POINT QUESTIONS EXAM 1

Ideally, when taking a blood pressure, the client should be instructed to what?

Avoid smoking 30 mins prior to the assessment

Mr. Smith presents to the clinic stating, "My face looks funny." You note that his face is asymmetric. What might you suspect is the client's problem?

Palsy

The client with psoriasis is admitted to a medical unit for unrelated reasons. When documenting the type of lesion represented by psoriasis, the nurse should document a

Papule

What are the glands that are located on the tarsal plates and open on the lid margins?

meiobomian glands

How would the nursing instructor explain the goal of guided questioning to his or her students?

" Facilitating the client's fullest communication".

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

Activity, Moisture, Nutrition

The nurse notes thrush on the palate of a client. The most appropriate question the nurse should ask is

"Have you been on antibiotics recently?"

A client is trying to explain how he feels about his eye problem. He pauses often during the conversation and often repeats himself when expressing his concern about his problem. After listening, the best response by the nurse would be

"I can understand why you feel the way you do".

When trying to explore a client's perspective on his or her illness, the question that would best determine the client's thoughts on the cause of the problem would be

"Why do you think you have (name the specific symptom)?"

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

1) intact, firm skin with redness 2) ulceration involving the dermis 3) full-thickness skin loss 4) necrosis with damage to underlying muscle

The nurse is performing a Braden assessment on a 62-year-old retired man. The nurse documents no impairment in sensory perception, skin usually dry, sitting in chair most of the day with ambulation short distances outside the room three times a day, and making frequent changes in position. The nurse would record those portions of the Braden score as

15

Which of the following scores on the Braden Scale signifies that the client is not at risk for a pressure sore?

19 to 23

A client in the clinic where you work is considered legally blind. The nurse knows that this means the vision in his better eye, corrected by glasses, is what?

20/200 or less

The nurse examines the pharynx of a client and records that the tonsils are touching the uvula. The nurse would grade the tonsils as

3+

Functionally, the most important range for hearing is the range of human speech. What is the range of human speech?

500 Hz to 3000 Hz

As a nursing student you learn that the normal range for an adult pulse is what?

60-100 BPM

A golden yellow pigment that is heavily keratinized and is found in subcutaneous fat is called what?

Carotene

A nurse knocks and enters a client room, makes introductions to the client and visitors, and explains to the client that she would like to conduct an interview so a plan of care can be completed. Which statement by the nurse would be most appropriate?

Correct option"Mrs. Smith, I would like to conduct an interview with you but I see you have visitors. I will come back in about 30 minutes so you can visit before you and I sit privately to talk."

What activity is known to aggravate a tension headache?

Driving

The apocrine glands are stimulated by what?

Emotional Stress

T O F: The frontal sinuses are the only ones readily accessible to clinical examination.

FALSE

T O F: When interviewing a client with a language barrier, it is best to use a family member to help interpret so the client has a level of comfort with the process.

FALSE

T o F: When documenting assessment data for a client experiencing a loss of muscle power, it is acceptable to state, "client is experiencing muscle fatigue."

False

When educating a client about the risks of malignant melanoma, what would you know to include?

Freckles, Red/Light Hair/ Immunosupression

A client presents to the clinic with "sores around the mouth." The nurse notes vesicular lesions on the upper lip and right corner of the lips. The client describes these as painful. The nurse suspects what condition?

Herpes simplex

A client presents at the clinic for a routine check-up. The nurse notes that she is dressed in warm clothing even though the temperature outside is 73°F (22.8°C). The nurse also notes that the client has gained 10 pounds (4.5 kg) since her last visit 9 months ago. What might the nurse suspect?

Hypothyroidism - intolerance to cold, preference for warm clothing, and many blankets, decreased sweating

Fatigue is considered a common symptom of what?

Infections, Depression, Panhypopituitarism

During your physical examination of he client you note an enlarged tender tonsillar lymph node. What would you do?

Look for a source such as infection in the area that it drains

When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc?

Medially toward the nose

A client tells the clinic nurse that his feet and lower legs turn a blue color. On assessment, the nurse notes that the client's oxygenation level is within normal levels. The nurse knows that the blue color the client described is caused by what?

Peripheral Cyanosis

A 16-year-old white female is brought to the clinic by her mother with a chief complaint of a severe headache lasting more than 24 hours. The mother states, "Just before the headache started my daughter was craving food. I couldn't feed her enough." What is this called?

Prodrome - unusual feelings such as euphoria, craving for food, fatigue, or dizziness

Mrs. Helms is admitted to your unit with an exacerbation of COPD. When you enter her room to do your initial assessment, you note that she is sitting on the side of the bed, leaning forward, with her arms on the bedside table. What would this indicate to you?

Respiratory distress

T or F: "Tell me about your pain" is an example of an open-ended question.

TRUE

T or F: Local redness of the skin warns of impending necrosis

TRUE

T or F: The thyroid gland is usually larger in women than in men.

TRUE

Your new client becomes visibly anxious during the nursing interview. You respond by telling her, "Don't worry, everything will be okay." What might this premature reassurance cause?

The blockage of further disclosures by the client

While interviewing a new client, you notice that he is mirroring your position. What can this signify?

an increasing sense of connectedness

"How many steps can you climb before you get short of breath?" is an example of what kind of question?

a question that elicits a graded response

Your client is complaining of nasal stuffiness. What drugs should you ask if she is taking?

alcohol, oral contraceptive, guanethidine

The student nurse learns that examining the skin can do all of the following except?

allow early identification of neurological defecits

What does the nurse assess the face for?

asymmetry, involuntary movements, edema

When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma?

asymmetry, notched border, diameter > than 6 mm

The principle of confidentiality is of paramount importance in the nurse-client relationship. When should you inform the client of with whom his or her information will be shared?

at the beginning of the interview

What are associated manifestations of a headache caused by a traumatic head injury?

attention span deficit, gait changes, seizures

An alternate pathway that bypasses the external and middle ear is called what?

bone conduction

What lines the cheeks?

buccal mucosa

The nurse does a health history. The client states he has lost 30 pounds in the last couple months without really trying. The client also states he feels warm all the time and sometimes feels like he has heart palpitations. The nurse would anticipate orders to evaluate the client for

hyperthyroidism

You are teaching a health class on a college campus. What would you teach the students to use during oral sex to help reduce the transmission of STDs?

dental dams

The nurse should know that some disease processes affect facial expression. What are they?

depression, parkinsonism, hyperthyroidism

When counting the client's pulse, what beats may be difficult to detect peripherally?

early beats

The nurse observes an inward turning of the lower lid in a 77-year-old client. The nurse documents

entropion

What is a characteristic symptom of Graves hyperthyroidism?

expothalmos - eyeball protrudes forward

T or F: When interviewing, the nurse should logically move from specific to open-ended questions.

false

What factors contribute to the client's individual makeup?

genetic composition, geographic location, cultural norms, ethnicity of client, nutrition

Learning about the effects of the illness does what for the nurse and the client?

gives them the opportunity to create a complete and congruent picture of the problem

A client has conjunctivitis. The nurses understand that conjunctivitis differs from conjunctival hemorrhage in that conjunctivitis

has watery, mucoid discharge

When assessing your new client, you note that he has no hair on his legs. What might this indicate about the client?

he has peripheral artery disease

What is vital in maintaining vision and a healthy outlook for clients?

health education

The nurse is using the ophthalmoscope to examine the client's eyes. The nurse holds the scope

in the right hand for the right eye and in the left hand for the left eye

The nurse should ask about which associated factors when a client complains of a cluster of headaches?

lacrimation, miosis, rhinnorhea, ptosis

You are assessing visual fields on a client newly admitted for eye surgery. The client's left eye repeatedly does not see your fingers until they have crossed the line of gaze. You would document that the client has what?

left temporal hemianopsia

A client with hypothyroidism is admitted to the medical unit. The nurse would expect to assess which signs/symptoms?

lethargy, constipation, cool skin, lower systolic blood pressure

A client asks to have her temperature taken because she feels hot and is sweating. The previous oral temperature 3 hours ago was 101.6°F. The nurse would expect the new temperature reading to be

lower than previous

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

macular degeneration

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

metastasis

What techniques encourage client disclosures while minimizing the risk for distorting the client's ideas or missing significant details?

offering multiple choices for answers, using reflection, asking a series of questions, one at a time

The current blood pressure measurement on a 24-hour uncomplicated postoperative client while standing at the bedside is 105/65. The last two readings were 130/75 and 125/70 while resting in bed. The nurse should be alert for signs of:

orthostatic hypotension

You note anterior bulging of the physiologic cup when performing a funduscopic examination of your client's eyes. What would you document?

papilledema

A client arrives in the emergency department by ambulance after falling down his front steps. The nurse notes two soft lumps, approximately 3 cm in diameter, on the side of his head. What would the nurse identify these as?

pilar cysts

What occurs during the termination phase of an interview?

planning for follow-up care

When interacting with a client, what conveys the extent of interest, attention, acceptance, and understanding of the nurse?

posture, tone of voice, gestures, eye contact

The nurse is having difficulty auscultating Korotkoff sounds. The nurse should

reposition the stethoscope, be certain there is full skin contact with the bell, consider shock

What systemic diseases may cause nodular episcleritis?

rheumatoid arthritis, systemic lupus erythematosus

You are educating your client on taking blood pressure at home. What would be important to include in your client education?

routine recalibration of the device

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

soft

A student nurse is conducting her first client interview. The student suddenly draws a blank on what to ask the client next. What is a useful interview technique for the student to use at this point?

summarization

The nurse is going to take a blood pressure on a client who has had a previous left mastectomy with lymph node dissection. What would be an appropriate action by the nurse?

take BP in the right arm

Which of the following are part of the preinterview of the nurse-client interview

taking notes, setting goals for the interview, taking time for reflection

What structure in the inner ear senses the position and movements of the head and helps to maintain balance?

the labyrinth

The nursing instructor is discussing assessment of the head and neck with the class. What identifying characteristic would the instructor use for the thyroid cartilage?

the notch on its superior edge

What are the bordering landmarks of the anterior triangle of the neck?

the sternomastoid, midline of neck, mandible

The nurse would expect to assess which symptoms in a client complaining of migraine headaches

throbbing, recurrent, photophobia

What is the primary purpose of the health history in relation to the eyes?

to identify changes

When assessing a client the nurse notes that the tonsils are touching the uvula. How would the nurse document the tonsils?

tonsils are T3

T or F: A client with a subdural hematoma may have an odor of alcohol.

true

T or F: Pain is frequently a motivator for people to seek health care and is considered the fifth vital sign.

true

During one of your clinical placements you encounter a client who becomes silent during the nursing interview. What would be appropriate for you to do?

watch the client closely for non-verbal cues, give brief encouragement to the client, appear attentive

The nurse notes that the ophthalmologist suspects death of the optic nerve. When looking into the eye, the nurse would expect to see what color if the disc is dead?

white