NSG 1135 - EAQ Modules 4 & 5

c.

A client who has had a cesarean birth has been having difficulty breast-feeding for 2 days and now asks the nurse to bring her a bottle of formula. Which would be there nurse's initial action? a. Obtaining the requested formula b. Administering the prescribed pain medication c. Assessing the client's breast-feeding technique d. Notifying the health care practitioner of the client's request to switch feeding methods rationale: The nurse would assess the client to determine why the client is having difficulty breast-feeding. She may be uncomfortable or in need of assistance with her breast-feeding technique. The nurse would also explore the client's feelings about breast-feeding. Immediately providing the formula without assessing the situation does not meet the client's needs at this time. Pain may be a factor in the client's frustration with breast-feeding; however, this should be determined through the assessment process. Notifying the health care practitioner of the clients request to switch feeding methods is premature. It is the nurse's responsibility to assess the situation and arrive at a solution in collaboration with the client.

d.

A registered nurse (RN) is teaching a nursing student about skin assessment. Which statement made by the nursing student is incorrect? a. "Skin assessments are best performed in daylight." b. "Skin assessments performed at cool room temperatures can result in cyanosis." c. "Skin assessment performed at warm room temperatures can result in vasodilation." d. "In the absence of sunlight, skin assessments are performed best with other sources of light instead of fluorescent light." rationale: Although skin assessments are best conducted in daylight, in the absence of sunlight, they are best performed in fluorescent lighting. Skin exposure during skin assessments in cool room temperature can result in cyanosis. Skin exposure during skin assessments made in warm room temperature can result in vasodilation.

2, 3, 5

Identify factors associated with an increased incidence of abuse within a family. Select all that apply. 1. Acute illness. 2. Pregnancy. 3. Drug abuse. 4. Chronic illness. 5. Sexual orientation. rationale: Pregnancy, drug abuse, and sexual orientation are associated with an increased incidence of abuse within a family. Acute and chronic illness may place stress on the family, but these factors are not specifically linked to a higher incidence of violence.

c.

The nurse discovers several palpable elevated masses on a client's arms. Which term accurately describes the assessment findings? a. erosions b. macules c. papules d. vesicles rationale: Papules are superficial and elevated up to 0.5 cm. Nodules and tumors are masses similar to papules but are elevated more than 0.5 cm and may infiltrate deeper into tissues. Erosions are characteristics as loss of the epidermis layer; macules are non palpable, flat changes in skin color less than 1 cm in diameter; and vesicles are usually transparent, filled with serous fluid, and are a blister like elevation.

d.

The nurse is reviewing the breast self-examination procedure with a client. Which comment by the client would the nurse consider significant for follow-up? a. "My breasts feel engorged when I'm having my period." b. "My breasts feel lumpy right before my period starts." c. "My left breast has always been a little bigger than my right one." d. "My right breast feels thicker and seems bigger than the left one." rationale: Together, lack of symmetry and palpation of a thickening are abnormal findings. Engorgement is an expected response to menstrual hormones. Premenstrual engorgement may cause the breasts to feel lumpy. Having one breast larger than the other is a common deviation that is within acceptable limits.

c.

The nursing student assesses a client with abdominal pain. Which action performed by the nursing student needs correction? a. assessing the factors that worsen the pain b. asking the client about sleeping patterns c. assessing the client for tenderness and dimpling d. asking the client about the time and type of pain rationale: The nursing student needs correction if checking for dimpling on a client with abdominal pain. The nursing student would assess a client with masses in the breast and inguinal areas for tenderness, heaviness, dimpling, and tender lymph nodes. The nursing student should assess any factors that worsen or relieve the pain. The nursing student should ask the client about the sleeping patterns and the pain associated with other symptoms that affect the ability to get adequate rest to assess the severity of the condition. Pain can be assessed by asking the client about the nature, type, intensity, timing, location, and duration of the pain and its relationship to menstrual, sexual, urinary, or gastrointestinal function.

a.

Which action would the nurse first take when a client is admitted to the unit with a crushed chest, abdominal trauma, a probable head injury, and multiple fractures? a. establish an airway and stabilize the cervical spine b. assess heart sounds, and find carotid and femoral pulses c. check for alertness, orientation, and pupil reaction to light d. remove clothing to enable further assessment of injuries rationale: The initial actions after a traumatic injury, are based on the ABCDE mnemonic: Airway/Cervical Spine, Breathing, Circulation, Disability, Exposure. The first action by the nurse would be to establish a patent airway, and ensure that the cervical spine is stabilized. Assessment of heart sounds and pulses would be done after breath sounds and ventilation were assessed. Assessment of neurological status is done as part of the disability assessment after circulation is assessed. Removal of clothing to enable assessment of other injuries is part of the exposure assessment, after assessment for disability.

1, 3

Which clinical finding would the nurse expect to observe in a client with a diagnosis of psoriasis? Select all that apply. 1. scaly lesions 2. pruritic pustules 3. reddened papules 4. multiple petechiae 5. erythematous macules rationale: Psoriasis is characterized by dry, scaly lesions that occur most often on the elbows, knees, scalp, and torso. Sharply defined, reddened papule or plaques covered by scales occur because of dermal inflammation; the inflammation occurs because of an abnormal growth of epidural cells related to an autoimmune reaction. Pustules or vesicles filled with purulent fluid do not occur in psoriasis. Petechiae are not characteristics of psoriasis. Macules are erythematous flat spots on the skin, as in measles.

d.

Which finding is more likely to indicate a malignancy in a 38-year-old client admitted for a biopsy of a breast lump? a. a soft mass that is movable and nontender b. hard, hot, reddened areas that are tender and painful c. multiple bilateral lesions that are well-delineated and moveable d. a lesion in the upper outer quadrant that is poorly delineated and immobile rationale: Most breast malignancies are painless, fixed, and in the upper outer quadrant. A soft mobile mass might indicate a lipoma. A hard, hot, painful reddened area would suggest an access. Multiple bilateral mobile lesions are characteristics of fibrocystic benign breast tumors.

a.

Which finding would be most important to communicate to the health care provider after the nurse assesses a client's head and neck for respiratory problems? a. polyps on the nasal mucosa b. nasal septum deviation to left c. small mobile nodes at the mandible d. gagging with touch to posterior pharynx rationale: Nasal polyps are an abnormal finding and indicate the need for treatment with corticosteroid medications or surgery. Many adults have slight deviation of the nasal septum. Small and mobile lymph nodes are normal; the nurse would be concerned about larger or tender nodes. Gagging when the posterior pharynx is touched indicates that the glossopharyngeal and vagus nerves are intact and that the client's airway is protected.

a.

Which is the first action of the nurse when a parent expresses concern about a child's diet? a. Perform a nutritional assessment. b. Provide a referral for a nutritionist. c. Encourage the parent to decrease juice intake. d. Speak to the provider about ordering blood tests. rationale: Before taking any action the nurse first performs a nutritional assessment, including a dietary history. The child may need blood testing, but the nutritional assessment should be performed first. Once the nurse has the appropriate data, the nurse will determine which, if any, interventions are necessary. Providing a referral for a nutritionist or encouraging the decreased intake of juice are potential interventions, depending on the outcome of the assessment.

2, 4

Which psychosocial clue would be explored to confirm substance abuse in an adolescent? Select all that apply. 1. Overly polite behavior. 2. Increased school absenteeism. 3. Presence of drug-oriented magazines. 4. Changes in interpersonal relationships. 5. Wearing light clothes, despite cold weather. rationale: psychosocial clues to substance abuse. Include increased, school, absenteeism, and changes in interpersonal relationships. Other psychosocial clues include falling, grades, changes in dress, isolation, and increased aggressiveness. Adolescence with substance abuse problems become increasingly aggressive, rather than overly polite. The presence of drug oriented magazines may indicate substance abuse, but this is an environmental clue, not a psychosocial one. Adolescents with substance abuse issues tend to wear long sleeved shirts in hot weather.

1, 2, 4

Which question would the nurse ask the client when obtaining their health history? Select all that apply. 1. "Tell me about your food habits." 2. "Do you use alcohol or tobacco?" 3. "Have you sustained any personal loss recently?" 4. "Have you ever experienced any allergic reactions?" 5. "Does any family member have a long-term illness?" rationale: The health, history of a client includes the clients food habits so that the nurse can obtain an assessment of the clients nutrition status. The nurse also assesses the clients habits and lifestyle patterns. Asking about the use of alcohol and tobacco helps determine the clients risk for diseases involving the liver or lungs. The health history includes descriptions of allergies and reactions to food, latex, drugs, or contact agents, such as soap. While assessing the family history, the nurse assesses the client for stress related problems by asking about recent personal losses. The family history provides information about family members to determine the risk for illnesses of a genetic or familial nature.

b.

Which response would the nurse have when the mother of a 10-month-old exclaims, "Look how much weight he's gained even though he drinks only orange juice"? a. "He's a little overweight." b. "Let's talk about his nutrition." c. "Is he getting an iron supplement?" d. "Why is he only drinking orange juice?" rationale: The nurse must assess the infants, overall nutrition, including whether the infant is eating solid foods, and receiving vitamin and mineral supplements. Using an open ended approach will engage the mother without appearing judgmental. It is inappropriate to comment on the infants weight; it is also insufficient to comment on just one aspect of the infants dietary history. Asking why the infant is drinking only orange juice is a judgmental and accusatory question; again, it is insufficient to comment on just one aspect of the infant's diet history.

d.

Which statement blade by the student nurse about the general principles to be followed, while assessing skin lesions indicates the need for further teaching? a. "I should use the metric system while taking measurements." b. "I should assess systematically and proceed from head to toe." c. "I should use appropriate terminologies and nomenclature when documenting." d. "I should perform a lesion, specific examination and then a general inspection." rationale: During a physical examination, there are some general principles to be followed when assessing skin lesions. General examination is performed before a lesion-specific examination. The other options are correct. The metric system is used for taking measurements of the lesions. Examination is done systematically from head to toe. Appropriate terminologies, and nomenclature should be used for reporting and documenting.

a.

Which type of abuse or neglect would the nurse suspect in a 5-year-old child with genital discharge and recurrent urinary tract infections? a. sexual abuse b. physical abuse c. physical neglect d. emotional neglect rationale: Genital discharge and recurrent urinary tract infections are signs pf sexual abuse in children. Bruises, burns, fractures, or dislocation may indicate physical abuse. Malnutrition and poor hygiene may indicate physical neglect. Enuresis and sleep disorders may indicate emotional neglect.

1, 2

While assessing a client's skin, the nurse notices the client's skin is dry. Which probable cause would the nurse associate with this condition? Select all that apply. 1. use of hard soap 2. frequent bathing 3. use of tanning pills 4. presence of an allergy 5. use of petroleum products rationale: The use of hard soap and frequent bathing may result in dry skin. A skin allergy may results in skin rashes but not dry skin. Using tanning pills and petroleum products may result in skin cancer.

3, 4, 5

While assessing an older adult during a regular heath checkup, the nurse finds signs of elder abuse. Which physical finding would confirm the nurse's suspicion? Select all that apply. 1. Presence of hyoid bone damage. 2. Presence of cognitive impairment. 3. Presence of burns from cigarettes. 4. Presence of bedsores. 5. Presence of unexplained bruises on the wrist(s). rationale: A physical finding of abuse in older adults can be the presence of burns from cigarettes. The physical presence of bedsores 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.