year-old client whose symptoms suggest a sexually transmitted infection (STI). the client's parent is unavailable, but the client's grandmother accompanied the client to the clinic. which of the following actions should the nurse take?

ask the adolescent to sign the consent form - unemancipated minors (those who don't live on their own, are not married, and are not in the military) can legally give informed consent for diagnostic procedures and treatment in some situations. these situations include treatment for STIs and substance use disorders

a nurse is assessing a client who is undergoing a physical exam. ff. the inspection, which of the following techniques should the nurse use next when assessing the client's abdomen?

auscultation - according to evidence-based-practice, the nurse should listen for bowel sounds in all 4 quadrants before palpating the client's abdomen. palpation and percussion can stimulate the bowel and increase the frequency of bowel sounds, leading to false results.

a nurse is caring for a client who just received a diagnosis of cancer. the client states, " i just dont know what I'm going to do now." which of the ff. responses should the nurse make?

can you explain the concerns you're having right now? -this response uses the therapeutic communication technique of asking a relevant question. by using an open-question. by using an open-ended question to ask the client to explain any present concerns, the nurse is encouraging the client to respond and provide additional information

a nurse is communicating w/ a group of clients about what to expect during the post.op phase of a total hip arthroplasty. Which of the following elements of the communication process should the nurse identify as an evaluation of effective communication?

feedback is provided - feedback in verbal and/or nonverbal forms is evidence of successful communication. feedback can indicate to the nurse whether the meaning of the message was understood by the recipient.

a nurse is teaching a client about lifestyle changes to manage a chronic illness. which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes.

help the client identify ways that these changes will result in positive personal outcomes - according to evidence-practice, the motivation to change must precede taking steps to make the change. therefore, helping clients identify ways that the changes will promote positive outcomes should precede other educational strategies for making the changes. the client should first see how the changes directly affect his/her life, thus enhancing the motivation to make the changes

a nurse in a provider's office is measuring a client and notes a loss in height form the previous year. the nurse should identify this findings as a manifestation of which of the ff. musculoskeletal system disorders?

osteoporosis - a loss of height is often an early indication of osteoporosis. this occurs due to loss of calcium in the vertebrae, which can cause them to fracture and collapse.

a nurse is preparing to perform mouth care for an unresponsive client. which of the following actions should the nurse plan to take?

raise the level of the bed - the nurse should raise the bed to allow the use of proper body mechanics and reduce the risk of self-injury

a nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular-sized cuff for a client who is obese. which of the following explanations should the nurse give the AP?

using a cuff that is too small will result in an inaccurately high reading - blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a reliable measurement. blood pressure readings can be falsely high if the cuff is too small for the client.

a nurse is initiating seizure precautions for a client who has seizure disorder. which of the following pieces of equipment should the nurse have readily available at the client's bedside?

Oxygen equipment - The nurse should have oxygen equipment at the bedside of a client who is on seizure precautions. the nurse should be able to apply oxygen via mask or nasal cannula to a client who experiences a seizure.