Level 3 Health & Physical Assessment (Nursing Fundamentals)

While assessing the pupils of a client, a healthcare professional notices pupillary dilatation. Which drug intake might have resulted in this condition? Multiple choice question Heroin Atropine Morphine Pilocarpine

Atropine The intake of eye medications such as atropine will cause dilatation of the pupils. Heroin, morphine, and pilocarpine cause pupillary constriction.

A client's breath has a sweet, fruity odor. Which condition is likely affecting this client? Multiple choice question Gum disease Uremic acidosis Diabetic acidosis Infection inside a cast

Diabetic acidosis A client with diabetic acidosis has a sweet, fruity odor to the breath. Gum disease is marked by halitosis. A stale urine smell indicates uremic acidosis. An infection inside a cast is accompanied by a musty odor of the casted body part.

The nurse cares for an unconscious client who underwent head surgery. Which site would be best used to monitor body temperature? Multiple choice question Skin Oral Axilla Rectal

Rectal Although the oral route is the most common route for monitoring body temperature, clients who are unconscious should have their temperatures monitored rectally. Skin temperature may be impaired due to diaphoresis; this measurement may not reliable. The axilla temperature may underestimate the core temperature.

The nurse is developing a nursing diagnosis for a client after surgery. The nurse documents the "related to" factor as first time surgery. Which assessment activity enabled the nurse to derive this conclusion? Multiple choice question The nurse notes nonverbal signs of discomfort. The nurse observes the client's position in bed. The nurse asks the client to explain the surgery. The nurse asks the client to rate the severity of pain.

The nurse asks the client to explain the surgery. The nurse must assess the client's knowledge about the surgery to determine if the client is aware of the outcome of surgery. The nurse observes for nonverbal signs of discomfort because some clients may not state that they are in pain. The nurse observes the client's positioning in bed to determine any abnormal signs such as discomfort or pain. The nurse asks the client to rate the severity of pain to determine a nursing diagnosis of pain related to a surgical wound.

A nursing student is recording the radial pulse rate in a client with dysrhythmias and documented a radial pulse of 80 beats per minute. The registered nurse reassesses the client and notices a pulse deficit of 15. What is the client's apical pulse? Multiple choice question 95 85 75 65

95 Dysrhythmias are often associated with pulse deficits. A pulse deficit is the difference between the apical and radial pulse rates. Thus, when the radial pulse (80) and the pulse deficit (15) are added together, the apical pulse would be 95.

A nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremities, the nurse notes that the client has thin, shiny skin; decreased hair growth; and thickened toenails. What might this indicate? Multiple choice question Venous insufficiency Arterial insufficiency Phlebitis Lymphedema

Arterial insufficiency Clients experiencing arterial insufficiency present with extremities that become pale when elevated and dusky red when lowered. Lower extremities may also be cool to touch, pulses may be absent or mild, and skin may be shiny and thin with decreased hair growth and thickened nails. Clients with venous insufficiency often have normal-colored extremities, normal temperature, normal pulses, marked edema, and brown pigmentation around the ankles. Phlebitis is an inflammation of a vein that occurs most often after trauma to the vessel wall, infection, and immobilization. Lymphedema is swelling in one or more extremities that is a direct result of impaired flow of the lymphatic system.

Which physical assessment technique involves listening to the sounds of the body? Multiple choice question Palpation Inspection Percussion Auscultation

Auscultation Auscultation involves listening to the sounds of the body. Palpation involves using the sense of touch to assess and collect data. An inspection involves the nurse carefully looking to collect data. Percussion involves tapping the skin with the fingertips to vibrate underlying tissues and organs.

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client? Multiple choice question Skin turgor Intake and output results Client's report about fluid intake Blood lab results

Blood lab results Blood lab results provide objective data about , as well as about hemoglobin and hematocrit. Skin turgor is not a reliable indicator of hydration status for the elderly client because it is generally decreased with age. Intake and output results provide data only about fluid balance, but do not present a comprehensive picture of the client's fluid and electrolyte status; therefore this is not the best answer. The client's report about fluid intake is subjective data in general and not reliable because this client has dementia and therefore has memory problems .

Which integumentary finding is related to skin texture? Multiple choice question Elasticity Vascularity Fluid buildup Character of the surface

Character of the surface Assessing for texture refers to the character of the surface of the skin. Assessing for elasticity determines the turgor of the skin. Assessing for vascularity determines skin circulation. Fluid buildup in the tissues indicates edema.

The findings of four clients who underwent eye examinations are given below. Which client is suspected to have sustained injury to the cranial nerve III? Client A: Drooping eyelids Client B: Nearsightedness Client C: Cross-eyes Client D: Protruding eyes

Client A: Drooping eyelids Injury to the third cranial nerve may result in edema or impairment of the third cranial nerve. This results in the abnormal drooping of the eyelids, a condition called ptosis. Myopia is nearsightedness, a refractive error in which rays of light enter the eye and focus in front of the retina. Cross-eyes result from strabismus, which results from neuromuscular injury or congenital anomaly. Protruding eyes (exophthalmoses) is indicative of hyperthyroidism.

The nurse tells a client undergoing diuretic therapy to avoid working in the garden on hot summer days. What condition is the nurse trying to prevent in this client? Multiple choice question Frostbite Heatstroke Hypothermia Hyperthermia

Heatstroke Clients undergoing diuretic therapy are at risk of heatstroke when exposed to temperatures higher than 40° C. Frostbite occurs when the body is exposed to ice-cold temperatures. Hypothermia is a condition in which the skin temperature drops below 36° C. Hyperthermia occurs when the body is exposed to temperatures higher than 38.5° C.

While inspecting the external eye structure of a client, a nurse finds bulging of the eyes. Which condition can be suspected in the client? Multiple choice question Eye tumors Hypothyroidism Hyperthyroidism Neuromuscular injury

Hyperthyroidism Bulging eyes may indicate hyperthyroidism. Tumors are characterized by abnormal eye protrusions. Hypothyroidism can be revealed by the coarseness of the hair of the eyebrows and the failure of the eyebrows to extend beyond the temporal canthus. Crossed eyes or strabismus may result from neuromuscular injury or inherited abnormalities.

A nurse is preparing a community health program for senior citizens. The nurse teaches the group that what physical findings are typical in older adults? Multiple choice question Increased skin elasticity and a decrease in libido Impaired fat digestion and increased salivary secretions Increased blood pressure and decreased hormone production An increase in body warmth and some swallowing difficulties

Increased blood pressure and decreased hormone production With aging, narrowing of the arteries causes some increase in the systolic and diastolic blood pressures; hormone production decreases after menopause. There may or may not be changes in libido; there is a loss of skin elasticity. Salivary secretions decrease, not increase, causing more difficulty with swallowing; there is some impairment of fat digestion. There may be a decrease in subcutaneous fat and decreasing body warmth; some swallowing difficulties occur because of decreased oral secretions.

A nurse is assessing a client's nails and finds a slight convex curve at the angle from the skin to nail base of about 160 degrees. Which condition does the nurse suspect? Multiple choice question Clubbing Paronychia Koilonychia Normal finding

Normal finding The client's nail, which has a slight convex curve at the angle from the skin to nail base of about 160 degrees, is normal. In clubbing, there is a change in the angle between the nail and the nail base that is larger than 180 degrees. Paronychia is the inflammation of the skin at the base of nail. Koilonychia is the concave curves on the nail.

Nurses care for clients in a variety of age groups. In which age group is the occurrence of chronic illness the greatest? Multiple choice question Older adults Adolescents Young children Middle-aged adults

Older adults The incidence of chronic illness increases in older adults because of the multiple stresses of aging. Younger individuals have greater physiologic reserves, and chronic illnesses are not common.

Which client assessment finding should the nurse document as subjective data? Multiple choice question Blood pressure 120/82 beats/min Pain rating of 5 Potassium 4.0 mEq Pulse oximetry reading of 96%

Pain rating of 5 Subjective data are obtained directly from a client. Subjective data are often recorded as direct quotations that reflect the client's feelings about a situation. Vital signs, laboratory results, and pulse oximetry are examples of objective data.

A client is admitted to the hospital with severe diarrhea, abdominal cramps, and vomiting after eating. These symptoms have lasted 5 days. Upon further assessment, the primary healthcare provider finds that the symptoms occurred after the client ate eggs, salad dressings, and sandwich fillings. Which food borne disease would be suspected in this client? Multiple choice question Listeriosis Shigellosis Salmonellosis Staphylococcus

Salmonellosis A client with salmonellosis will experience severe diarrhea, abdominal cramps, and vomiting; these symptoms last as long as 5 days after the intake of contaminated food. This disorder may be caused by Salmonella typhi or Salmonella paratyphi. The causative organism is usually present in such foods as eggs, salad dressings, and sandwich fillings. A client with listeriosis will experience severe diarrhea, fever, headache, pneumonia, meningitis, and endocarditis 3 to 21 days after infection. The symptoms of shigellosis range from cramps and diarrhea to a fatal dysentery that lasts for 3 to 14 days. Pain, vomiting, diarrhea, perspiration, headache, fever, and prostration lasting for 1 or 2 days are the symptoms of a Staphylococcus infection.

Which of the following is a description of the percussion technique? Multiple choice question Listening to sounds that the body makes Using the sense of touch to assess and collect data Carefully looking for abnormal findings Tapping the skin with the fingertips to vibrate underlying tissues

Tapping the skin with the fingertips to vibrate underlying tissues Percussion is a technique used to assess the skin by tapping the skin with the fingertips to vibrate underlying tissues and organs. Auscultation involves listening to the sounds that the body makes. Palpation involves using the sense of touch to assess and collect data. Generally during an inspection, the nurse should carefully look for abnormal findings.

The nurse is assessing a client who had knee replacement surgery. Which assessment finding gathered by the nurse is an example of subjective data? Multiple choice question The client weighs 151 lbs (68.5 Kg). The client's pain is 7 on a scale of 1 to 10. The client's fasting blood sugar is 95 mg/dL. The client's blood pressure is 140/90 mm/Hg.

The client's pain is 7 on a scale of 1 to 10. Subjective data is information conveyed to the nurse by the client, such as the client's feelings, perceptions, and self-reporting of symptoms. The client rates pain as a 7 on a scale of 1 to 10, therefore it is subjective data. Objective data are observations or measurements of a client's health status. The client's weight is measured on a weighing scale; therefore, it is objective data. A laboratory result such as fasting blood sugar and blood pressure are measurable quantities.

A nurse is assessing an older adult during a regular checkup. Which findings during the assessment are normal? Multiple selection question Loss of turgor Urinary incontinence Decreased night vision Decreased mobility of ribs Increased sensitivity to odors

-Decreased night vision -Decreased mobility of ribs -Loss of turgor In older adults, the skin loses its turgor or elasticity and there is fat loss in the extremities. Visual acuity declines with age; therefore, decreased night vision is a normal finding in older adults. Decreased mobility of the ribs is found in older adults due to calcification of the costal cartilage. Urinary incontinence is an abnormal finding in older adults. In older adults, diminished sensitivity to odor, not increased sensitivity, is often found.

A nurse is assessing an older adult client. Which clinical findings are expected responses to the aging process? Multiple selection question Slowed neurologic responses Lowered intelligence quotient Long-term memory impairment Forgetfulness about recent events Reduced ability to maintain an erection

-Slowed neurologic responses -Forgetfulness about recent events -Reduced ability to maintain an erection Slowing of neurologic responses is part of the aging process. Memory for short-term situations and events is reduced. The ability of the male to attain and sustain an erection is reduced. There should not be a loss of intellectual ability. Memory of long-term experiences and events should not be impaired.

Which degree of edema will result in a 6-mm deep indentation upon pressure application? Multiple choice question 4+ 3+ 2+ 1+

3+ The depth of pitting determines the degree of pitting edema. An indentation of 6 mm is scored to be a 3+ degree edema. An indentation of 8 mm is scored as 4+. An indentation of 4 mm is scored as 2+. An indentation of 2 mm is scored as 1+.

Which response by the nurse during a client interview is an example of back channeling? Multiple choice question "All right, go on..." "What else is bothering you?" "Tell me what brought you here." "How would you rate your pain on a scale of 0 to 10?"

"All right, go on..." Back channeling involves the use of active listening prompts such as "Go on...", "all right", and "uh-huh." Such prompts encourage the client to complete the full story. The nurse uses probing by asking the client, "What else is bothering you?" Such open-ended questions help to obtain more information until the client has nothing more to say. The statement, "Tell me what brought you here" is an open-ended statement that allows the client to explain his health concerns in his or her own words. Closed-ended questions such as, "How would you rate your pain on a scale of 0 to 10?" are used to obtain a definite answer. The client answers by stating a number to describe the severity of pain.

A client presents with bilateral leg pain and cramping in the lower extremities. The client has a history of cardiovascular disease, diabetes, and varicose veins. To guide the assessment of the pain and cramping, the nurse should include which question when completing the initial assessment? Multiple choice question "Does walking for long periods of time increase your pain?" "Does standing without moving decrease your pain?" "Have you had your potassium level checked recently?" "Have you had any broken bones in your lower extremities?"

"Does walking for long periods of time increase your pain?" Clients with a medical history of heart disease, hypertension, phlebitis, diabetes, or varicose veins often develop vascular-related complications. The nurse should recognize that the relationship of symptoms to exercise will clarify whether the presenting problem is vascular or musculoskeletal. Pain caused by a vascular condition tends to increase with activity. Musculoskeletal pain is not usually relieved when exercise ends. Low potassium levels can cause cramping in the lower extremities; however, given the client's health history, vascular insufficiency should be suspected. Previously healed broken bones do not cause cramping and pain.

Which statement made by the nurse indicates that the client interview is coming to a close? Multiple choice question "I have just one more question for you." "I hope you are comfortable and not in pain." "I would like to spend some time to understand your concerns." "I assure you that information I gather now will be confidential."

"I have just one more question for you." The nurse should give the client a clue that the interview is drawing to a close. The nurse can do this by letting the client know that after one more question the interview will be over. The nurse sets the stage for the interview by ensuring that the client is comfortable and not in pain. The nurse begins the interview by stating that he or she would like to spend some time to understand the client's health concerns. The nurse informs the client at the beginning of the interview that the information shared by the client is confidential.

A registered nurse is teaching a nursing student about precautions to be taken for physical examination of a client. Which statements made by the nursing student indicate effective learning? Multiple selection question "I should examine the client in noise-free areas." "I should use latex gloves during the physical examination." "I should perform a physical examination in a cool room." "I should leave a combative client alone during a physical examination." "I should wear eye shields while examining a client with excessive drainage."

"I should examine the client in noise-free areas." "I should wear eye shields while examining a client with excessive drainage." Clients should be examined in noise-free areas to prevent interruptions. Wearing eye shields while examining a client with excessive drainage helps to reduce contamination. Latex gloves should be used with caution because they may cause allergy in clients who are allergic to latex. A physical examination should be performed in a warm room to minimize discomfort. Combative clients should never be left alone during physical examinations.

The registered nurse is teaching a nursing student about ways to minimize heat radiation. Which statements made by the nursing student indicate effective learning? Multiple selection question "I will apply an ice pack to the client." "I will cover the client with dark clothes." "I will instruct the client to remove extra clothes." "I will instruct the client to lie in the fetal position." "I will advise the client to wear sparsely woven clothes."

"I will apply an ice pack to the client." "I will cover the client with dark clothes." "I will instruct the client to lie in the fetal position." Applying an ice pack will increase conductive heat loss, which results in minimizing heat radiation. Wearing dark clothes and lying in the fetal position will minimize heat radiation. Removing extra clothes will increase heat radiation. Wearing sparsely woven clothes will enhance heat radiation.

A nurse teaches a client about various measures to protect against food-borne illness. Which statement by the client indicates a need for further teaching? Multiple choice question "I'll clean the inside of my refrigerator and microwave regularly." "I'll wash my cooking utensils and cutting boards with tap water." "I'll wash my hands with warm, soapy water before touching or eating food." "I won't eat any leftovers in my refrigerator after they've been there for 5 days."

"I'll wash my cooking utensils and cutting boards with tap water." Eating leftovers that have been kept in a refrigerator for more than 2 days may result in a food-borne illness caused by microbial growth in the food. Cleaning the inside of the refrigerator and microwave regularly will help prevent microbial growth. Cooking utensils and cutting boards should be washed with hot, soapy tap water as a means of preventing food-borne illness. Washing the hands with warm, soapy water before touching or eating food is one technique for preventing food borne illness.

The nurse administers a pneumococcal vaccine to a 70-year-old client. The client asks "Will I have to get this every year like I do with the flu shot?" How should the nurse respond? Multiple choice question "You need to receive the pneumococcal vaccine every other year." "The pneumococcal vaccine should be received in early autumn every year." "You should get the flu and pneumococcal vaccines at your annual physical examination." "It is unnecessary to have any follow-up injections of the pneumococcal vaccine after this dose."

"It is unnecessary to have any follow-up injections of the pneumococcal vaccine after this dose." The Centers for Disease Control and Prevention recommend that adults be immunized with pneumococcal vaccine at age 65 years or older with a single dose of the vaccine; if the pneumococcal vaccine was received before 65 years of age or if there is the highest risk of fatal pneumococcal infection, revaccination should occur 5 years after the initial vaccination. The pneumococcal vaccine should not be administered every 2 years. The pneumococcal vaccine should not be administered annually.

A client with recent history of head trauma is at risk of orthostatic hypotension. Which assessment findings would help to diagnose the condition? Multiple selection question Fainting Headache Weakness Light headedness Shortness of breath

-Fainting -Weakness -Light headedness Head trauma may cause blood loss. Clients with recent blood loss are at risk of orthostatic hypotension. While obtaining the orthostatic measurements, the nurse should check for fainting, light-headedness, and weakness. Headaches and shortness of breath are the symptoms of hypertension.

Which sites would be safe and inexpensive for temperature measurement? Multiple selection question Skin Oral Axilla Rectal Tympanic membrane

-Skin -Axilla The skin and axilla are safe and inexpensive sites of the body for temperature measurement. The oral route is an easily accessible site for temperature measurement but it may not be the safest route because of the exposure to body fluids. The rectal route may not be easily accessible and safe because a measurement via this route may increase the risk of body fluid exposure. The tympanic membrane is an easily accessible site for temperature measurement but care should be taken when used in neonates, infants, and children.

After recovery from a modified neck dissection for oropharyngeal cancer, the client receives external radiation to the operative site. For which most critical reaction to the radiation should the nurse assess the client? Multiple choice question Dry mouth Skin reactions Mucosal edema Bone marrow suppression

Mucosal edema The mucosal lining of the oral cavity, oropharynx, and esophagus is sensitive to the effects of radiation therapy; the inflammatory response causes mucosal edema that may progress to an airway obstruction. A decrease in salivary secretions resulting in dry mouth may interfere with nutritional intake, but it is not life threatening. Erythema of the skin may cause dry or wet desquamation, but it is not life threatening. Radiation to the neck area should not produce as significant bone marrow suppression as radiation to the other sites.

While performing a physical assessment of a client, a nurse notices patchy areas with loss of pigmentation on the skin, hands, and arms. What is the probable etiology for this condition? Multiple choice question Anemia Pregnancy Lung disease Autoimmune disease

Autoimmune disease Patchy areas with loss of pigmentation on skin, hands, and arms are due to vitiligo, which is caused by an autoimmune or congenital disease. Anemia results in pallor due to a reduced amount of oxyhemoglobin. A tan-brown color of the skin is noticed in pregnancy due to an increased amount of melanin. Lung disease or heart failure can cause cyanosis due to an increased amount of deoxygenated hemoglobin.

While assessing the eyes of a client, a healthcare provider notices there is an obstruction to the outflow of aqueous humor. Which additional finding might be noted to support a diagnosis of glaucoma? Multiple choice question Blurred central vision Increased opacity of the lens Elevated intraocular pressure Changes in retinal blood vessels

Elevated intraocular pressure In glaucoma, there is an obstruction of the outflow of aqueous humor due to an intraocular structural damage, which may result from elevated intraocular pressure. Blurred central vision is seen in macular degeneration. Increased opacity of the lens may be seen in cataracts. Retinopathy may result from the changes in retinal blood vessels.

While assessing a client's range of motion, the nurse explains adduction to the nursing student. Which statement made by the nursing student indicates effective learning? Multiple choice question "I will ask the client to move his or her arm towards the body." "I will ask the client to bend his or her limb by decreasing the angle." "I will ask the client to move his or her hand so that the ventral surface faces downward." "I will ask the client to move his or her head beyond its normal resting extended position."

"I will ask the client to move his or her arm towards the body." Adduction is moving the arm towards the body. Assessing the range of motion by bending the limb and decreasing the angle indicates flexion. Moving the hand by facing the ventral surface downwards indicates pronation. The movement of the head beyond the normal resting extended position indicates hyperextension.

The nurse was assessing an elderly client and recorded the pulse rate as 85. After assessment the nurse determined the cardiac output as 5950. What could be the approximate stroke volume? Multiple choice question 70 mL 60 mL 50 mL 40 mL

70 mL Cardiac output is obtained by multiplying the heart rate and the stroke volume. Therefore to obtain the stroke volume, the cardiac output should be divided by pulse rate. Dividing 5950 by 85 yields a stroke volume of 70 mL.

Which client body temperatures are indicative of moderate hypothermia? Multiple selection question 80° F (26.7° C) 84° F (28.9° C) 88° F (31.1° C) 92° F (33.3° C) 96° F (35.6° C)

88° F (31.1° C) 92° F (33.3° C) Moderate hypothermia is a body temperature between 86°F and 93.2°F (30° C to 34° C). Therefore clients with body temperatures between 88°F and 92°F (31.1° C to 33.3° C) have moderate hypothermia. Mild hypothermia is a body temperature between 93.2°F and 96.8°F (34° C to 36° C). Therefore clients with body temperatures of 96°F (35.6° C) have mild hypothermia. Body temperature below 86°F (30° C) indicates severe hypothermia.

While assessing a client who experienced an accident, the nurse found that the client is unable to move eyeballs laterally. Which nerve damage led to this condition in the client? Multiple choice question Optic nerve Facial nerve Abducens nerve Oculomotor nerve

Abducens nerve The abducens nerve is the VI cranial nerve, which helps in lateral movement of the eyeballs. Damage to this nerve limits lateral movement of the eyeball. Injury to the optic nerve causes changes in visual acuity. Injury to the facial nerve results in loss of facial expressions and loss of taste perception from the anterior one third of the tongue. Injury to the oculomotor nerve limits the extraocular movements and pupillary responses.

Which activity by the community nurse can be considered an illness prevention strategy? Multiple choice question Encouraging the client to exercise daily Arranging an immunization program for chicken pox Teaching the community about stress management Teaching the client about maintaining a nutritious diet

Arranging an immunization program for chicken pox An illness prevention program protects people from actual or potential threats to health. A chickenpox immunization program is an illness prevention program. It motivates the community to prevent a decline in health or functional levels. A health promotion program encourages the client to maintain the present levels of health. The nurse promotes the health of the client by encouraging the client to exercise daily. Wellness education teaches people how to care for themselves in a healthy manner. The nurse provides wellness education by teaching about stress management. The nurse promotes the health of the client by teaching the client to maintain a nutritious diet.

The nurse assesses an elderly client with a diagnosis of dehydration and recognizes which finding as an early sign of dehydration? Multiple choice question Sunken eyes Dry, flaky skin Change in mental status Decreased bowel sounds

Change in mental status adults are sensitive to changes in fluid and electrolyte levels, especially sodium, potassium, and chloride. These changes will manifest as a change in mental status and confusion. It is difficult to assess dehydration in older adults based on sunken eyes, dry skin, and decreased bowel sounds because these can be prominent as general normal findings in the elderly client.

A client who sustained head injuries is admitted to the hospital. During assessment of cranial nerves, the nurse notices that the client lost the perception of taste, especially in the anterior portion of the tongue. Which cranial nerve might have been injured in this client? Cranial nerve X Cranial nerve IX Cranial nerve XII Cranial nerve VII

Cranial nerve VII Cranial nerve VII is the facial nerve. Injury to the facial nerve limits the sensory impulses from the anterior two-thirds of the tongue, along with altered facial expressions. Cranial nerve X is the vagus nerve, injury to which causes limitation of palatal movements. Cranial nerve IX is the glossopharyngeal nerve. Injury to this nerve results in loss of taste impulses from the posterior one-third of the tongue. Cranial nerve XII is the hypoglossal nerve, damage of which results in improper movements of the tongue.

While assessing the nails of a client with diabetes, the nurse finds that the skin on the client's hands and feet are dry due to infection. What could be the reason for this dryness? Multiple choice question Applying moisturizing lotion between toes Cutting nails after soaking them for 10 minutes in warm water Cutting nails straight across and even with the tops of the fingers or toes Using sharp objects to poke or dig under the toenail or around the cuticle

Cutting nails after soaking them for 10 minutes in warm water Normally, nails should be cut after soaking them in warm water for 10 minutes. This action should not be performed for diabetic patients because soaking the nails will dry out the hands and feet, which may lead to infection. Applying moisturizing lotion between the toes will promote microorganism growth; it will not dry the skin. Cutting nails straight across and even with the tops of the fingers or toes is the proper way to maintain nail hygiene. Diabetic clients are advised not to use sharp objects to poke or dig under the toenails or around the cuticles to avoid injury to the skin.

The nurse is assessing a young client who presents with recurrent gastrointestinal disorders. On further assessment, the nurse learns that the client is experiencing job-related pressure. What is the most important nursing intervention for this client? Multiple choice question Educate the client on managing stress. Teach the client to maintain a balanced diet. Instruct the client to have regular health checkups. Ask the client to use sunscreen when working outdoors.

Educate the client on managing stress. The client is experiencing job-related pressure, so the nurse should educate the client about managing stress as it is a lifestyle risk factor. Stress threatens both mental health and physical well-being. Stress is associated with illnesses such as heart disease, cancer, and gastrointestinal disorders. The nurse teaches the client to maintain a balanced diet as a primary preventive care to promote health. The nurse should instruct the client to have regular health checkups as a primary preventive measure. The nurse should ask the client to use sunscreen when working outdoors to avoid excess sun exposure and prevent skin cancer.

The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this pulse can be characterized as what? Multiple choice question Diminished Normal Full Bounding

Full The strength of a pulse is a measurement of the force at which blood is ejected against the arterial wall. A 3+ rating indicates a full increased pulse. A zero rating indicates an absent pulse. A rating of a 1+ indicates a diminished pulse that is barely palpable. A 2+ rating is an expected or normal pulse, and a 4+ rating is a bounding pulse.

While assessing the muscle tone of a client, the client demonstrates a full range of muscle motion against gravity with some resistance. What score on the Lovett scale can be given to the client? Multiple choice question Fair (F) Good (G) Trace (T) Normal (N)

Good (G) According to the Lovett score, a full range of motion against gravity with some resistance can be categorized as G (good). F (fair) can be given if the client exhibits a full range of motion with no resistance. T (trace) score is given when the client exhibits slight contractility with no movement. N (normal) on the Lovett scale indicates full range of motion against gravity with full resistance.

The nurse is performing a weight assessment for different people in a community. Which question should the nurse ask a client to determine a disease-related change in weight? Multiple choice question Do you follow a strict calorie intake? Have you notices any changes in the social aspects of eating? Are you taking diuretics or insulin? Have you noticed any unintentional weight loss in the past six months?

Have you noticed any unintentional weight loss in the past six months? Unintentional or undesired weight loss during a certain period of time may indicate a weight change due to a disease, such as gastrointestinal problems. A strict calorie intake in a permitted limit is not related to any disease. Assessing the social aspects of a client's eating habits determines any lifestyle changes that may cause a weight change. Diuretics and insulin may cause weight loss or weight gain; this change is not disease-related.

A client with a head injury underwent a physical examination. The nurse observes that the client's temperature assessments do not correspond with the client's condition. An injury to which part of the brain may be the reason for this condition? Multiple choice question Pons Medulla Thalamus Hypothalamus

Hypothalamus The hypothalamus controls the body temperature. Damage to the hypothalamus may cause abnormalities in the body temperature values during a physical assessment. The pons is responsible for maintaining level of consciousness. The medulla controls heart rate and breathing. The thalamus performs motor and sensory functions.

Which type of breathing pattern alteration is manifested with hypercarbia? Multiple choice question Eupnea Tachypnea Hypoventilation Kussmaul's respiration

Hypoventilation Hypercarbia may occur during hypoventilation. The respiratory rate is abnormally low and the depth of ventilation is depressed in hypoventilation. In eupnea, the normal rate and depth of respiration is interrupted while singing. The rate of breathing is regular, but abnormally rapid in tachypnea. Respirations are abnormally deep, regular, and the rate is increased in Kussmaul's respirations.

After an eye assessment, the nurse finds that both of the client's eyes are not focusing on an object simultaneously and appear crossed. What could be the cause for this condition? Multiple choice question Loss of elasticity of the lens Impairment of the extraocular muscles Obstruction of the aqueous humor outflow Progressive degeneration of the center of the retina

Impairment of the extraocular muscles Strabismus is a condition where the eyes appear crossed; this condition is caused by the impairment of the extraocular muscles. A loss of lens elasticity may lead to presbyopia, which causes impaired near vision. An obstruction of the aqueous humor outflow may lead to glaucoma. The progressive degeneration of the center of the retina indicates macular degeneration and leads to blurred central vision.

A nurse is discussing weight loss with an obese individual with Ménière disease. Which suggestion by the nurse is most important? Multiple choice question Limit intake to 900 calories per day. Enroll in an exercise class. Get involved in diversionary activities when there is an urge to eat. Keep a diary of all foods eaten each day.

Keep a diary of all foods eaten each day. Keeping a record of what one eats helps to limit nonconscious and nervous eating by making the individual aware of intake. Limiting calories to 900 per day is a severe restriction that requires a primary healthcare provider's prescription. Exercise causes rapid head movements, which may precipitate a Ménière attack. Although diversionary activities are a therapeutic intervention, the nurse first should make suggestions that help increase the client's awareness of personal eating habits.

A client shows an increase in rate respirations that are abnormally deep and regular. What condition would the nurse expect? Multiple choice question Hypoventilation Biot's respiration Kussmaul's respiration Cheyne-Stokes respiration

Kussmaul's respiration Kussmaul's respiration is an alteration in the breathing process that is characterized by an increased and abnormal deep and regular rate of respiration. A client suffering from hypoventilation would have an abnormally low respiratory rate and the depth of ventilation is depressed. In Biot's respiration, respirations are abnormally shallow for two to three breaths, followed by irregular periods of apnea. An irregular respiratory rate and depth characterized by alternating periods of apnea and hyperventilation would be observed in a client with Cheyne-Stokes respiration.

A registered nurse (RN) must assess the body temperature of a client with a history of epilepsy. Which site for measuring temperature is contraindicated in this client? Multiple choice question Skin Axilla Oral cavity Temporal artery

Oral cavity The oral cavity is not a preferred site to measure the body temperature of a client with epilepsy, oral surgery, trauma, or shaking chills. Epileptic clients become rigid during seizures and any sudden seizure attack during temperature measurement poses the risk of breaking the thermometer in the mouth, lacerations, accidental mercury ingestion, and possibly aspirating the broken pieces. The skin, axilla, and temporal artery are sites that can be safely used to measure topical body temperature in an epileptic client.

The nurse discovers several palpable elevated masses on a client's arms. Which term most accurately describes the assessment findings? Multiple choice question Erosions Macules Papules Vesicles

Papules The nurse discovers several palpable elevated masses on a client's arms. Which term most accurately describes the assessment findings?

Which assessing technique involves tapping a client's skin with the fingertips to cause vibrations in the underlying tissues? Multiple choice question Palpation Inspection Percussion Auscultation

Percussion Percussion is the process of tapping the body parts with the fingers or hands to determine the consistency and borders of the body organs. Palpation is the act of feeling with the hand by applying pressure to the body surface to determine the condition of the skin and underlying tissues. Inspection is the process of visual observation of the body during physical examination. Auscultation means to listen to the internal sounds of the body.

When assessing a client, the nurse auscultates a murmur at the second left intercostal space (ICS) along the sternal border. This reflects sound from which valve? Multiple choice question Aortic Mitral Pulmonic Tricuspid

Pulmonic The second left intercostal space (ICS) along the sternal border reflects sounds from the pulmonic valve. The correct landmark for auscultating the aortic valve is at the right second ICS at the sternal border; for the mitral valve (apical pulse) at the left fifth ICS in the midclavicular line; and for the tricuspid valve at the left fifth ICS at the sternal border.

How does the nurse identify an illness as chronic? Multiple selection question The illness is reversible and often severe. The illness persists for longer than six months. The client may develop life threatening relapse. The symptoms are intense and appear abruptly. The illness affects the functioning of one or more systems.

The illness persists for longer than six months. The client may develop life threatening relapse. The illness affects the functioning of one or more systems. A chronic illness usually lasts longer than six months. The client with chronic illness often fluctuates between maximal functioning and serious health relapses that may be life threatening. The illness affects the functioning of one or more systems. A chronic illness is irreversible, whereas an acute illness is reversible and often much more severe than a chronic illness. The client with acute illness develops intense symptoms that appear abruptly and often subside after a relatively short period.

Which site is best used to inspect a client who is suspected to have jaundice? Multiple choice question Skin Palm Sclera Conjunctiva

Sclera The sclera is the best site to inspect for jaundice. Because the skin may become pale due to anemia or jaundice, a skin inspection is not recommended. The palms and conjunctiva are inspected to assess pallor.

When teaching about aging, the nurse explains that older adults usually have what characteristic? Multiple choice question Inflexible attitudes Periods of confusion Slower reaction times Some senile dementia

Slower reaction times A decrease in neuromuscular function slows reaction time. The ability to be flexible has less to do with age than with character. Confusion is not necessarily a process of aging, but it occurs for various reasons such as multiple stresses, perceptual changes, or medication side effects. Most older adults do not have organic mental disease.

Which assessment should the nurse exclude when dealing with a client with receptive and expressive aphasia? Multiple choice question Ask the client to read simple sentences aloud Point to a familiar object and ask the client to name it Test the mental status by asking for feedback from the client Ask the client to respond to simple verbal commands such as "Stand up"

Test the mental status by asking for feedback from the client Receptive and expressive aphasia are the two types of aphasia. A client with receptive is unable to understand written or verbal speech. A client with expressive aphasia understands written and verbal speech but cannot write or speak appropriately. A client with aphasia may not have the mental ability to give feedback; asking for feedback is ineffective. Asking the client to read simple sentences aloud is an effective way of dealing with this client. Pointing to a familiar object and asking the client to name it is also effective. A client with aphasia can understand simple verbal commands.

A nurse is caring for a client with diarrhea. The nurse anticipates a decrease in which clinical indicator? Multiple choice question Pulse rate Tissue turgor Specific gravity Body temperature

Tissue turgor Skin elasticity will decrease because of a decrease in interstitial fluid. The pulse rate will increase to oxygenate the body's cells. Specific gravity will increase because of the greater concentration of waste particles in the decreased amount of urine. The temperature will increase, not decrease.

While assessing a client, the nurse finds inflammation of the skin at the bases of the client's nails. What might be the reason behind this condition? Multiple choice question Trauma Trichinosis Pulmonary disease Iron-deficiency anemia

Trauma Paronychia is an abnormality of the nail bed. The condition is marked by inflammation of the skin at the base of the nail; this condition may be caused by trauma or a local infection. Trichinosis is associated with red or brown linear streaks in the nail bed. Pulmonary diseases can cause changes in the angle between nail and nail base, which is a phenomenon known as clubbing. Koilonychia, a concave curvature of the nails, may occur as a result of iron-deficiency anemia.

Following assessment, a nurse documents auscultation of course rhonchi in the anterior upper lung fields bilaterally that clears with coughing. What would be the cause of these sounds? Multiple choice question Parietal pleura rubbing against visceral pleura Random, sudden reinflation of groups of alveoli Turbulence due to muscular spasm and fluid or mucus in the larger airways High-velocity airflow through severely narrowed or an obstructed airway

Turbulence due to muscular spasm and fluid or mucus in the larger airways Loud, low pitched, rumbling coarse sounds heard over the trachea and bronchi are due to turbulence caused by muscular spasm when fluid or mucous is present in the larger airways. Pleural rub produces a dry or grating quality sound, best heard in the lower portion of the anterior lateral lung. Random and sudden reinflation of groups of alveoli produces crackling sounds predominantly heard in the left and right lung bases. High-velocity airflow through severely narrowed or obstructed airways results in a wheezing sound heard all over the lung.

While assessing a client's vascular system, the nurse finds that pulse strength is diminished or barely palpable. Which documentation is appropriate in this situation? Multiple choice question 1+ 2+ 3+ 4+

1+ A diminished or barely palpable pulse is documented as 1+. A normal and expected pulse strength is documented as 2+. A full, strong pulse is documented as 3+. A bounding pulse is documented as 4+.

A client develops an allergic reaction when a student nurse is performing a physical assessment. Which statement made by the student nurse in response to this incident indicates the need for further teaching? Multiple choice question "Type I immune response to latex has an immediate onset." "Type I immune reaction to latex leads to release of IgE antibodies." "The client's first exposure to latex will cause a type IV allergic reaction." "Type IV immune response to latex occurs after 12 to 48 hours after exposure."

"The client's first exposure to latex will cause a type IV allergic reaction." Both type I and type IV hypersensitive reactions require prior exposure to cause an immune response in a subsequent exposure. The most immediate immune response is a type I reaction, in which the body produces IgE antibodies against the allergen. A type IV immune response occurs 12 to 48 hours after the exposure to the allergen and is referred to as a delayed hypersensitivity response.

The nurse is performing a breast assessment. Which statement made by the client indicates the risk of breast cancer? Multiple selection question "I had a late onset of menarche." "My first child was born when I was 32." "I noticed a slight discharge from a nipple." "I perform breast self-examinations frequently." "I consume two to four glasses of alcohol a day."

-"My first child was born when I was 32." -"I noticed a slight discharge from a nipple." -"I consume two to four glasses of alcohol a day." Clients who gave birth to a first child after the age of 30 are at a risk of breast cancer. Discharge from the nipple may indicate an early symptom of breast cancer. Consuming two to four glasses of alcohol daily may also increase the risk of breast cancer. An early onset of menarche is a risk factor for breast cancer. Performing breast self-examinations frequently may help to identify the early stages of breast cancer.

A registered nurse is teaching a student nurse about various sites for assessing body temperature. Which statements made by the student nurse indicates the need for further teaching? Multiple selection question "The axilla is not recommended to measure body temperature in unconscious clients." "The oral cavity is not suitable for clients with epilepsy to measure body temperature." "The tympanic membrane is not a preferred site of measuring body temperature in infants." "The rectum is not a preferred site of measuring body temperature in clients who underwent rectal surgeries." "The temporal artery is not a preferred site of thermometer placement to measure rapid changes in core temperature."

-"The axilla is not recommended to measure body temperature in unconscious clients." -"The tympanic membrane is not a preferred site of measuring body temperature in infants." -"The temporal artery is not a preferred site of thermometer placement to measure rapid changes in core temperature." The axilla is the preferred site for measuring body temperature in unconscious clients. The tympanic membrane is the preferred site for measuring body temperature in newborns to reduce infant handling and heat loss. The region of the temporal artery reflects rapid changes in core temperature. The oral cavity is not a preferred site to measure body temperature for a client with epilepsy, oral surgery, trauma, or shaking chills. In clients with diarrhea, rectal abnormalities, bleeding tendencies, and clients who underwent rectal surgeries, the rectum is not the preferred site for measuring body temperature.

Which clients suffer from impaired near vision? Multiple selection question A client with myopia A client with presbyopia A client with hyperopia A client with retinopathy A client with macular degeneration

-A client with presbyopia -A client with hyperopia A loss of elasticity of the lens causes impaired near-vision in presbyopia. Light rays focusing behind the retina are the cause of impaired near vision in clients with hyperopia. Myopia is caused by a refractive error where the light rays focus in front of the retina. Retinopathy is a noninflammatory change in the retinal blood vessels. Macular degeneration is a blurring of central vision caused by progressive degeneration of the central retina.

The nurse recognizes that which are important components of a neurovascular assessment? Multiple selection question Orientation Capillary refill Pupillary response Respiratory rate Pulse and skin temperature Movement and sensation

-Capillary refill -Pulse and skin temperature -Movement and sensation A neurovascular assessment involves evaluation of nerve and blood supply to an extremity involved in an injury. The area involved may include an orthopedic or soft tissue injury. A correct neurovascular assessment should include evaluation of capillary refill, pulses, warmth and paresthesias, and movement and sensation. Orientation, pupillary response, and respiratory rate are components of a neurologic assessment.

Which actions by the nurse help set the stage for a patient-centered interview during the first visit after admission to the healthcare facility? Multiple selection question Close the door after entering the room. Greet the client using his or her last name. Open the curtains to allow plenty of light in the room. Introduce oneself with a smile and explain the reason for the visit. Obtain an authorization from the client after the interview.

-Close the door after entering the room. -Greet the client using his or her last name. -Introduce oneself with a smile and explain the reason for the visit. The nurse should maintain the client's privacy by closing the door after entering the room. The nurse should maintain the dignity of the client by greeting the client using his or her last name. Smiling is a positive sign of warmth and immediacy when first establishing the nurse-client relationship. The nurse should explain his or her role in the providing care for the client. The nurse should ensure the room is adequately lit, comfortable, and soothing for the client. The nurse need not open the curtains to allow plenty of light in the room. The Health Insurance Portability and Accountability Act (HIPAA) requires the nurse to obtain an authorization from the client before collecting personal health data.

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Multiple selection question Tetany Seizures Diarrhea Weakness Dysrhythmias

-Diarrhea -Weakness -Dysrhythmias Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are associated with low calcium or sodium levels. Because of potassium's role in the sodium/potassium pump, hyperkalemia will cause diarrhea, weakness, and cardiac dysrhythmias.

An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult, the nurse recalls what expected sensory losses associated with aging? Multiple selection question Difficulty in swallowing Diminished sensation of pain Heightened response to stimuli Impaired hearing of high frequency sounds Increased ability to tolerate environmental heat

-Diminished sensation of pain -Impaired hearing of high frequency sounds Because of aging of the nervous system, an older adult has a diminished sensation of pain and may be unaware of a serious illness, thermal extremes, or excessive pressure. As people age they experience atrophy of the organ of Corti and cochlear neurons, loss of the sensory hair cells, and degeneration of the stria vascularis, which affects an older person's ability to perceive high frequency sounds. An interference with swallowing is a motor loss, not a sensory loss, and it is not an expected response to aging. There is a decreased, not heightened, response to stimuli in older adults. There is a decreased, not increased, ability to physiologically adjust to extremes in environmental temperature.

A nurse is caring for an older adult with a hearing loss secondary to aging. What can the nurse expect to identify when assessing this client? Multiple selection question Dry cerumen Tears in the tympanic membrane Difficulty hearing high pitched voices Decrease of hair in the auditory canal Overgrowth of the epithelial auditory lining

-Dry cerumen -Difficulty hearing high pitched voices Cerumen (ear wax) becomes drier and harder as a person ages. Generally, female voices have a higher pitch than male voices; older adults with presbycusis (hearing loss caused by the aging process) have more difficulty hearing higher pitched sounds. There is no greater incidence of tympanic tears caused by the aging process. The hair in the auditory canal increases, not decreases. The epithelium of the lining of the ear becomes thinner and drier.

When should the nurse observe the client to assess his or her level of functioning? Multiple selection question During meal time When talking about pain When preparing medication During the assessment interview When administering insulin injections

-During meal time -When preparing medication -When administering insulin injections An observation of the functional level of the client often occurs during a return demonstration. The nurse may also observe the client while eating to determine if the client is able to eat without assistance. The nurse teaches the client how to prepare medications and asks for a return demonstration to assess the client's understanding. The nurse also observes the client administering insulin injections to ensure that the client is able to perform it properly. Observation of functional level differs from the observation during a physical examination. The nurse closely observes the client during the physical assessment when the client talks about pain. During the assessment interview, the nurse observes the client's facial expressions and eye contact to form accurate conclusions about the client's condition. The nurse does not assess the client's functional abilities during the subjective assessment.

During a physical assessment, a client was diagnosed with increased temperature due to an increased basal metabolic rate (BMR). Which hormonal imbalances may the client have? Multiple selection question Cortisol Thyroid Estrogen Testosterone Progesterone

-Thyroid -Testosterone Body temperature is assessed during physical assessment. An increased basal metabolism rate increases the body temperature. Hormonal imbalances may alter the basal metabolic rate (BMR). Testosterone regulates the BMR in males. Thyroid hormone regulates the BMR of the body. Increases in the levels of these hormones may increase the BMR, which may in turn raise body temperature. Cortisol regulates blood glucose levels. Estrogen and progesterone are female hormones that do not regulate the BMR.

The community nurse is assessing an elderly client who lives alone at home. The nurse finds that the client refrains from physical activity for fear of falling when walking. Which interventions by the nurse are most beneficial to promote a healthy lifestyle? Multiple selection question Instruct the client to apply bed side rails. Encourage the client to wear nonskid shoes. Suggest that the client use an assistive device. Ask the client to install hand rails in the bathroom. Help the client rearrange furniture in the house.

-Encourage the client to wear nonskid shoes. -Suggest that the client use an assistive device. -Help the client rearrange furniture in the house The nurse should encourage the client to wear nonskid shoes that will provide a firm grip while walking and help reduce the chance of falls. The nurse should suggest that the client use an assistive device such as a cane or walker for support while walking. The nurse should make environmental changes by helping the client rearrange the furniture in the house. This will help reduce the incidence of falls within the house. These interventions reduce the fear of falling and encourage the client to participate in physical activity indoors and outdoors. The bed side rails protect the client from falling from the bed. The hand rails in the bathroom assist provide support while using the bathroom.

A client with a recent history of head trauma is at risk for orthostatic hypotension. Which assessment findings observed by the nurse would relate to this diagnosis? Multiple selection question Fainting Headache Weakness Lightheadedness Shortness of breath

-Fainting -Weakness -Lightheadedness Head trauma may cause blood loss and clients with recent blood loss are at risk for orthostatic hypotension. Symptoms of hypotension include fainting, lightheadedness, and weakness. Headaches and shortness of breath are symptoms of hypertension.

What should the nurse do when the defining characteristics of assessment data for a client can apply to more than one diagnosis? Multiple selection question Reassess the client. Reject all diagnoses. Gather more information. Identify related factors. Review all defining characteristics.

-Gather more information. -Identify related factors. -Review all defining characteristics. The nurse must gather more information to clarify interpretations of assessment data. Correct interpretation of information allows the nurse to select the right diagnosis that applies to the client. A related factor is a condition or etiology that gives a context for the defining characteristics. The nurse should identify related factors to individualize a nursing diagnosis for the client. The nurse should review all the defining characteristics, eliminate irrelevant ones, and confirm the relevant ones. The nurse must interpret the data to form data clusters only after reassessing and validating it. At this stage, the nurse should have only validated assessment data in the database. The nurse need not reject all diagnoses. The nurse should review all the defining characteristics to support or eliminate the irrelevant ones.

A nurse is performing an eye assessment in an older adult. The older adult is unable to see near objects. Which conditions may be suspected in the older adult? Multiple selection question Cataract Glaucoma Hyperopia Presbyopia Macular degeneration

-Hyperopia -Presbyopia In hyperopia, the client has farsightedness. In this condition, the client is unable to see near objects. Presbyopia is an impaired near vision that may occur with aging. Therefore, the nurse can suspect either of the conditions. In cataracts, there is an increased opacity of the lens that blocks light rays from entering the eye, leading to impaired vision. Glaucoma is a condition in which there is intraocular structural damage resulting from elevated intraocular pressure. Macular degeneration is caused due to blurred central vision that often occurs suddenly. This is caused by a progressive degeneration of the center of the retina.

Which age-related change should the nurse consider when formulating a plan of care for an older adult? Multiple selection question Difficulty in swallowing Increased sensitivity to heat Increased sensitivity to glare Diminished sensation of pain Heightened response to stimuli

-Increased sensitivity to glare -Diminished sensation of pain Changes in the ciliary muscles, decrease in pupil size, and a more rigid pupil sphincter contribute to an increased sensitivity to glare. Diminished sensation of pain may make an older adult unaware of a serious illness, thermal extremes, or excessive pressure. There should be no interference with swallowing in older adults. Older adults tend to feel the cold and rarely complain of the heat. There is a decreased response to stimuli in older adults.

Which statement best describes a diagnostic label? Multiple choice question It is a condition that responds to nursing interventions. It describes the essence of the client's response to health conditions. It describes the characteristics of the client's response to health conditions. It is identified from the client's assessment data and associated with the diagnosis.

-It describes the essence of the client's response to health conditions. A diagnostic label is the name of the nursing diagnosis as approved by the North American Nursing Diagnosis Association International (NANDA-I). It describes the essence of the client's response to health conditions in as few words as possible. The etiology of a nursing diagnosis is a condition that responds to nursing interventions. All NANDA-I approved diagnoses have a definition that describes the characteristics of the client's response to health conditions. The related factor of a nursing diagnosis is identified from the client's assessment data and associated with the diagnosis.

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency? Diplopia Skin rash Leg cramps Tachycardia Muscle weakness

-Leg cramps -Muscle weakness Leg cramps occur with hypokalemia because of potassium defiit. Muscle weakness occurs with hypokalemia because of the alteration in the sodium potassium pump mechanism. Diplopia does not indicate an electrolyte deficit. A skin rash does not indicate an electrolyte deficit. Tachycardia is not associated with hypokalemia; bradycardia is.

A nurse is assessing a client with a history of marijuana use. Which long-term effects are associated with marijuana? Multiple selection question Lung cancer Emphysema Heart disease Laryngeal disorder Stroke Chronic nasal irritation

-Lung cancer -Emphysema -Heart disease Lung cancer, emphysema, and heart disease are outcomes that may occur due to marijuana use. Laryngeal disorders, stroke, and chronic nasal irritation are associated with the abuse of cocaine but are not associated with marijuana use.

Which features distinguish nursing diagnoses from medical diagnoses? Multiple selection question Nursing diagnoses involve the client when possible. Nursing diagnoses are based on results of diagnostic tests and procedures. Nursing diagnoses are the identification of a disease condition in the client. Nursing diagnoses involve the sorting of health problems within the nursing domain. Nursing diagnoses involve clinical judgment about the client's response to health problems.

-Nursing diagnoses involve the client when possible. -Nursing diagnoses involve the sorting of health problems within the nursing domain. -Nursing diagnoses involve clinical judgment about the client's response to health problems. Establishing a nursing diagnosis is the second step in the nursing process. It is unique and involves the client's participation in the process. Nursing diagnoses classify health problems to be treated primarily by nurses. The nurse reviews the client assessment, sees cues and patterns in the data, and identifies the client's specific health care problems. The nursing diagnosis is a clinical judgment about the client's actual or potential health problems that the nurse is licensed to treat. A medical diagnosis is based on results of diagnostic tests and procedures, whereas a nursing diagnosis is based on the results of the nursing assessment. A medical diagnosis identifies a disease condition in the client.

A nurse assesses the vital signs of a 50-year-old female client and documents the results. Which of the following are considered within normal range for this client? Multiple selection question Oral temperature of 98.2° F (36.8° C) Apical pulse of 88 beats per minute and regular Respiratory rate of 30 per minute Blood pressure of 116/78 mm Hg while in a sitting position Oxygen saturation of 92%

-Oral temperature of 98.2° F (36.8° C) -Apical pulse of 88 beats per minute and regular -Blood pressure of 116/78 mm Hg while in a sitting position The client's temperature, pulse, and blood pressure are within normal ranges for a 50-year-old female. The client's respirations are mildly elevated, and the oxygen saturation level is below normal. A normal respiratory rate for a female client in this age group would be 12 to 20 per minute, and oxygen saturation level should be 95%.

While demonstrating the method of measuring blood pressure to a student nurse, the registered nurse measures the blood pressure in a client as 130/80 mm Hg. After the demonstration, when the student nurse is measuring the blood pressure in the same client, it is found to be 120/90 mm Hg. What could be the possible reasons for this difference? Multiple selection question Poor fitting of the cuff Inflating the cuff too slowly Deflating the cuff too quickly Inflating the cuff inadequately Applying the stethoscope too firmly

-Poor fitting of the cuff -Deflating the cuff too quickly Poor fitting of the cuff or deflating the cuff too quickly causes false low systolic and false high diastolic readings. Inflating the cuff too slowly results in false high diastolic readings. Inflating the cuff inadequately yields false low systolic readings. Applying the stethoscope too firmly against antecubital fossa yields false low diastolic readings.

While assessing an older adult during a regular health checkup, a nurse finds signs of elder abuse. Which physical findings would further confirm the nurse's suspicion? Multiple selection question Presence of hyoid bone damage Presence of cognitive impairment Presence of burns from cigarettes Presence of bed sores. Presence of unexplained bruises on the wrist(s)

-Presence of burns from cigarettes -Presence of bed sores. -Presence of unexplained bruises on the wrist(s) A physical finding of abuse in older adults can be the presence of burns from cigarettes. The physical presence of bed sores also indicates client abuse. Unexplained bruises on the wrist(s) may also be an indication of abuse in older adults. The presence of hyoid bone damage is an indication of intimate partner violence. The presence of cognitive impairment is a behavioral finding in older adult abuse.

A client with a history of cardiac dysrhythmias is admitted to the hospital due to a fluid volume deficit caused by a pulmonary infection. The registered nurse is assessing the vital signs recorded by the student nurse. Which vital sign assessments require reassessment based on the data given by the student nurse? Multiple selection question Respiratory rate of 14 breaths/minute Blood pressure of 120/80 mmHg Oxygen saturation of 95% Temporal temperature of 37.4 °C Radial pulse rate of 72 and irregular

-Respiratory rate of 14 breaths/minute -Blood pressure of 120/80 mmHg -Oxygen saturation of 95% In pulmonary infections, the respiratory rate may increase and oxygen saturation may decrease. In fluid volume deficit, the blood pressure may be decreased. A respiratory rate of 14 breaths/minute, a blood pressure of 120/80 mmHg, and an oxygen saturation of 95% are normal readings. Therefore, the registered nurse should reassess these vital signs. The normal temperature range is 36 to 38 0C; this range is unaffected by a pulmonary infection. Therefore, the nurse does not need to reassess the temperature. Cardiac dysrhythmias are associated with a pulse deficit in which the radial pulse would be irregular. Therefore reassessment would not be required.

A registered nurse instructed the nursing assistive personnel (NAP) to measure the temperature of a client who reports chills and coldness. The nurse believes that the reading is inaccurate. What observations may have led to this conclusion? Multiple selection question The client has a habit of breathing through his or her mouth. The client smoked 40 minutes after his or her temperature was taken. The client ingested juice 20 minutes before his or her temperature was taken. The client ingested food 20 minutes after having his or her temperature was taken. The client ingested medications 10 minutes after having his or her temperature was taken.

-The client has a habit of breathing through his or her mouth. -The client ingested juice 20 minutes before his or her temperature was taken. Habitual mouth breathing may result in inaccurate temperature readings. A client who ingested any fluids or food orally or smoke should wait for 20 to 30 minutes his or her temperature was taken. Smoking, ingesting

While performing a physical assessment of a female client, the nurse positions the client in Sims' position. Which body system will be assessed in this position? Multiple selection question Heart Vagina Rectum Female genitalia Musculoskeletal system

-Vagina -Rectum Sims' position is indicated to examine vagina and rectum. Lithotomy to check female genitalia. Lateral recumbent position will aid in detecting murmurs of the heart. Prone position is indicated while assessing the musculoskeletal system.

A client is admitted to the hospital after an accident. The nurse uses the Glasgow Coma Scale (GCS) with the client. The client is alert and opens his or her eyes when there is a sound or when someone talks. When questions are asked, the client answers in a confused manner. The client obeys commands, such as being asked to move a leg. What would be the client's total score? Record your answer using a whole number.

13 The Glasgow Coma Scale (GCS) is used to measure the level of a client's consciousness and assigns a numerical score for each area of neurological status. The score for opening eyes on sound or speech is a 3. The score assigned for confused verbal responses is a 4. A score of 6 is assigned to the motor response of obeying commands. Therefore, the total score of the client is 13.

What would be the respiratory rate in two-year-old child? Multiple choice question 20 30 40 50

30 The normal range for the respiratory rate in a two-year-old kid (toddler) is between 25 and 32 breaths per minute. Twenty breaths per minute is the normal respiratory rate in adolescents and adults. The normal respiratory rate in newborns is 40. The normal respiratory rate in infants is 50 breaths per minute.

While conducting an assessment, the nurse finds that the client shivers uncontrollably and experiences memory loss, depression, and poor judgment. What might the client's body temperature be? Multiple choice question 29° C 33° C 36° C 38° C

33° C A body temperature in the range of 36° to 38 ° C is normal. When skin temperature drops below 35° C, the client may exhibit uncontrolled shivering, loss of memory, depression, and poor judgment as a result of hypothermia. A body temperature lower than 30° C represents severe hyperthermia. In this condition, the client will demonstrate a lack of response to stimuli and extremely slow respiration and pulse. Based on the signs given, the client's temperature is most likely 33° C.

A nurse is caring for a client who has been admitted with right-sided heart failure. The nurse notes that the client has dependent edema around the area of the feet and ankles. To characterize the severity of the edema, the nurse presses the medial malleolus area, noting an 8 mm depression after release. How should the edema be documented? Multiple choice question 1+ 2+ 3+ 4+

4+ Dependent edema around the area of feet and ankles often indicates right-sided heart failure or venous insufficiency. The nurse should assess for pitting edema by pressing firmly for several seconds, then releasing to assess for any depression left on the skin. The grading of 1+ to 4+ characterizes the severity of the edema. A grade of 4+ indicates an 8 mm depression. A grade of 1+ indicates a 2 mm depression. A grade of 2+ indicates a 4 mm depression. A grade of 3+ indicates a 6 mm depression.

The student nurse prepares a concept map while caring for a client recovering from surgery. What is the first step that the student nurse should take when preparing the concept map? Multiple choice question Assess the client and gather information. Arrange cues into clusters that form patterns. Identify patterns reflecting the client's problem. Identify specific nursing diagnoses for the client.

Arrange cues into clusters that form patterns. A concept map is a visual representation of the connection between the client's many health problems. The first step is to arrange all the cues into clusters that form patterns. This helps the nurse identify specific nursing diagnoses for the client. During the assessment stage, the nurse assesses the client and gathers information. This step is performed before preparing the concept map. After placing all cues into clusters, the nurse begins to identify patterns reflecting the client's problem. The concept map helps the nurse obtain a holistic view of the client's needs. The next step is to identify specific diagnoses so that appropriate nursing interventions can be provided.

An adolescent is taken to the emergency department of the local hospital after stepping on a nail. The puncture wound is cleansed and a sterile dressing applied. The nurse asks about tetanus immunization. The adolescent responds that all immunizations are up to date. Penicillin is administered, and the client is sent home with instructions to return if there is any change in the wound area. A few days later, the client is admitted to the hospital with a diagnosis of tetanus. Legally, what is the nurse's responsibility in this situation? Multiple choice question The nurse's judgment was adequate, and the client was treated accordingly. The possibility of tetanus was not foreseen because the client was immunized. Nurses should routinely administer immunization against tetanus after such an injury. Assessment by the nurse was incomplete, and as a result the treatment was insufficient.

Assessment by the nurse was incomplete, and as a result the treatment was insufficient. The nurse's data collection was not adequate because the nurse did not ask about the date of the previous tetanus inoculation. The nurse failed to support the life and well-being of a client. The nurse's assessment was not thorough in regard to determining the date of immunization. It was essential to determine when the client was last immunized; for a "tetanus-prone" wound, like a puncture from a rusty nail, some form of tetanus immunization usually is given. Administering immunization against tetanus is not an independent function of the nurse.

A client was admitted to a surgical unit in an unconscious state due to head trauma. Which site would be most appropriate to obtain the client's temperature? Multiple choice question Oral Axilla Temporal artery Tympanic membrane

Axilla The axilla would be the most appropriate site to obtain a temperature measurement in a client who is unconscious due to head trauma. The oral route is not accessible when the client is unconscious. Because the client is in a surgical unit, his or her head may be covered. Therefore, obtaining a temperature measurement through the temporal artery or tympanic membrane may not be possible.

A nurse is teaching a parenting class. What should the nurse suggest about managing the behavior of a young school-age child? Multiple choice question Avoid answering questions. Give the child a list of expectations. Be consistent about established rules. Allow the child to plan the day's activities.

Be consistent about established rules. Because of a short attention span and distractibility, consistent limit setting is essential toward providing an environment that promotes concentration, prevents confusion, and minimizes conflicts. Questions should be answered, but the answers should not be judgmental. A list of expectations may be overwhelming at this age. Parents need to assist children with routine tasks; children this age may not be concerned with time frames.

A client is diagnosed with acquired immunodeficiency syndrome (AIDS). When examining the client's oral cavity, the nurse assesses white patchy plaques on the mucosa. The nurse recognizes that this finding most likely represents what opportunistic infection? Multiple choice question Cytomegalovirus Histoplasmosis Candida albicans Human papillomavirus

Candida albicans White patchy plaques on the oral mucosa would most likely be a result of C. albicans, a yeastlike fungal infection. This condition is also known as "thrush." Cytomegalovirus may cause a serious viral infection in persons with human immunodeficiency virus (HIV), resulting in retinal, gastrointestinal, and pulmonary manifestations. Histoplasmosis is an infection caused by inhalation of spores of the fungus Histoplasma capsulatum and is characterized by fever, malaise, cough, and lymphadenopathy. Human papillomavirus typically manifests as warts on the hands and feet, as well as mucous membrane lesions of the oral, anal, and genital cavities. It may be transmitted without the presence of warts through body fluids, with some forms associated with cancerous and precancerous conditions.

A client complains of chronically recurring ulcers on the lower leg. Upon assessment, a nurse finds the absence of hair growth on the legs and asks the client to consult the primary healthcare provider immediately. Which condition does the nurse suspect? Multiple choice question Phlebitis Clubbing Occlusion Circulatory insufficiency

Circulatory insufficiency Chronically recurring ulcers in the lower legs or the feet accompanied by an absence of leg hair growth are serious signs of circulatory insufficiency. This finding requires a primary healthcare provider's intervention. The symptoms of phlebitis include localized redness, tenderness, and swelling over the vein sites of the calves. Clubbing is caused by insufficient oxygenation at the periphery. This can result from chronic emphysema and congenital heart disease. Occlusion is characterized by pain, pallor, pulselessness, paresthesias, and paralysis.

A nurse is assessing clients with gastrointestinal problems. Which client does the nurse suspect to have shigellosis?

Client 2; Food consumed: milk and seafood; Symptoms: Abdominal cramps and diarrhea; Onset of symptoms: 12 hours after ingestion Shigellosis is a food-borne disease and may be due to the ingestion of milk products, seafood, or salad. The symptoms of infection include abdominal cramps and severe diarrhea and can occur 12 hours after ingestion. Therefore, shigellosis is suspected in client 2. Client 1, who has symptoms of severe abdominal cramps, pain, vomiting, diarrhea, perspiration, headache, and fever after consuming custard or processed meats, may have a Staphylococcus infection. These symptoms may appear 3 days after ingestion contaminated foods. Client 3, who has symptoms of severe diarrhea, fever, headache, and breathing difficulty after consuming soft cheese, meat, or unpasteurized milk, may have an Escherichia coli infection. These symptoms may appear 3 days after ingestion of contaminated food. Client 4 with symptoms of severe diarrhea, cramps, and vomiting after consuming milk, custards, egg dishes, or sandwich fillings may have salmonellosis. These symptoms may appear 4 days after ingestion of those foods.

Which client is at a high risk for a rise in blood pressure based on the given data? Client A- Age:20; HR: 70 beats/min; SV: normal Client B- Age: 30; HR: 90 beats/min; SV: decreased Client C- Age: 40; HR: 40 beats/min; SV: increased Client D- Age: 50; HR: 100 beats/min; SV: normal

Client C The blood pressure rises when the heart rate is decreased and the stroke volume is increased. In adults, the pulse rate should be between 60 and 100 beats/min. Client C's heart rate is 40 beats/min, which is less than normal, and the stroke volume is increased. Thus, client C has a high risk of high blood pressure.

A nurse performs lung assessments of four clients. The details are given below. Which client has inflamed pleura? Client A- Site: Overall Lung; Type of Sound: Inspiratory & Expiratory wheezes Client B- Site: Trachea & Bronchi; Type of Sound: Coarse crackles Client C- Site: Right & Left lung bases; Types of Sound: Fine crackles Client D- Site: Anterior lateral lung; Type of Sound: Frictional rub

Client D The breathing sounds in a pleural rub or an inflamed pleura are of a dry or grating quality that is heard in the lower portion of the anterior lateral lung, as observed in client D. High-pitched, continuous musical sounds heard all over the lung are wheezing breath sounds heard when there is a high-velocity airflow through severely narrowed or an obstructed airway. Loud, low-pitched, rumbling coarse sounds heard in the trachea and bronchi are rhonchi, which are observed during muscular spasm or when fluid or mucus is present the in larger airways. Fine crackles, medium crackles, and coarse crackles heard in client C are heard in lung bases due to random and sudden reinflation of groups of alveoli, which causes a disruptive passage of air through the small airways.

While assessing a client, a nurse finds that the ratio of the anteroposterior diameter and transverse diameter of the chest is 1:1. What is indicated by this finding? Multiple selection question Client has lordosis. Client is an older adult. Client has osteoporosis. Client has a history of smoking. Client has chronic lung disease.

Client is an older adult. Client has a history of smoking. Client has chronic lung disease. The 1:1 ratio of the anteroposterior diameter and transverse diameter of the chest indicates a barrel-shaped chest. This is a characteristic feature in an older adult who smokes and has chronic lung disease. In lordosis, there is an increase in lumbar curvature. Osteoporosis is a systemic skeletal condition in which there is a decreased bone mass and deterioration of bone tissue.

The client reports difficulty in breathing. The nurse auscultates lung sounds and assesses the respiratory rate. What is the purpose of the nurse's action? Data collection Data validation Data clustering Data interpretation

Data collection The nurse is gathering objective data to support the subjective data. The client's report of difficulty breathing is subjective data that needs to be supported by data from physical examination. The nurse reviews the database after data collection to decide if it is accurate and complete. This step is called data validation. Grouping of data that forms a pattern is called data clusters. The nurse uses critical thinking to interpret the data and analyze it before it is classified and organized into data clusters.

What type of interview is most appropriate when a nurse admits a client to a clinic? Multiple choice question Directive Exploratory Problem solving Information giving

Directive The first step in the problem-solving process is data collection so that client needs can be identified. During the initial interview a direct approach obtains specific information, such as allergies, current medications, and health history. The exploratory approach is too broad, because in a nondirective interview the client controls the subject matter. Problem solving and information giving are premature at the initial visit.

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? Multiple choice question Rapid, thready pulse Distended jugular veins Elevated hematocrit level Increased serum sodium level

Distended jugular veins Because of fluid overload in the intravascular space, the neck veins become visibly distended. Rapid, thready pulse and elevated hematocrit level occur with a fluid deficit. If sodium causes fluid retention, its concentration is unchanged; if fluid is retained independently of sodium, its concentration is decreased.

While assessing the client's skin, a nurse notices a skin condition, the pathophysiology of which involves increased visibility of oxyhemoglobin caused by an increased blood flow due to capillary dilation. Which condition is associated with this client? Multiple choice question Pallor Vitiligo Cyanosis Erythema

Erythema Erythema occurs due to an increased visibility of oxyhemoglobin, which is caused by increased blood flow. Pallor is caused by a reduced amount of oxyhemoglobin or a reduced visibility of oxyhemoglobin. Vitiligo is a pigmentation disorder caused by autoimmune diseases. Cyanosis is a bluish discoloration of the skin around the lips; this occurs due to an increased amount of deoxygenated hemoglobin in the blood.

During a survey, the community nurse meets a client who has not visited a gynecologist after the birth of her second child. The client says that her mother or sister never had annual gynecologic examinations. Which factor is influencing the client's health practice? Multiple choice question Spiritual belief Family practices Emotional factors Cultural background

Family practices Family practices influence the client's perception of the seriousness of diseases. The client does not feel the need to seek preventive care measures because no family member practices preventive care. The client is not influenced by spiritual beliefs in this instance. An individual's spiritual beliefs and religious practices may restrict the use of certain forms of medical treatment. Emotional factors such as stress, depression, or fear may influence an individual's health practice; however, this client does not show signs of being affected by emotional factors. The client is said to be influenced by cultural background if he or she follows certain beliefs about the causes of illness and uses customary practices to restore health.

A mother is worried about the sudden behavioral changes in her child. The child has suddenly developed a fear of certain people and places. The child's school performance is declining rapidly, and the child has developed poor relationships with his or her peers. After assessing the physical findings of the child, the nurse suspects child abuse. Which physical findings might have led the nurse to this suspicion? Multiple choice question Sunken eyes and loss of weight Uncommunicative and uninteractive with others Foreign bodies in the rectum, urethra, or vagina Strangulation marks on neck from rope burns or bruises

Foreign bodies in the rectum, urethra, or vagina One of the physical findings that may be required to confirm child abuse is the presence of foreign bodies in the rectum, urethra, or vagina. Weight loss and sunken eyes may be a physical finding for older adult abuse. When the abuse is related to an intimate partner, the nurse may observe strangulation marks on the neck from rope burns or bruises. Staying isolated and not communicating with others are behavioral findings that may be related to older adult abuse.

While assessing a client, the nurse finds bluish coloration of the skin. The nurse finds that this discoloration is due to cyanosis. Which condition may be suspected? Multiple choice question Anemia Liver disease Heart disease Autoimmune disease

Heart disease A bluish discoloration of the skin indicates cyanosis. This condition may be caused by increased amounts of deoxygenated hemoglobin, which may lead in heart disease or lung disease. In clients with anemia, the skin has a pallor due to a reduced amount of oxyhemoglobin. In clients with liver disease, the skin appears yellow or orange due to increased deposits of bilirubin. In autoimmune diseases, the skin will lose its pigmentation.

An older adult with a history of diabetes reports giddiness, excessive thirst, and nausea. During an assessment, the nurse notices the client's body temperature as 105° F. Which condition does the nurse suspect in the client? Multiple choice question Heat stroke Heat exhaustion Accidental hypothermia Malignant hyperthermia

Heat stroke Older adults are more at a risk of heat stroke. Symptoms of heat stroke include giddiness, excessive thirst, nausea, and increased body temperature. Heat exhaustion is indicated by a fluid volume deficient. Heat exhaustion occurs when profuse diaphoresis results in excess water and electrolyte loss. Accidental hypothermia usually develops gradually and goes unnoticed for several hours. When the skin temperature drops below 95° F, the client suffers from uncontrolled shivering, memory loss, depression, and poor judgment. Malignant hyperthermia is an adverse effect of inhalational anesthesia that is indicated by a sudden rise in body temperature in intraoperative or postoperative clients.

A client reports to the hospital with skin lesions. Upon physical examination, the nurse notices circumscribed elevations of the skin, measuring about 0.5 × 0.5 cm. The lesions are filled with serous fluid. What is the suspected cause of these skin lesions? Multiple selection question Venous stasis ulcer Arterial insufficiency Staphylococcal infection Herpes simplex infection

Herpes simplex infection Circumscribed elevated skin lesions filled with serous fluid smaller than 1 cm are called vesicles. Vesicles are found in conditions such as herpes simplex infection and chicken pox. Venous stasis ulcers are characterized by deep loss of skin surface that extends to the dermis and is associated with frequent bleeding. The appearance of shiny and translucent skin with loss of normal furrow indicates arterial insufficiency. In a staphylococcal infection, the skin lesion is similar to that of vesicle, but is filled with pus instead of serous fluid.

A client has a history of a persistent cough, hemoptysis, unexplained weight loss, fatigue, night sweats, and fever. Which risk should be assessed? Multiple choice question Lung cancer Cerebrovascular disease Cardiopulmonary alterations Human immunodeficiency virus (HIV) infection

Human immunodeficiency virus (HIV) infection A client with a history of persistent cough, hemoptysis, unexplained weight loss, fatigue, night sweats, or fever may have a human immunodeficiency virus (HIV) infection or tuberculosis. Lung cancer and cerebrovascular disease are risks to be assessed in the client with a history of tobacco or marijuana use. Cardiopulmonary alterations may be present in a client with a persistent cough (productive or nonproductive), sputum streaked with blood, or voice changes.

The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)? Multiple choice question Pregnancy Inactivity Aerobic exercise Tight clothing

Inactivity A DVT, or thrombus, may form as a result of venous stasis. It may lodge in a vein and can cause venous occlusion. Inactivity is a major cause of venous stasis leading to DVT. Pregnancy and tight clothing are also risk factors for DVT secondary to inactivity. Aerobic exercise is not a risk factor for DVT.

The nurse recognizes that a common conflict experienced by older adults is the conflict between what? Multiple choice question Youth and old age Retirement and work Independence and dependence Wishing to die and wishing to live

Independence and dependence A common conflict confronting older adults is between the desire to be taken care of by others and the desire to be in charge of their own destiny. The conflict between the young and old age may occur but is not common. The conflict between the retirement and working may occur but is not common. The conflict between wishing to die and wishing to live may occur but is not common.

Which error will result in false high diastolic readings while measuring a client's blood pressure during a physical examination? Multiple choice question Inflating the cuff too slowly Wrapping the cuff too loosely Applying the stethoscope too firmly Repeating the assessment too quickly

Inflating the cuff too slowly Which error will result in false high diastolic readings while measuring a client's blood pressure during a physical examination?

A nurse is assessing an 89-year-old client with a history of severe congenital spinal deformity. Which condition would most likely describe the nurse's finding? Lordosis Kyphosis Presbycusis Osteoporosis

Kyphosis Kyphosis is an increase in the curvature of the thoracic spine and may result from a congenital abnormality. Lordosis, also known as swayback, is an increased lumbar curvature and may not be a congenital abnormality. Presbycusis is the loss of acuity for high-frequency tones and is not related to the spine. Osteoporosis is a condition in which the bones become brittle and fragile from the loss of tissue and bone mass.

Which positioning should be avoided while assessing a client with a history of asthma? Multiple choice question Sitting Supine Dorsal recumbent Lateral recumbent

Lateral recumbent The lateral recumbent position is used to assess heart function. A client with asthma or other respiratory problems may not tolerate the lateral recumbent position. The sitting position is used to assess the heart, thorax, and lungs; this position should be avoided in physically weakened clients. The supine position is used to assess the heart, abdomen, extremities, and pulses. The dorsal recumbent position is used for an abdominal assessment and to assess the head, neck, and lungs.

Which finding is inferred from a grade 4 intensity of heart murmurs? Multiple choice question Thrill is easily palpable Quiet and clearly audible thrill Loud murmur associated with thrill Moderately loud murmur without thrill

Loud murmur associated with thrill Grade 4 indicates loud murmurs with an associated thrill. A thrill is a fine vibration that is felt by palpation. A grade 5 intensity is characterized by an easily palpable thrill. A grade 2 intensity is characterized by quiet and clearly audible murmurs. A moderately loud murmur without a thrill is noted as grade 3.

The nurse is caring for an African American client with renal failure. The client states that the illness is a punishment for sins. Which cultural health belief does the client communicate? Multiple choice question Yin/Yang balance Biomedical belief Determinism belief Magicoreligious belief

Magicoreligious belief An African American client may have magicoreligious beliefs, which focuses on hexes or supernatural forces that cause illness. Such clients may believe that illness is a punishment for sins. The yin/yang belief system does not consider illness as a punishment. The biomedical belief system maintains that health and illness are related to physical and biochemical processes with disease being a breakdown of the processes. The belief of determinism focuses on outcomes that are externally preordained and cannot be changed.

The nurse performs a respiratory assessment and auscultates breath sounds that are high pitched, creaking, and accentuated on expiration. Which term best describes the findings? Multiple choice question Rhonchi Wheezes Pleural friction rub Bronchovesicular

Wheezes Wheezes are one of the most common breath sounds assessed and auscultated in clients with asthma and chronic obstructive pulmonary disease (COPD). Wheezes are produced as air flows through narrowed passageways. Rhonchi are coarse, rattling sounds similar to snoring and are usually caused by secretions in the bronchial airways. A pleural friction rub is an abrasive sound made by two acutely inflamed serous surfaces rubbing together during the respiratory cycle. Bronchovesicular sounds are intermediate between bronchial (upper) and vesicular (lower) breath sounds; they are normal when heard between the first and second intercostal spaces anteriorly and posteriorly between scapulae.

A client with internal bleeding is in the intensive care unit (ICU) for observation. At the change of shift an alarm sounds, indicating a decrease in blood pressure. What is the initial nursing action? Multiple choice question Perform an assessment of the client before resuming the change-of-shift report. Continue the change-of-shift report and include the decrease in blood pressure. Lower the diastolic pressure limits on the monitor during the change-of-shift report. Turn off the alarm temporarily and alert the oncoming nurse to the decrease in blood pressure.

Perform an assessment of the client before resuming the change-of-shift report. The cause of the alarm should be investigated and appropriate intervention instituted; after the client's needs are met, then other tasks can be performed. An alarm should never be ignored; the client's status takes priority over the change-of-shift report. The diastolic pressure limit has been prescribed by the primary healthcare provider and should not be changed for the convenience of the nurse. Alarms always should remain on; the alarm indicates that the client's blood pressure has decreased and immediate assessment is required.

What does a nurse consider the most significant influence on many clients' perception of pain when interpreting findings from a pain assessment? Multiple choice question Age and sex Physical and physiological status Intelligence and economic status Previous experience and cultural values

Previous experience and cultural values Interpretation of pain sensations is highly individual and is based on past experiences, which include cultural values. Age and sex affect pain perception only indirectly because they generally account for past experience to some degree. Overall physical condition may affect the ability to cope with stress; however, unless the nervous system is involved, it will not greatly affect perception. Intelligence is a factor in understanding pain so it can be tolerated better, but it does not affect the perception of intensity; economic status has no effect on pain perception.

A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes? Multiple choice question Skeletal and nervous Circulatory and urinary Respiratory and urinary Muscular and endocrine

Respiratory and urinary Increased respirations blow off carbon dioxide (CO 2), which decreases the hydrogen ion concentration and the pH increases (less acidity). Decreased respirations result in CO 2 buildup, which increases hydrogen ion concentration and the pH falls (more acidity). The kidneys either conserve or excrete bicarbonate and hydrogen ions, which helps to adjust the body's pH. The buffering capacity of the renal system is greater than that of the pulmonary system, but the pulmonary system is quicker to respond. Skeletal and nervous systems do not maintain the pH, nor do muscular and endocrine systems. Although the circulatory system carries fluids and electrolytes to the kidneys, it does not interact with the urinary system to regulate plasma pH.

When nurses are conducting health assessment interviews with older clients, what step should be included? Multiple choice question Leave a written questionnaire for clients to complete at their leisure. Ask family members rather than the client to supply the necessary information. Spend time in several short sessions to elicit more complete information from the clients. Keep referring to previous questions to ascertain that the information given by clients is correct.

Spend time in several short sessions to elicit more complete information from the clients. Spending time in several short sessions reduces client fatigue and compensates for a shortened attention span, which is common in the older adult. The questionnaire may never be completed if it is left for the client to complete at their leisure. Asking family members rather than the client to supply the necessary information is degrading to the client; the client should be asked initially and, if necessary, family can be asked to fill in details later. Constantly referring to previous questions may be overwhelming and create feelings of anger and resentment.

A nursing student under the supervision of a registered nurse is performing a pulse assessment. While preparing to assess the client, the registered nurse asks the nursing student to check the apical pulse after assessing the radial pulse. What could be the reason behind for this change? Multiple choice question The client may have a dysrhythmia The client may have physiologic shock The client underwent surgery earlier in the day The cient may have peripheral artery disease

The client may have a dysrhythmia A client with dysrhythmia may have an intermittent or abnormal radial pulse. For this condition, the registered nurse should advise the nursing student to assess the apical pulse because it will be more accurate. If the client is in shock, then assessing the carotid or femoral pulse would be appropriate. The femoral pulse is preferred to assess a client with peripheral artery disease.

Which client is likely to have a health promotion nursing diagnosis? Multiple choice question The client with acute pain due to appendicitis. The client who is willing to take a 30-minute walk daily. The elderly client with dementia admitted to the healthcare facility. The client with reduced cognitive ability while recovering from surgery.

The client who is willing to take a 30-minute walk daily. A health promotion nursing diagnosis is a clinical judgment of an individual's desire to increase well-being. A client who is willing to take a 30-minute walk daily is expressing a desire to improve health behavior. The nurse identifies a health promotion nursing diagnosis for this client. Acute pain due to appendicitis is an actual nursing diagnosis. The nurse selects an actual nursing diagnosis when there is sufficient assessment data to establish the nursing diagnosis. It describes the client's response to a particular health condition. A risk nursing diagnosis describes an individual's response to health conditions that may develop in a vulnerable individual. The elderly client with dementia may have a risk nursing diagnosis for confusion. The client recovering from surgery has reduced cognitive ability and may have a risk nursing diagnosis for confusion or falls

Which feature is characteristic of a risk nursing diagnosis? Multiple choice question The diagnosis does not have related factors. The diagnosis can be used in any health state. The defining characteristics support the diagnostic judgment. The defining characteristics are supported by a client's readiness.

The diagnosis does not have related factors. A risk nursing diagnosis describes human responses to health conditions that may develop in a vulnerable individual, family, or community. Risk diagnoses do not have related factors or defining characteristics because they have not occurred yet. A risk diagnosis has risk factors that help the nurse plan preventive measures. A health promotion nursing diagnosis can be applied to any individual with a desire to enhance health behaviors in any health state. An actual diagnosis is formed when the defining characteristics support the diagnostic judgment. There must be sufficient nursing assessment data to establish an actual diagnosis. A health promotion nursing diagnosis is a clinical judgment of an individual's readiness to increase well-being.

Which diagnosis made by the nurse is helpful in providing the right nursing interventions for the client? Multiple choice question The nurse understands that the client has pain due to a tracheostomy. The nurse identifies that the client is anxious about the cardiac catheterization. The nurse realizes that the client has diarrhea and needs the bedpan frequently. The nurse identifies that the client is not aware of perineal care and has impaired skin integrity.

The nurse identifies that the client is not aware of perineal care and has impaired skin integrity. The nurse observes that the client has impaired skin integrity due to lack of knowledge about perineal care. The nurse identifies the need for educating the client about perineal care. This nursing diagnosis is correct as it will help enhance the client's health outcomes. The nursing diagnosis should identify the problem caused by a treatment such as tracheostomy, not the treatment itself. A tracheostomy is a medical condition and should not be included in the nursing diagnosis. This client is likely to have pain following the trauma of the surgical incision. The nursing diagnosis should contain the client's response to the medical procedure rather than the medical procedure itself. The client is probably anxious due to lack of knowledge about the need for cardiac catheterization or the outcome of the procedure rather than the catheterization itself. A correct diagnosis helps the nurse put the client at ease by providing necessary teaching. The nurse should plan nursing interventions after identifying the client's problem. Therefore, the nurse should identify that the client has diarrhea due to food intolerance. This helps the nurse select appropriate interventions rather than just one intervention of offering bedpan.

While assessing a client who sustained a road traffic accident, a nurse notices that the client is unable to clench his teeth. Which cranial nerve might have been affected? Multiple choice question Facial nerve Trochlear nerve Abducens nerve Trigeminal nerve

Trigeminal nerve The trigeminal nerve provides sensory innervation to the facial skin and motor innervation to the muscles of the jaw. A client with a damaged trigeminal nerve will be unable to clench his teeth. The facial nerve provides sensory and motor innervations for facial expressions. The trochlear nerve is involved in downward and inward eye movements. The abducens nerve helps in the eyeball's lateral movement.

Which pulse site is used to perform Allen's test? Multiple choice question Ulnar Brachial Femoral Dorsalis pedis

Ulnar The ulnar pulse site is used to perform Allen's test. The brachial pulse site is used to assess the status of circulation to the lower arm and to auscultate blood pressure. The femoral site is used to assess the character of the pulse during physiological shock or cardiac arrest. The dorsalis pedis site is used to assess the status of circulation in the foot.

Which pulse site is used for the Allen's test? Multiple choice question Ulnar Popliteal Brachial Femoral

Ulnar The ulnar site is used for the Allen's test. The popliteal pulse is used to assess status of circulation to lower leg. The status of the circulation in the lower arm and blood pressure are assessed using the brachial pulse. The femoral pulse is used to assess the character of the pulse during physiological shock or cardiac arrest when other pulses are not palpable.

The nurse is caring for a client whose forehead feels warm to the touch. The nurse uses a thermometer and obtains the client's temperature. What is the nurse doing? Multiple choice question Validation Assessment Interpretation Documentation

Validation The nurse is validating the presence of fever in the client. Validation is the process of gathering more assessment data. It involves clarifying vague or unclear data. Assessment is the first step of the nursing process. It involves collecting information from the client and secondary sources. During interpretation, the nurse recognizes that further observations are needed to clarify information. Data documentation is the last part of a complete assessment. The nurse must document facts in a timely, thorough, and accurate manner to prevent information from getting lost.