PREP U questions

The nurse assess for kidney tenderness at what location? Costovertebral angle Midclavicular line Hypogastric area Umbilical region

Costovertebral angle

A client complains of abdominal pain with cramping diarrhea, nausea, vomiting, weight loss, and loss of energy. The nurse should suspect which of the following as the underlying cause? Crohn's disease Gastric ulcer Pancreatitis Gastroesophageal reflux

Crohn's disease

A nurse has been called to testify in a lawsuit brought by a client against his employer. This institution uses charting by exception (CBE). What type of legal problems does CBE pose? The charting format is not ethical Details are often missing Subjective information is often missing It reflects poor assessment skills on the part of the nurse

Details are often missing

A nurse recognizes that which of these are possible health risks for a client who is obese? Select all that apply. Diabetes Hypertension Sleep apnea Anorexia Cirrhosis

Diabetes Hypertension Sleep apnea

The nurse is conducting a physical examination of a client who is lying down. Which is the most appropriate for the nurse to assess while the client is in this position? Range of motion of the spine Posterior chest excursion Head and neck range of motion Dorsiflexion of the foot

Dorsiflexion of the foot

In which disease process should a nurse expect to see a client with the presence of pitting edema? End stage renal disease Colon cancer Diabetes mellitus Liver disease

End stage renal disease

A community health nurse is planning an educational event for the parent-teacher association of the local elementary school. In discussing chickenpox, how would the nurse describe the rash? Fluid-filled lesions greater than 1 cm in diameter Purulent, fluid-filled, raised lesions of any size Raised, reddened, edematous papules or plaques, varying in size and shape Fluid-filled lesions less than 1 cm in diameter

Fluid-filled lesions less than 1 cm in diameter

Which of the following people need to be vaccinated for hepatitis A and B? Food-service workers Office personnel Truck drivers Animal care workers

Food-service workers

The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is the preceptor talking about? Functional Focused Head-to-toe Body system

Head-to-toe

A diagnostic finding which is unrelated to nutritional deficiency is High 24 hours urine creatinine High serum albumin High lymphocyte count Low prealbumin level

High serum albumin

When teaching a nutrition class, what would you recommend for adults older than the age of 50? Increase foods rich in vitamin B6 and saturated fats Increase foods rich in vitamin E and folic acid Increase foods rich in vitamin B12 and calcium Increase foods rich in vitamin B6 and vitamin D

Increase foods rich in vitamin B12 and calcium

You should use the bell of the stethoscope when auscultating what type of sounds? Abnormal sounds High-frequency sounds Low-frequency sounds Sounds that are partially audible without a stethoscope

Low- frequency sounds

A nurse is preparing to physically examine a client. The nurse recognizes that it is best to begin the objective data collection with which procedure? Measure the client's vital signs, height, and weight. Begin at the head and move in a systematic approach. Auscultate all necessary body systems to prevent disturbing any organs. Allow the client to undress and put on a gown.

Measure the client's vital signs, height, and weight.

A client with an elevated blood pressure asks the nurse why he is not taking his blood pressure medication from home while he is hospitalized. The nurse reviews the orders and discovers that indeed the client is not taking his usual blood pressure medication. Which preventive measure was most likely omitted on admission? SBAR communication Medication reconciliation High-alert labeling Client teaching of side effects

Medication reconciliation

During the health-history interview, which of the following components of cognitive function can the nurse quickly assess? Memory and attention Judgment and behavior Calculation and language Abstract thinking and perceptions

Memory and attention

A client reports the onset of discomfort and pain in the right upper quadrant of the abdomen after eating. The nurse should assess this finding using which test? Obturator Murphy's Psoas Rovsing's

Murphys

A client recovering from a stroke complains of pain. The nurse suspects this client is most likely experiencing which type of pain? Nociceptive Neuropathic Somatic Idiopathic

Neuropathic

The nursing student understands that data analysis is referred to as the diagnostic phase because the end result is the identification of which of the following? nursing intervention nursing rationale nursing diagnosis data organization

Nursing diagnosis

An older adult client had hip replacement surgery 2 days ago. The nurse enters the client's room and encourages the client to use the incentive spirometer ten times every hour. What is this action an example of? Nursing intervention Nursing goal Nursing evaluation Nursing assessment

Nursing intervention

A nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing? Initial comprehensive Ongoing or partial Focused or problem-oriented Emergency

Ongoing or partial

When assessing a client's respirations, what is most important to include in the documentation? Numerical pain rating Position of the client Assessment of pedal pulses Presence of dyspnea

Presence of dyspnea

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions? Psoriasis, fungal infections, trauma Vitiligo, hirsutism, vitamin deficiency Eczema, melanoma, herpes zoster Alopecia, dermatitis, chemotherapy

Psoriasis, fungal infections, trauma

Since the nurse is unable to obtain an oversized cuff to assess an adult client with a large arm, the nurse uses an average-sized cuff. What blood pressure reading will the nurse most likely obtain for this client? Correct reading Reading will be low Reading will be high Reading cannot be obtained

Reading will be high

The nurse identifies the UAP recorded the client's blood pressure as 78/52 mm Hg. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse? Have the UAP retake the blood pressure Notify the physician Recheck blood pressure in 30 minutes Reassess blood pressure

Reassess blood pressure

When percussing the posterior lung fields, which of the following findings is expected? Hyperresonance over apices Dullness over the lung bases Resonance over all lung fields Tympany over 11th interspace, right scapular line

Resonance over all lung fields

The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication? PIE SBAR DAR SOAP

SBAR

An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse? The client has chronic hypoxia The client has melanoma The client has COPD The client has asthma

The client has chronic hypoxia

A client who only speaks Spanish is admitted to the unit. The client's sister, who speaks English, is in the room when the English-speaking nurse starts the admission assessment. Why would it be inappropriate to use the sister as an interpreter for this client? The sister may not tell the client exactly what the nurse says The client's sister may not understand medical terminology The sister may not be there every time the nurse needs to talk to the client The client may not want the sister to know their private information

The client may not want the sister to know their private information

The nursing instructor informs the students that there are pitfalls that decrease the reliability of cues and decrease diagnostic reasoning. The first set of pitfalls is related to the collection of data and includes which of the following? reliable data too many or too few data valid data cues available to support the diagnosis

Too many or too few data

An adult client visits the clinic and tells the nurse that he has been "spitting up rust-colored sputum." The nurse should refer the client to the physician for possible pulmonary edema. bronchitis. asthma. tuberculosis.

Tuberculosis

What is the most important focus area for the integumentary system? UV radiation exposure Chemical exposure Moles with defined borders smaller than 6 mm Washing the face and hands

UV radiation exposure

Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis? The presence of crepitus on palpation A depressed sternum and cartilages Retraction of intercostal spaces Unequal expansion of the chest

Unequal expansion of the chest

How should the nurse place the ear of an adult when using the otoscope? Up and back Down and back Up and forward Down and forward

Up and back

After collecting subjective and objective data for the admission database, what is the nurse's next action? Set nurse-driven goals for the client. Evaluate effectiveness of nursing actions. Validate the client's identified problems. Discuss the action plan with the client.

Validate the client's identified problems.

An inexperienced nurse has just performed percussion on a client's chest and detected hyper-resonance, which would tend to indicate emphysema. However, the client is 35 years old, appears healthy otherwise, and denies ever having smoked. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case? Repeat the percussion using the nondominant hand. Clarify the data by asking whether the client has experienced any trouble breathing lately. Verify the data by having another nurse come in to perform the percussion. Confirm that the client has truly never been a smoker by asking him.

Verify the data by having another nurse come in to perform the percussion.

When performing a nutritional assessment on a client, a nurse observes that the client has a red, beefy tongue. The nurse recognizes this finding as a deficiency of which essential nutrient? Vitamin B Thiamine Iodine Niacin

Vitamin B

A nurse has just determined a client's body mass index (BMI). Which measurement should the nurse add to the BMI to increase the predictive ability for health risk to the client? Mid-arm circumference Triceps skinfold measurement Waist circumference Mid-arm muscle circumference

Waist circumference

Which action by a nurse demonstrates the correct application of the principles of standard precautions? Using an antiseptic hand scrub to cleanse visibly soiled hands. Wearing a gown, gloves, and mask for the physical exam Wearing gloves when palpating the tongue, lips, & gums Change gloves after each body area is examined

Wearing gloves when palpating the tongue, lips, and gums

A nursing instructor is teaching students about the principles governing documentation. The teacher emphasizes that quality documentation remains confidential and is also (check all that apply): accurate organized complete biased timely concise

accurate organized complete timely concise

While conducting a physical examination, the nurse notices the client's mucous membranes are pale in color. Which nutritional deficiency is most likely for this client? anemia vitamin A protein vitamin C

anemia

To assess for anemia in a dark-skinned client, the nurse should observe the client's skin for a color that appears greenish. ashen. bluish. olive.

ashen.

A nurse notes that the pulse rate of a client is less than 60 beats per minute. Which question is appropriate for the nurse to ask the client in regards to this finding? "How is your stress level today?" "What vitamin supplements are you currently taking?" "Have you been sitting for a long time?" "Are you feeling feverish today?"v

"Have you been sitting for a long time?"

The nurse is preparing to interview a client with a documented history of mental illness. Which question should the nurse use to begin this interview? "What medication do you take for your depression?" "When was the last time you talked with a psychiatrist?" "Have you considered counseling for your mental problems? "Have you ever had a problem with mental or emotional illness?"

"Have you ever had a problem with mental or emotional illness?"

A nurse observes silvery, white striae on the abdomen of a middle-aged female client during the examination of the abdomen. What is an appropriate question to ask this client in regards to this finding? "How many times have you been pregnant?" "Are you experiencing any abdominal pain?" "Have you noticed any color change to the skin?" "Do you have high blood pressure?"

"How many times have you been pregnant?"

The nurse measures a male client's waist circumference as 43 inches (109 cm). Which statement is most appropriate for the nurse to make given this finding? "Let's discuss your risk factors for heart disease." "You probably have a vitamin deficiency." "We should review the amount of protein in your diet." "Waist circumference can vary over the course of the day."

"Let's discuss your risk factors for heart disease."

A nurse is discussing with a client the client's personal health history. Which of the following would be an appropriate question to ask at this time? "Are both of your parents still living?" "What do you usually eat in a typical day?" "What diseases did you have as a child?" "How do you feel about having to seek health care?"

"What diseases did you have as a child?"

A nurse is collecting data on a client's chief complaint, which is a spell of numbness and tingling on her left side. Which of the following questions would be best for eliciting information related to associated factors? "How bad was the tingling and numbness?" "How long did the spell last?" "Where did the numbness and tingling occur?" "What other symptoms occurred during the spell?"

"What other symptoms occurred during the spell?"v

The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write "bilateral lung sounds clear." "the client's lung sounds were clear on both sides." "client's lung sounds were auscultated with stethoscope and were clear on both sides." "after listening to client's lung sounds, both lungs appeared clear."

"bilateral lung sounds clear."

When calculating ideal body weight for women, the health care professional adds how many pounds for each inch over 5 feet? 1 3 5 7

5

The peritoneum is a serous membrane that contains which of the following? Antibodies A parietal layer A visceral ligament A drying agent

A parietal layer

A community health nurse provides information to a client with newly diagnosed multiple sclerosis for a support group at the local hospital for clients diagnosed with multiple sclerosis and their families. Providing this information is an example of which of the following? A referral A consultation Conferring Reporting

A referral

A client is reporting pain and rates it as 7 on a scale of 1 to 10. When the nurse asks him to describe the pain, he states, "It feels like a knife is stabbing or cutting me." The nurse knows that this type of pain is conducted by which fibers? C fibers A-delta fibers AC fibers P fibers

A-delta fibers

As a nurse is adjusting a client's hospital bed, the nurse accidently pinches a finger between the bed and the wall. Which of the following components is involved in the transduction of the pain the nurse feels? A-delta fibers C-fibers K-fibers L-beta fibers

A-delta fibers

A client is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the client? Breathing Airway Circulation Disability

Airway

A hospitalized client experiences respiratory distress. The nurse should include which most appropriate client outcome in the plan of care? Gas exchange with oxygen saturation greater than 85% Airway patent, breathing quiet, denies dyspnea Client maintains safety; no falls Pain level stabilized at client goal

Airway patent, breathing quiet, denies dyspnea

The nurse has learned that after completing the assessment phase of the nursing process, the next step is the diagnostic phase. What does the diagnostic phase allow for the nurse to do? Collect the data Analyze the data Validate the data Organize the data

Analyze the data

Chris is a 20-year-old college student who has had abdominal pain for 3 days. It started at his umbilicus and was associated with nausea and vomiting. He was unable to find a comfortable position. Yesterday, the pain became more severe and constant. Now, he hesitates to walk, because any motion makes the pain much worse. It is localized just medial and inferior to his iliac crest on the right. Which of the following is most likely? Peptic ulcer Cholecystitis Pancreatitis Appendicitis

Appendicitis

The nurse is caring for a client who is experiencing visceral pain. What is this client's most likely diagnosis? Shingles Bone fracture Myocardial infarction Appendicitis

Appendicitis

What are nurses able to detect through the health assessment? Areas that need continuous care Areas that need in-hospital care Areas that need referral to a specialist Areas in need of health adjustments

Areas in need of health adjustments

The nurse enters the room of a client and sees that visitors are present. What is the nurse's best action? Politely tell the visitors to leave. State that the visiting hours are over. Ask permission to talk to the client in front of visitors. Make eye contact solely with the client.

Ask permission to talk to the client in front of visitors.

How does a nurse best facilitate the nursing health assessment? Maintaining privacy Asking the appropriate questions Formulating a nursing diagnosis Creating a nursing care plan

Asking the appropriate questions

How may a nurse demonstrate cultural competence when responding to clients in pain? Treat every client exactly the same, regardless of culture. Be knowledgeable and skilled in medication administration. Know the action and side effects of all pain medications. Avoid stereotyping responses to pain by clients.

Avoid stereotyping responses to pain by clients.

A client has a BMI of 28. The nurse should assess which areas for additional risk factors for heart disease? Select all that apply. blood pressure cholesterol activity level temperature medications

Blood pressure cholesterol activity level

While auscultating a client's abdomen, the nurse hears the client's stomach growling. The nurse knows that this is which type of bowel sound? Absent Hypoactive Borborygmus Erratic

Borborygmus

Upon inspection of a client's chest, a nurse observes an increase in the ratio of anteroposterior to transverse diameter. The nurse recognizes this as a finding in which disease process? Carcinoma of the lungs Pneumothorax Chronic obstructive pulmonary disease Tuberculosis

Chronic Obstructive pulmonary disease

During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched, bubbling, moist sounds that persist from early inspiration to early expiration. How should the nurse document these sounds? Coarse crackles Pleural friction rubs Sonorous wheezes Sibilant wheezes

Coarse crackles

A college student presents to the health care clinic with reports of no bowel movement for 4 days, bloating, and generalized abdominal discomfort. She states that she has not been eating and drinking correctly and is stressed because she has a final exam in 2 days. A nurse assesses the abdomen and finds positive bowel sounds in all four quadrants and tenderness in the left lower quadrant with a few small, round, firm masses. The Rovsing's sign and Psoas sign are negative. What nursing diagnosis can the nurse confirm for this client? Ineffective Nutrition: Less Than Body Requirements Constipation related to decrease in fluid intake Ineffective Health Maintenance Risk for Fluid Volume Deficit

Constipation related to decrease in fluid intake

The nurse assesses an adult client's breath sounds and hears sonorous wheezes, primarily during the client's expiration. The nurse should refer the client to a physician for possible asthma. chronic emphysema. pleuritis. bronchitis.

bronchitis

The nurse is conducting a physical examination of a client who is in the lying position. Place in order the areas the nurse will assess when completing this examination. a. Shins and ankles b. Groin, hips, and knees c. Breasts d. Chest and thorax e. Cardiovascular c, d, e, b, a d, b, a, e, c a, c, b, d, e c, e, b, d, a d, e, b, a, c

c, d, e, b, a

A client has 3+ pitting edema, crackles in lungs, and dyspnea. The nurse is monitoring the client's vital signs and O2 saturations, and the physician has prescribed 40 mg of intravenous Furosemide (Lasix). What type of problem is this considered? Collaborative problem Nursing problem Physician problem Problem with compliance

collaborative problem

Consider the nurse's role in the health assessment of a client. What action will the nurse perform initially when admitting a client to a long-term care facility? collecting information regarding the client's health status stabilizing the client's physical condition developing an effective, respectful nurse-client relationship creating an environment that encourages client autonomy

collecting information regarding the client's health status

The nurse learns that a client is unable to sleep because of high anxiety. On which category of health patterns should the nurse focus? sleep-rest activity-exercise coping-stress-tolerance self-perception/self-concept

coping-stress-tolerance

When depression goes undiagnosed, what consequences occur eight times more frequently than in the general population? Polyhedonia Comorbidity Death Bankruptcy

death

The pancreas of an adult client is located below the diaphragm and extending below the right costal margin. posterior to the left midaxillary line and posterior to the stomach. high and deep under the diaphragm and can be palpated. deep in the upper abdomen and is not normally palpable.

deep in the upper abdomen and is not normally palpable.

Hair follicles, sebaceous glands, and sweat glands originate from the epidermis. eccrine glands. keratinized tissue. dermis.

dermis

When the nurse clusters the data to make a judgment or statement about the client's condition, this is known as what? Assessment Diagnosis Planning Evaluation

diagnosis

An assessment form commonly used in long-term care facilities is the nursing minimum data set. One primary advantage to this type of assessment form is that it establishes comparability of nursing data across clinical populations. clusters all the nursing and medical diagnoses in one place. allows for individualization for each client in the health care setting. uses a flowchart format for easy documentation of objective data.

establishes comparability of nursing data across clinical populations.

A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment? Assessment Diagnosis Implementation Evaluation

evaluation

Revising the plan as needed occurs in what part of the nursing process? Assessment Diagnosis Planning Evaluation

evaluation

The nurse is preparing to interview an adult client for the first time. The nurse observes that the client appears very anxious. The nurse should allow the client time to calm down. avoid discussing sensitive issues. set time limits with the client. explain the role and purpose of the nurse.

explain the role and purpose of the nurse.

What abnormal physical response should the nurse be prepared to manage after noting pallor in a client? fainting vomiting diarrhea diaphoresis

fainting

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

hypothyroidism.

What physical assessment technique should a nurse use to obtain a pulse on a client? Light palpation Moderate palpation Deep palpation Bimanual palpation

light palpation

After receiving morning report the nurse prepares to assess a client who was admitted the day before. Which type of assessment will the nurse complete at this time? Initial Focused Ongoing Emergency

ongoing

The nurse is assessing the bowel sounds of an adult client. After listening to each quadrant, the nurse determines that bowel sounds are not present. The nurse should refer the client to a physician for possible aortic aneurysm. paralytic ileus. gastroenteritis. fluid and electrolyte imbalances.

paralytic ileus

A client has a 10-year history of being treated for hypertension. Where should the nurse document this information? health patterns review of systems health maintenance past medical history

past medical history

An adult male client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. The nurse should further assess the client for: symptoms of stress. recent radiation therapy. pigmentation irregularities. allergies to certain foods.

symptoms of stress

When the client begins to cry, the nurse recognizes the need to focus the assessment on the client's emotional health. What factor will have the greatest effect on the nurse's ability to gather information concerning why the client is crying? the client's ability to communicate verbally the nurse's ability to ask relevant questions the type and degree of physical issues the client is experiencing the rapport that exists between the nurse and the client

the rapport that exists between the nurse and the client

A nursing instructor is teaching about diagnostic reasoning and the importance of culture. The student needs further explanation when making which statement? "It is important to look closely at cultural norms." "All clients have the same defining characteristics." "It is essential to look at all client responses accurately." "Labels for specific diagnoses do not always accurately describe diverse client responses."

"All clients have the same defining characteristics."

A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough? "Have you changed your diet within the past few weeks?" "How much do you exercise during the week?" "Are you taking any medications on a regular basis?" "Do you feel that you are under a great deal of stress?'

"Are you taking any medications on a regular basis?"

When focusing on the client's perspective of a symptom or problem, the nurse will ask which questions? Select all that apply. "Do you have any fears about the headaches you experience?" "Can you tell me when the headaches first began?" "Do you have any idea concerning why you are experiencing these headaches?" "Do the headaches negatively impact your day-to-day life?" "What do you do to make the headaches go away?"

"Do you have any idea concerning why you are experiencing these headaches?" "Do the headaches negatively impact your day-to-day life?" "Do you have any fears about the headaches you experience?"

A nurse is performing an admission assessment on a new client to the unit. What would be the best way to phrase a question about the client's marital status? "Is your spouse living with you?" "Are you living with your spouse?" "Do you live alone or with someone?" "Are you married, divorced, or widowed?"

"Do you live alone or with someone?"

A nurse is interviewing a man complaining of a pain in his shoulder. The nurse asks him where exactly the pain is, and he points to a spot on the lateral, posterior upper arm. The nurse has seen similar cases in other clients and recognizes that is likely from prolonged work at a computer, particularly using a mouse. Which of the following is the most effective use of inferring that the nurse might implement in this situation? "I recommend that you change your posture while working at the computer." "You work at a computer a lot, don't you?" "When did the pain start?" "Do you perform any sustained or continually repetitive motions with that arm?"

"Do you perform any sustained or continually repetitive motions with that arm?"

During the chest auscultation portion of a general survey, a 31-year-old client suddenly stands up and leaves the room quickly, stating, "I'm sorry, I just can't do this." How should the clinician best document this event? "Client visibly agitated during assessment and unwilling to continue." "Client became upset and terminated assessment." "During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room." "During chest auscultation, client decided that she could no longer participate in assessment and removed herself from the room."

"During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room."

Which of the following data entries follows the recommended guidelines for documenting data? "Patient is overwhelmed by the diagnosis of pancreatic cancer." "Patient kidneys are producing sufficient amount of measured urine." "Following oxygen administration, vital signs returned to baseline." "Patient complained about the quality of the nursing care provided on previous shift."

"Following oxygen administration, vital signs returned to baseline."

A client is being admitted to the medical unit after being seen in the emergency department. Which statement by the nurse indicates an understanding of the importance of the appropriate timing of a health assessment? "The client has been ordered a nutritional consult; I do the health assessment right after that is finished." "I'll do the health assessment when the client's family leaves so that distractions will be minimal." "I'm going to assess the client now so that I can begin formulating the care plan." "The health assessment will be more thorough if I wait until the client is pain free."

"I'm going to assess the client now so that I can begin formulating the care plan."

A 74-year-old man has been taking a beta-blocker for several years, and his care provider has chosen to add a diuretic to his regimen to better control his hypertension. What should the clinician teach the client about the relationship between his new medication and his nutritional health? This might make you constipated at first, so try to include more fiber in your diet. "This will make you urinate more often, so make sure you drink plenty of fluids." "Let me know if you feel nauseous after you start these pills, because it's not uncommon." "When you pick up your prescription at the pharmacy, it would be a good idea to buy some over-the-counter iron supplements as well."

"This will make you urinate more often, so make sure you drink plenty of fluids."

To calculate the ideal body weight for a woman, the nurse allows 106 pounds for 5 feet of height. 6 pounds for each additional inch over 5 feet. 100 pounds for 5 feet of height. 80 pounds for 5 feet of height.

100 pounds for 5 feet of height.

A client had ingested hot coffee immediately after having an oral temperature reading obtained of 101°F. The health care provider is asking for the temperature measurement to be repeated using a tympanic membrane thermometer. What temperature will the nurse most likely obtain using this different measurement route? 102.4°F 99.6°F 98.6°F 103.8°F

102.4°F

A nurse has an order to obtain orthostatic blood pressure readings on a client admitted with dehydration. The sitting blood pressure is 140/75 mm Hg. Which blood pressure reading with the client standing should the nurse recognize as orthostatic hypotension? 160/85 mm Hg 130/65 mm Hg 120/55 mm Hg 140/55 mm Hg

120/55 mm Hg

A nurse is establishing an ideal body weight for a 5' 9" healthy female. Based on the rule-of-thumb method, what would be this client's ideal weight? 130 lb 135 lb 140 lb 145 lb

145 lb

A nurse assesses a 105-pound adult client who is 5 feet 8 inches tall. What is the estimated body mass index (BMI) for this client? 16 18 20 22

16

A nurse assesses a 114-pound adult client who is 5 feet 5 inches tall. What is the estimated body mass index (BMI) for this client? 19 BMI 20 BMI 21 BMI 22 BMI

19 BMI

At what percent of weight over ideal weight is a person considered obese? 20% 40% 60% 100%

20%

A nurse assesses a 175-pound adult client who is 5 feet 11 inches tall. What is the estimated body mass index (BMI) for this client? 18.9 24.4 29.9 34.4

24.4

An individual is considered obese when his or her BMI is: Less than 24 25-29 30-39 Greater than 40

30-39

A nurse assesses a 350-pound adult client who is 6 feet 1 inch tall. What is the estimated body mass index (BMI) for this client? 29 34 46 52

46

Upon assessing the skin, the nurse finds pustular lesions on the face. The nurse identifies that these could be what? Acne Psoriasis Varicella Herpes simplex

Acne

The nurse formulates a nursing diagnosis of pain, acute, from assessment data collected from a client who has complained of pain of a 7 (1 to 10 scale). What type of nursing diagnosis would this be considered? Actual Nursing Diagnosis Risk Nursing Diagnosis Wellness Nursing Diagnosis Rule Out Nursing Diagnosis

Actual Nursing Diagnosis

A post-operative client is observed breathing 24 breaths/minute while complaining of 10/10 abdominal pain. The client's oxygen saturation is 90% on 2 liters nasal cannula. What is the nurse's priority action? Administer prescribed analgesia as ordered. Teach and encourage incentive spirometry use. Explain why deep breathing and coughing is important. Manually ventilate client with ambu bag at bedside.

Administer prescribed analgesia as ordered.

The nurse notes that a client has had an 8 kg weight loss over the last 3 months. On which mental health issue should the nurse focus when assessing this client? Select all that apply. Anxiety Psychosis Eating disorder Early dementia Substance abuse

Anxiety eating disorder early dementia

A client presents to the health care clinic with reports of a 2-day history of sore throat, ear pressure, fever, and stiff neck. The client states she has taken Tylenol and lozenges without relief. Which nursing diagnosis can be confirmed by this data? Anxiety related to prolonged pain Impaired physical mobility related stiff neck Risk for deficient fluid volume related to fever Acute pain related to sore throat

Anxiety related to prolonged pain

The nurse identifies the client has a positive Obturator sign. The nurse identifies this is due to what? Appendicitis Inflammation of the gallbladder Liver engorgement Kidney pain

Appendicitis

The nurse has completed a plan of care for a client having a total knee replacement. In order to develop goals which are realistic for the client, what should the nurse do prior to implementing the plan? Discuss the plan of care with all of the health care providers involved. Share the assessment and plan with the client's primary health care provider. Ask the client for opinions and willingness to proceed with the interventions. Identify the needs of the client's family in relation to the priority problem.

Ask the client for opinions and willingness to proceed with the interventions.

The nurse is preparing to perform a physical examination of a client who is an Orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client, based on his religious beliefs? Allow the client to pray before the examination Let the client remained fully dressed for the examination Have a nurse who is the same sex as the client examine him Avoid asking any questions regarding the client's lifestyle

Avoid asking any questions regarding the client's lifestyle

he nurse is preparing to percuss a client's anterior chest area. Which approach will the nurse use for this assessment? Begin at the sternal notch and percuss all areas on the right chest then all areas on the left chest. Begin at the sternal notch and percuss all areas on the left chest then all areas on the right chest. Begin above the left clavicle and percuss all areas on the left chest, then reverse the process and assess the right chest moving upward from the liver. Begin above the right clavicle and percuss each section comparing the right chest with the left chest.

Begin above the right clavicle and percuss each section comparing the right chest with the left chest.

A nurse cares for a client with a stage II pressure ulcer on the right hip. The nurse anticipates finding what type of appearance to the skin over this area? Unbroken but red in color Ulceration resembling a crater Exposure of subcutaneous tissue and muscle Broken with the presence of a blister

Broken with the presence of a blister

Which of the following statements relating to assessment of the lungs and thorax is most accurate? Hemoptysis is more common in children and adolescents than in older clients. Moderate to severe chest pain is associated with a cardiac etiology, while mild to moderate chest pain is most often respiratory in origin. Loud and very loud percussion notes denote pathological findings. Bronchitis is characterized by excess mucus production and chronic cough.

Bronchitis is characterized by excess mucus production and chronic cough.

The nurse is caring for a 22-year-old client with a crush injury. The nurse would be alert for what pain description(s) that would indicate neuropathic pain? Select all that apply. Burning Painful numbness Gnawing Sharp Crushing

Burning Painful numbness

The nurse should assess for which pain complaints from a client diagnosed with Type II Diabetes Mellitus? Sharp, stabbing Aching, gnawing Burning, tingling Pain only on movement

Burning, tingling

One of the goals of nursing is to provide care that is safe to clients. What is the best way for nurses to realize this goal? By accurately charting client care By continually assessing client laboratory values By continual communication with all members of the health care team By giving client care conferences including all members of the health care team

By continual communication with all members of the health care team

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

Carotene

A nurse is providing nutritional instruction to a client with cardiovascular disease. The nurse mentions a nutrient that is a necessary component of bile salts (which aid in digestion), serves as an essential element in all cell membranes, is found in brain and nerve tissue, and is essential for the production of several hormones such as estrogen, testosterone, and cortisone. The nurse warns the client, however, that this nutrient when consumed in excess can lead to heart attacks and strokes. To which of the following nutrients is the nurse referring? Cholesterol Saturated fat Unsaturated fat Protein

Cholesterol

A 62-year-old construction worker presents to the clinic reporting almost a chronic cough and occasional shortness of breath that have lasted for almost 1 year. Although symptoms have occasionally worsened with a cold, they have stayed about the same. The cough has occasional mucus drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married with two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. Examination reveals a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his symptoms? Spontaneous pneumothorax Chronic obstructive pulmonary disease (COPD) Asthma Pneumonia

Chronic obstructive pulmonary disease (COPD)

A mental status examination consists of various components. Which assessment data is associated with cognitive function? Select all that apply. Client is dressed appropriately for the weather. Client is able to successfully multiple 24 times 32. Client correctly names the last three presidents of the United States. Client's verbal skills are appropriate for age. Client reports frequently seeing a dead parent.

Client is able to successfully multiple 24 times 32. Client correctly names the last three presidents of the United States.

A nurse is documenting a client's headache. Which of the following would be the best entry to include for this finding? Client has a dull, aching pain in the back of his head that began 2 weeks ago. The pain is constant and seems to be worse in the mornings. Client has severe headache, probably related to alcoholism. Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m. Client reports headache.

Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m.

Which entry demonstrates correct documentation by a nurse regarding assessment of the client admitted for abdominal pain? Abdominal pain x 2 weeks, no medications taken, denies diarrhea or constipation Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10 Abdominal pain most likely due to client's unhealthy lifestyle and poor eating habits Bowel sounds are present in all four quadrants, all organ within normal limits

Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10

What can the nurse use to learn new information and add to their knowledge base? Clinical experience. Past experience of other nurses. Reading a medical-surgical textbook. Doing several written care plans

Clinical experience.

During the admission assessment, the nurse notes the client has cuts to her face and bruises on her chest and back. Which of the following demonstrates the most appropriate documentation of these findings? Multiple bruises and cuts on client's body. Client states she fell down a flight of stairs. Dark purple-blue area on the right side of chest and on right lower back. Open areas on the left side of the lower lip and above right eye. Bruises and cuts to face and torso. Client appears to have been severely beaten by her husband. Bruises on chest and back with multiple cuts on her face.

Dark purple-blue area on the right side of chest and on right lower back. Open areas on the left side of the lower lip and above right eye.

During palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing light palpation. moderate palpation. deep palpation. very deep palpation.

Deep palpation

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands? Dermis Epidermis Subcutaneous layer Connective layer

Dermis

The nurse is focusing an interview on a client's respiratory status. Which question should the nurse ask first to begin this interview? Do you currently have a cough? Do you have any difficulty producing sputum? Describe how you breathe for me? Do you experience any pain when you breathe?

Describe how you breathe for me?

A client recovering from a burn injury is told by the health care provider that hair will no longer grow on the body part that was burned. When the client questions why this is true, the nurse will base the response on what physiological event that occurred as a result of the burn? The damage to keratin producing cells in the epidermis layer Destruction of hair follicles located in the dermis layer The impairment of apocrine gland to function effectively in the subcutaneous layer The ability of the adipose layer to produce carotene has been destroyed

Destruction of hair follicles located in the dermis layer

A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What should the nurse do before auscultating? Disinfect the stethoscope before touching the client Disinfect the stethoscope after touching the client Make sure the stethoscope is placed directly on the client's skin so that there is complete contact with the skin surface Put on a personal protection gown

Disinfect the stethoscope before touching the client

The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions? Type Color Distribution Arrangement

Distribution

Which clients are most at risk for depressive symptoms? (Select all that apply.) Married clients Divorced clients Females Males Chronically ill clients

Divorced clients females chronically ill clients

The nurse is admitting a client to the mental health unit with a diagnosis of attempted suicide. Which is the best question for the nurse to ask first? Do you have any thoughts of wanting to harm or kill yourself? Do you hear voices that tell you what to do? On a sense of 0 to 10, with 10 being most intense, how suicidal do you feel now? Do you have a sense of hope for the future?

Do you have any thoughts of wanting to harm or kill yourself?

A nurse cares for a client of Asian descent and notices that the client sweats very little and produces no body odor. What is an appropriate action by the nurse in regards to this finding? Assess the client for changes in sensation due to vascular problems Monitor the client for additional findings of cystic fibrosis Suggest that the client use antiperspirant products Document the findings in the client's record as normal

Document the findings in the client's record as normal

A nursing instructor is showing the nursing student how to correct an error when documenting on the chart. The instructor directs the student to do the following: Erase thoroughly and then rewrite the entry. Black out the incorrect information with a marker and write the correct entry above. Draw a line through the error and place initials above the correction. Use whiteout to make the chart appear neat and rewrite the entry.

Draw a line through the error and place initials above the correction.

The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes? Evidence in a situation of wrongdoing Evaluate nursing care provided Discharge planning for the client Reimbursement for care provided

Evidence in a situation of wrongdoing

A client, with a family history of melanoma, wants to have specific body moles assessed. In order to perform this assessment effectively, the nurse should have access to what equipment? (Select all that apply.) Warm water Examination table Chair Mask Natural lighting

Examination table Chair Natural lighting

A male client who was transferred from intensive care and extubated less than 24 hours ago exhibits drooling and a weak voice. At meal time, what is the nurse's priority action? Delegate feeding the client to a nursing assistant. Place the client in semi-Fowler's position for feeding. Call the healthcare provider to request a liquid diet. Explain to the client why he should not eat anything by mouth yet.

Explain to the client why he should not eat anything by mouth yet.

The nurse is working on a pediatric unit caring for a 4-year-old who is recovering from the surgical repair of the pelvis. When assessing the client's pain, what is the most appropriate pain assessment tool for the nurse to use? Face, Legs, Activity, Cry, Consolability Scale Visual Analog Scale FACES Pain Scale Numeric Pain Intensity Scale

FACES pain scale

A nurse assesses a cognitively impaired adult client who grimaces and points to the right knee following a motor vehicle accident. Which pain scale would be most appropriate for the nurse to use to assess the client's pain? Verbal Descriptor Scale Numeric Rating Scale Faces Pain Scale Visual Analog Scale

Faces Pain Scale

How would the nursing instructor explain the goal of guided questioning to his or her students? Providing the most plausible answer to the client Facilitating the client's fullest communication Developing a basis for accurate health promotion activities Creating an opportunity for the early generation of a plan

Facilitating the client's fullest communication

Which action by the nurse will facilitate relaxation of the abdominal muscles during examination of the abdomen? Flex the client's legs by placing a pillow under the knees Raise the client's arms or fold them behind the head Avoid the use of pillow under the head during examination Provide privacy to the client and instruct him to relax

Flex the client's legs by placing a pillow under the knees

On inspection of the abdomen, a nurse notes that the client's skin appears pale and taut. The nurse recognizes that this finding is most likely due to what process occurring within the abdominal cavity? Bleeding Fluid accumulation Inflammation Obstruction

Fluid accumulation

A client comes to the clinic and states, "I have a bad cold and am having trouble breathing." The nurse checks the client's breath sounds and hears bilateral fine crackles at the base. Of what is this finding indicative? Fluid in the alveoli Fluid in the bronchioles Fluid in the bronchus No fluid present

Fluid in the alveoli

The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what? Funnel chest Pigeon chest Intercostal bulging Pectoriloquy

Funnel chest

A client on a medical-surgical unit reports pain of 10 on a scale of 0 to 10 and wants more pain medication. The nurse does not think the pain is as bad as the client says. The physician left orders for prn morphine for breakthrough pain. What is the priority nursing action? Give the prn morphine Hold the medication and wait 30 minutes Call the physician to check the order Document the client's pain rating on a scale of 0 to 10

Give the prn morphine

Learning about the effects of the illness does what for the nurse and the client? Gives them the basis to establish a trusting relationship Gives them each a better understanding of the other Gives them the ability to communicate better Gives them the opportunity to create a complete and congruent picture of the problem

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

After completing the physical examination of a client who is 12 weeks pregnant, a new nurse leaves the room only to realize she forgot to complete an examination of the skin. What should the nurse do? Omit this part of the physical examination. Review the documented client history. Ask a colleague who saw the client earlier. Go back in to complete a physical examination of the skin.

Go back in to complete a physical examination of the skin.

A client complains of pain in several areas of the body. How should the nurse assess this client's pain? Ask the client to rate the area with the highest pain level. Mark each site on the client's body with a marker. If pain does not radiate, there is no need to rate that area. Have the client rate each location separately.

Have the client rate eat location separately

An older adult client with COPD has come to the clinic for a routine follow-up visit. The nurse escorts the client to an examination room and measures vital signs. The nurse would expect the client's vital signs to be what? Higher than normal Lower than normal Within normal limits The nurse would not routinely take this client's vital signs

Higher than normal

A nurse is assessing the effect of a client's chronic back pain on his affective dimension. Which question should the nurse ask for this assessment? What medical conditions do you have? Where is the pain located? What is the highest level of education you've completed? How does the pain influence your overall mood?

How does the pain influence your overall mood?

A client with diabetes mellitus visits the health care clinic with reports of excessive thirst and excessive urination. She states that her appetite has been low for the past 3 months, and has lost 20 pounds. Which nursing diagnosis should the nurse confirm based on this data? Fluid volume, excessive Imbalanced nutrition Activity intolerance Knowledge deficit

Imbalanced nutrition

The nurse gathers the following data: complaint of headache and sore throat, redness noted on pharynx with white exudates on tonsils, minimal cough, temperature 100.6°F orally. It was noted that the client had another sore throat 2 weeks ago. The most appropriate nursing diagnosis for this data would be: Impaired comfort related to headache and sore throat pain Ineffective health maintenance related to repeated sore throat Infection related to elevated temperature Stress related to illness

Impaired comfort related to headache and sore throat pain

A client who is 2 days postoperative reports pain and requests pain medication. After assessing the client's pain level, the nurse decides to give the client oral oxycodone hydrochloride-acetaminophen instead of intravenous morphine. This nurse is doing which step of the nursing process? assessment implementation evaluation diagnosis

Implementation

A few nursing students revealed to a faculty advisor that they were concerned about the effects of their program demands on their personal health practices. Follow-up with other students indicated that this was a common concern among the student group. Further assessment showed that the students expressed their belief in the importance of maintaining good health practices, but that most students had discontinued weekday efforts because of their focus on school-related stress and limited economic resources. Faculty members supported the concept of integrated health programs and were prepared to develop a program as a project. To assess the need for health promotion among the group of students, which of the following assessment methods would be most useful? Physical assessment and health history Individual student interview and questionnaire Review of literature and consultation with faculty Walk-through of education facility and faculty questionnaire

Individual student interview and questionnaire

A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action? Inspect the area Ask further questions Document the statement Move on to next body system

Inspect the area

A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse? Listen again with the bell of the stethoscope Instruct the client to cough forcefully Have the client breathe through the mouth Assess for the use of accessory muscles

Instruct the client to cough forcefully

A client presents to the emergency department with reports of new onset of abdominal pain for the past 3 days. The client states there is also a pulling feeling on the right side. Upon examination, the nurse notices a 5-cm transverse scar in the right lower quadrant. The nurse recognizes that this client may be experiencing what type of process? Internal adhesions from previous surgery Intestinal obstruction at the sigmoid colon Acute onset of appendicitis with possible rupture Peritonitis from a ruptured diverticulum

Internal adhesions from previous surgery

The U.S. government has created guidelines for health care providers caring for clients in pain. Which of the following reflect these guidelines? Joint Commission Standards for Pain Management. National Institutes of Health Standards for Pain Treatment. American Cancer Society Guidelines for Pain Management. American Pain Society Guidelines for Pain Management.

Joint Commission Standards for Pain Management.

Which of the following assessment findings most likely constitutes a secondary skin lesion? Keloid formation at the site of an old incision Facial acne Facial lesions associated with herpes simplex Psoriasis

Keloid formation at the site of an old incision

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: Limiting abbreviations to those approved for use by the institution. Using only abbreviations whose meaning is self-evident to an educated health professional. Ensuring that abbreviations are understandable to clients who may seek access to their health records. Using only those abbreviations that are defined in full at another location in the client's chart.

Limiting abbreviations to those approved for use by the institution.

A nurse is inspecting the abdomen of a young, fit client who has well-defined abdominal muscles. The nurse recognizes the vertical line that appears in the center of the client's abdomen as which of the following? Peritoneum Linea alba Internal abdominal oblique Transverse abdominis

Linea alba

A nurse auscultates for bowel sounds on a client admitted for nausea and vomiting and hears no gurgling in the right lower quadrant after 1 minute. What is an appropriate action by the nurse? Document the absence of bowel sounds Assess for findings of dehydration Listen for a total of 5 minutes Palpate for abdominal rigidity

Listen for a total of 5 minutes

Which action should a nurse implement when assessing a nonnative client to facilitate collection of subjective data? Speak to the client using local slang. Maintain a professional distance during assessment. Avoid any eye contact with the client. Ask one of the client's children to interpret.

Maintain a professional distance during assessment.

23-year-old ticket agent is brought in by her husband because he is concerned about her recent behavior. He states that for the last 2 weeks she has been completely out of control. She hasn't showered in days, stays awake most of the night cleaning their apartment, and has run up more than $5,000 on their credit cards. While he is talking the client interrupts him frequently, declares this is all untrue, and says she has never been so happy and fulfilled in her whole life. She speaks very quickly, changing the subject often. After a longer than normal interview, the nurse learns that the client has had no recent illnesses or injuries. Her past medical history is unremarkable. Both her parents are healthy, but the husband has heard rumors about an aunt with similar symptoms. The client and her husband have no children. She smokes one pack of cigarettes a day (although she has been chain smoking in the last 2 weeks), drinks four to six times a week, and smokes marijuana occasionally. She is very loud and outspoken. Physical examination findings are unremarkable. Which mood disorder does she most likely have? Major depressive episode Manic episode Dysthymic disorder Schizophrenia

Manic episode

A nurse needs to record the height of a client who refuses to stand because of blisters on the feet. What alternative method should the nurse implement to obtain the client's height? Measure the arm span to estimate height Provide support or hold the client to record the height Obtain this information subjectively from the client Use a standard chart for height by age and gender

Measure the arm span to estimate height

A nurse is documenting information about a client in a long-term care facility. What is used in a Medicare-certified facility as a comprehensive assessment and as the foundation for the Resident Assessment Instrument (RAI)? PIE system Minimum data set OASIS Charting by exception

Minimum data set

When formulating a nursing diagnosis, the format that is most useful to clearly document the client's problem is NANDA label (for problem) + related to + etiology + AMB (as manifested by) + defining characteristics. NANDA label + defining characteristics + AMB (as manifested by) the etiology. NANDA label + definition + defining characteristics + AMB (as manifested by) etiology. NANDA label + definition + etiology + AMB (as manifested by) + defining characteristics.

NANDA label (for problem) + related to + etiology + AMB (as manifested by) + defining characteristics

A nurse is collecting a thorough and accurate subjective history of a client's nail problems. The client asks why this is necessary. Which of the following should the nurse mention in response? Nail problems may affect a persons body image negatively Nail problems can be caused by an underlying systemic illness Local irritation can cause damage to the nail bed Abnormalities may be a sign of poor hygiene

Nail problems can be caused by an underlying systemic illness

Which of the following examples of documentation best exemplifies sound clinical documentation practices? "Client is anxious during questioning regarding health history and family history." "Abnormal chest sounds noted during posterior chest auscultation." "Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter." "Client reports sharp pain to chest on deep inspiration."

Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter."

An older adult client had hip replacement surgery 2 days ago. The nurse enters the client's room and encourages the client to use the incentive spirometer ten times every hour. What is this action an example of? Nursing intervention Nursing goal Nursing evaluation Nursing assessment

Nursing intervention

You are the clinic nurse assessing a new client that has come in to see a physician. The assessment data that you collect reveals that the client is a 23 year-old female weighing 175 lb with a height of 5 ft 3 in. Her body mass index is 31. What would she be considered? Average weight Obese Overweight Underweight

Obese

A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation? Auscultate for the presence of crackles Palpate for tactile fremitus Percuss to determine diaphragmatic excursion Observe for the use of accessory muscles

Observe for the use of accessory muscles

When auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following? One quiet full inspiration through pursed lips Two full breaths every 10 seconds through the nose One deep inspiration and expiration through the open mouth Two full breaths in through the mouth and out through the nose

One deep inspiration and expiration through the open mouth

A nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commode. Which of the following health problems should the nurse consider when client falls occur? Orthostatic hypotension Dyspnea Primary hypertension Secondary hypertension

Orthostatic hypotension

A nurse provided dietary counsel for a client who recently immigrated to the United States from Japan. During the initial interview, the client had his eyes lowered and did not make eye contact with the nurse. In analysis of the data, the nurse wrote down the following hunch: "risk for imbalanced nutrition related to client's unwillingness to listen to dietary advice." At the next meeting with the client a month later, however, the nurse was surprised to find that the client had adopted all recommended changes from their initial interview. Which error did the nurse commit in this case? Clustering together unrelated cues Diagnosing a client without hypothesizing several diagnoses Incorrectly wording a diagnostic statement Overlooking consideration of the clients cultural background

Overlooking consideration of the clients cultural background

Which of the following cultural expressions of pain would be likely to be found in a person of Hispanic culture? Pain is honorable and should be endured. Pain is part of the preparation for the next life in the cycle of reincarnation. Pain must be endured to perform gender role duties, but response to it is very expressive. Pain may be caused by past transgressions and helps to atone and achieve higher spirituality.

Pain must be endured to perform gender role duties, but response to it is very expressive.

In interviewing a client about his heart rate, the nurse asks whether he has noticed any alteration to his heartbeat. The client responds that he sometimes feels his heart race even when he has not been exerting himself physically. This alteration is known as which of the following? Dyspnea Pulse pressure Apical beats Palpitation

Palpitation

The nurse needs to assess the abdomen of a hospitalized client post gastrointestinal surgery. Place the following assessment steps in order as the nurse enters the client's room. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Perform a general survey of safety hazards. 2Inspect the abdomen. 3Auscultate all four quadrants. 4Palpate for tenderness. 5Document the findings.

Perform a general survey of safety hazards. Inspect the abdomen. Auscultate all four quadrants. Palpate for tenderness. Document the findings.

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? Reynaud disease Central cyanosis Neurofibromatosis Peripheral cyanosis

Peripheral cyanosis

A client admitted to the health care facility for new onset of abdominal pain expresses to the nurse that she was treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information? History of present illness Review of systems Chief complaint Personal health history

Personal health history

A nursing instructor is discussing nutrition screening and assessment with a clinical group. What would this instructor identify for the students as parts of a complete nutrition screening assessment? Select all that apply. Physical examination Dietary log Calorie count Focused history of common symptoms Serial laboratory values

Physical examination Focused history of common symptoms Serial laboratory values

A client presents to the emergency department complaining of new onset chest pain. What is the priority action of the nurse? Collect client's health history. Reconcile current medications. Place on cardiac monitor. Record the client's allergies.

Place on cardiac monitor.

In order to help out the staff in completing admission tasks during a busy shift, the charge nurse is completing the admission database for a staff nurse. What is the charge nurse's best action? Document the highlights of the physical exam. Place the completed assessment in the medical record. File the admission database for nurse only access. Omit the fall risk assessment since the client is a young adult.

Place the completed assessment in the medical record.

What precaution should the nurse take when measuring a client's abdominal girth to screen for cardiovascular risk factors? Ensure that the client has had a full meal before measuring the abdomen Ask the client to be seated and relaxed when taking the measurement Inform the client that the pen mark on the abdomen should not be washed off Place the tape measure behind the client and measure at the umbilicus

Place the tape measure behind the client and measure at the umbilicus

The nurse obtains a flat sound when percussing the right lower lobe of a client. What does this assessment finding indicate to the nurse? Healthy lung tissue Gastric air bubble Emphysema Pleural effusion

Pleural effusion

The nurse assesses a client's indwelling urinary catheter bag and observes cloudy urine. The client also complains of lower back pain. What is the nurse's best action? Encourage the client to increase PO fluid intake. Record the findings as expected for a client with an indwelling catheter. Flush the catheter tubing with sterile normal saline. Prepare to obtain a urine specimen for culture.

Prepare to obtain a urine specimen for culture.

A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan? Data base Problem list Plan of care Progress notes

Progress notes

When assessing for appendicitis, what signs might the nurse look for? (Select all that apply.) Murphy sign Psoas sign Obfuscator sign Rovsing sign Cutaneous hyperesthesia

Psoas sign Rovsing sign Cutaneous hyperesthesia

A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse? Pulse is strong, and light pressure causes it to disappear. Pulse is felt with difficulty and disappears with slight pressure. Pulse is felt easily, and moderate pressure causes it to disappear. Pulse is strong and remains despite moderate pressure.

Pulse is strong, and light pressure causes it to disappear.

A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow? Reading is erroneously high. Reading is erroneously low. Pressure on the cuff would be painful. It will be difficult to pump up the bladder.

Reading is erroneously high

The client comes to the emergency department reporting indigestion and left arm pain. The physician orders an EKG along with drawing of cardiac enzymes. When the results are back, the client is informed of the diagnosis of heart attack. The indigestion and arm pain are examples of which of the following? Visceral pain Referred pain Cutaneous pain Somatic pain

Referred pain

A nurse who has been working at the health clinic for 20 years has just taken a client's blood pressure and found it to be 110/70. When consulting the client's record, the nurse sees that he has had persistent hypertension for the past 5 years and has been on antihypertensive medication the whole time. His blood pressure has never been below 150/90 and was 180/95 at his last visit, 1 year ago. The client's weight has remained the same. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case? Repeating the measurement with a different sphygmomanometer and stethoscope Asking the physician to come in and take the client's blood pressure Asking the client whether his diet has changed in the past year Asking the client whether his exercise habits have changed recently

Repeating the measurement with a different sphygmomanometer and stethoscope

A nurse is performing percussion on a client's back to assess the lungs, and hears a loud, low-pitched, hollow sound, indicating normal lungs. Which of the following describes this finding? Hyper-resonance Resonance Tympany Dullness

Resonance

The nursing instructor is discussing standard precautions with a group of students. What else should the instructor talk about to prevent the transmission of pathogens? Use of alcohol-based hand cleaner Respiratory/cough hygiene How to recycle personnel protective equipment How to clean client equipment

Respiratory/cough hygiene

The nurse enters an unassigned client's room to investigate an alarm. The client's intravenous (IV) bag is empty and the IV bag on the pole, left by the client's assigned nurse to hang next, is a different solution. What is the nurse's best action? Hang the IV solution the client's assigned nurse left on the pole. Obtain an IV bag of the current solution and hang it. Review the client's prescribed medication orders. Discontinue the current solution and disconnect it from the client.

Review the client's prescribed medication orders.

Which actions should a nurse perform before beginning the initial shift assessment of a client? Select all that apply. Gather assessment tools after meeting the client Review the client's record before meeting the client Revise nursing care plans to reflect improvements in the clients condition Check the client's status with the nurse of the previous shift Determine knowledge of self-care based on age, education, and experience

Review the client's record before meeting the client Revise nursing care plans to reflect improvements in the clients condition Check the client's status with the nurse of the previous shift

Susanne is a 27-year-old woman who has had headaches, muscle aches, and fatigue for the last 2 months. The nurse has completed a thorough history, examination, and laboratory workups, the results of which are normal. What would the next action be? A referral to a neurologist A referral to a rheumatologist Telling the client nothing has been found Screening for depression

Screening for depression

A nurse is assessing a client with acute asthma. Which adventitious breath sound should the nurse expect to hear in this client? Fine crackles occurring late in inspiration Course crackles occurring from early inspiration to early expiration Sibilant wheezes heard primarily during expiration but may also be heard on inspiration Sonorous wheezes heard primarily during expiration but may be heard throughout the respiratory cycle

Sibilant wheezes heard primarily during expiration but may also be heard on inspiration

Which of the following occurs in respiratory distress? The client speaks in sentences of 10-20 words. Skin between the ribs moves inward with inspiration. Neck muscles are relaxed. Client torso leans posteriorly.

Skin between the ribs moves inward with inspiration.

A client presents to the health care clinic with reports of changes in the skin. Which data should the nurse document as objective with regards to the skin? Small lesion left forearm for one month Denies any skin color changes Skin warm and dry to the touch Dry and flaky skin in the winter months

Skin warm and dry to the touch

A nurse is preparing to perform a physical examination of an obese client who is beginning a diet and exercise program. The physician would like to establish a baseline percent body fat measurement for the client so that the client's progress in reducing body fat can be tracked over time. Which piece of equipment should the nurse anticipate needing for this purpose? Platform scale with height attachment Metric ruler Sphygmomanometer Skinfold calipers

Skinfold calipers

The nurse enters an older client's room to assess for pain and discovers the client is hard of hearing. What is the nurse's best action? Utilize the FLACC scale. Speak to the client face to face. Suggest client purchase a hearing aid. Ask client to numerically rate pain in a high-pitched voice.

Speak to the client face to face.

Which of the following statements most accurately conveys an aspect of the gate-control theory? The transmission and sensation of pain exist completely within the spinal cord. Substances such as endorphins are noted to increase pain sensation. Specialized cells can decrease pain transmission by exciting inhibitory neurons. Pain transmission and emotional state exist independently of each other.

Specialized cells can decrease pain transmission by exciting inhibitory neurons.

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? Transition Summarization Reassurance Termination

Summarization

The nurse is assessing a client with a bladder disorder. Where would the nurse expect the pain to be? Upper abdomen Suprapubic Back Perineal

Suprapubic

In palpating the chest of a client, a nurse feels a U-shaped indentation on the superior border of the manubrium. The nurse recognizes this landmark as which of the following? Suprasternal notch Sternal angle Acromion of the scapula Xiphoid process

Suprasternal notch

Upon entering an adult client's room to begin a shift assessment, the nurse should call the rapid response team based on which assessment finding? Systolic pressure 180 mm Hg. Apical pulse 70 beats/minute. Respirations 12 breaths/minute. Oxygen saturation 95% on room air.

Systolic pressure 180 mm Hg.

A nurse is preparing to assess a client's vital signs. In which order should the nurse assess them? Blood pressure, temperature, pulse, and respirations Respirations, blood pressure, pulse, and temperature Temperature, pulse, respirations, and blood pressure Pulse, temperature, respirations, and blood pressure

Temperature, pulse, respirations, and blood pressure

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which of the following observations can be made by the nurse and athletes by measuring the blood pressure? The ability of the arteries to stretch The thickness of the circulating blood The oxygen levels in the blood The volume of air entering the lungs

The ability of the arteries to stretch

An elderly client with Parkinson's disease and his wife, who appears to be much younger than he, are being interviewed by the nurse to update the client's health history. The nurse also has the client's electronic health record on her tablet computer. Earlier in the day, the nurse had spoken with the client's primary care physician, who had relayed some concerns to the nurse regarding the progression of the client's disease. Which source of biographic information should the nurse view as primary? The client The client's wife The physician The client's medical record

The client

The nurse is caring for a client with a nursing diagnosis of impaired skin integrity related to a stage III pressure ulcer. What would be the most important outcome for this client? The client exhibits no signs or symptoms of infection The client changes position every 2 hours The client keeps the area clean and dry The client knows prevention measures for pressure ulcers

The client exhibits no signs or symptoms of infection

Which of the following statements provides the most accurate guide to the assessment of the gallbladder? The gallbladder should be percussed and palpated prior to the liver to avoid confusing it with the larger organ. The gallbladder is deep to the liver and cannot normally be distinguished from the liver clinically. Cholecystitis and cholelithiasis are not amenable to diagnosis in the clinical setting. The margins of the gallbladder are obscured by the spleen.

The gallbladder is deep to the liver and cannot normally be distinguished from the liver clinically.

Which illustrates the nurse using the technique of inspection? The nurse detects a fruity odor of the client's breath. The nurse notes increased warmth surrounding the client's incision. The nurse notes a rhythmic lub-dub over the client's anterior thorax. The nurse detects tympany over the client's lower abdomen.

The nurse detects a fruity odor of the client's breath.

A nurse assesses an older adult client with confusion. When collecting clinical information from the client, which factor is the most important for the nurse to consider? The client will have a long problems list. The quality of the data may be low. Clinical information can be interpreted subjectively. The client will have multi-system problems.

The quality of the data may be low

A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. What opioid neuromodulator may be responsible for this increased level of comfort? The release of endorphins The release of insulin The release of melatonin The release of dopamine

The release of endorphins

Which observation confirms to the nurse that the client is experiencing a normal inspiration? The thoracic cavity enlarges. The abdominal wall is pushed inward. Air can be heard moving out of the tracheobronchial tree. The diaphragm is seen relaxing.

The thoracic cavity enlarges.

A 4-year-old child presents to the health care clinic with circular lesions. Which of the following conditions should the nurse most suspect in this client, based on the configuration of the lesions? Multiple nevi Tinea versicolor Herpes simplex Tinea corporis

Tinea corporis

A nurse is conducting a comprehensive nutritional assessment on a client with suspected malnutrition. Why would it be important to assess this client's ability to cook? To determine if the client is interested in preparing nutritious food To assess if the client has the ability to obtain or prepare food To determine the client's understanding of the principles of nutrition To evaluate the client's food preferences

To assess if the client has the ability to obtain or prepare food

While interviewing a client, the nurse asks, "What happens when you have low blood glucose?" This type of response to the client is used for what purpose? To summarize the conversation To restate what the client has said To promote objectivity To clarify

To clarify

A clinical instructor is discussing with students the care provided to a client. The instructor asks the student why it is important to make timely entries into the medical record. What would be the student's best answer? To have up-to-date information on which to base clinical decisions To be able to verify what care has been given To communicate with other health care providers To be able to update the plan of care

To have up-to-date information on which to base clinical decisions

A nurse caring for a client at a health care facility has to maintain a medical record for the client. Which of the following is a use of the medical record? To transmit health records between insurance companies To investigate the quality of care in the agency To inform family and others concerned about the client's care To release the entire health record for research

To investigate the quality of care in the agency

When would a nurse obtain a mid-arm circumference measurement? To confirm an abnormal albumin level. To provide percentage of body fat and muscle tissue. To screen for nutritional excess or deficits. To assist in determining body mass index.

To provide percentage of body fat and muscle tissue.

Rovsing's sign is a test of referred rebound tenderness in appendicitis. True False

True

The nurse prepares to assess a client newly admitted to the care area. Which approach ensures that the data will guide the identification of appropriate interventions? Follows the ABC approach Uses evidence-based techniques Asks unlicensed staff to measure vital signs Focuses on the system that caused the hospitalization

Uses evidence-based techniques

A nurse is caring for a client with dull ache in her abdomen. On the way to the health care facility, the client vomits and shows symptoms of pallor. What kind of pain is the client experiencing? Visceral pain Cutaneous pain Somatic pain Neuropathic pain

Visceral pain

What is the most common measurement used to determine abdominal visceral fat? Waist circumference. Body mass index. Subcutaneous fat determination. Triceps skinfold thickness.

Waist circumference

The nurse is assessing a client's respiratory rate. Which of the following should the nurse do to ensure accuracy of this assessment? Watch chest movement before removing the stethoscope after counting the apical beat Ask the client to breathe normally Observe the client's chest movement before calling the client back to the examination room Perform the assessment at the beginning, middle, and end of the examination and average the results

Watch chest movement before removing the stethoscope after counting the apical beat

The nurse is determining a priority problem that would be appropriate for a client with heart failure. Which problem would have the highest priority for the client? Weight gain of 3 pounds (1.5 kilograms) over 1-2 days Ineffective health maintenance related to having last mammogram 2 years ago Knowledge deficit related to lack of information regarding low-sodium diet Anxiety related to ineffective coping during hospitalization

Weight gain of 3 pounds (1.5 kilograms) over 1-2 days

A client who is overweight tells the nurse that he wants to lose weight but he doesn't know the best way to begin. The client states that he participates in routine exercise, but wants to increase the intensity of his workout. Which type of nursing diagnosis should the nurse choose for this client based on this information? Collaborative problem Risk diagnosis Wellness diagnosis Referral to dietitian

Wellness diagnosis

A client on the orthopedic unit is being discharged home. The client is elderly and has a broken right humerus; the client is right handed. The client's closest family member lives 50 miles away. What should the nurse consider before discharging the client? Select all the apply. (select all that apply.) Who will be there to help the client with ADLs? How will the client get home from the hospital? How will the client cook and eat? How will the client use her left arm? How will the client drive?

Who will be there to help the client with ADLs? How will the client get home from the hospital? How will the client cook and eat?

Parents of a 15 month old state they are worried about the rolls of fat on the toddler's thighs; so they have switched him over to skim milk. What is the nurse's best response? "You should start seeing some weight loss while he's drinking the skim milk." "As he starts walking more, he will develop more fat rolls." "Whole milk is recommended until age 2." "You should transition to skim milk by giving him 2% milk first."

Whole milk is recommended until age 2."

A young toddler is brought to the emergency room by his parents. The mother states that the child was playing on the floor with toys and suddenly began to wheeze. The mother reports no recent illnesses. The nurse suspects that the most likely cause of the wheezing is a foreign body obstruction increased secretions a severe cold exercise-induced asthma

a foreign body obstruction

When assisting a client with health promotion, what must the nurse also nurture? A healthy environment Knowledge of the Healthy People 2020 indicators Family communication School/work attendance

a healthy environment

During a lecture on pain management, the nursing instructor informs the group of nursing students that the primary treatment measure for pain is which of the following? Analgesics Surgery Relaxation techniques Cutaneous stimulation

analgesics

A female client is admitted to the health care facility due to reports of decreased appetite, loss of sleep, feelings of being unsafe in her own home, and inability to concentrate. She appears pale; her hair is disheveled, she is not wearing makeup, and she will not make eye contact. Based on this data, which nursing diagnosis can the nurse confirm? Imbalanced nutrition: less than body requirements Anxiety Risk for self-directed violence Impaired verbal communication

anxiety

A nurse is teaching a client who suffers from peptic ulcers how to reduce the risk of their recurrence. Which of the following should the nurse recommend? Avoid eating overcooked foods Avoid excessive alcohol intake Avoid taking pain medications with food Avoid taking antacid medications

avoid excessive alchol intake

While assessing the skin of an older adult client, the nurse observes that the client has small yellowish brown patches on her hands. The nurse should instruct the client that these spots are signs of an infectious process. caused by aging of the skin in older adults. precancerous lesions. signs of dermatitis.

caused by aging of the skin in older adults.

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

charting by exception

The nurse is performing the technique shown. What is the nurse assessing? Breath sounds Tactile fremitus Chest expansion Tissue consolidation

chest expansion

During an assessment the client says "I've been having bad pain in my left leg for a week." In which section should the nurse document this information? health patterns chief complaint review of systems history of present illness

chief complaint

The nurse assesses an adult client and observes that the client's breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a physician for possible chronic bronchitis. atelectasis. renal failure. congestive heart failure.

chronic bronchitis.

A client reports the health status of living parents, siblings, and deceased grandparents. What should the nurse do with this information? create a genogram document it in a narrative note include in the past medical history consider using it when planning care

create a genogram

The nurse is caring for an adult client who tells the nurse "For weeks now, I've been so tired. I just can't get to sleep at night because of all the noise in my neighborhood." An actual nursing diagnosis for this client is fatigue related to excessive noise levels as manifested by the client's statements of chronic fatigue. sleep deprivation related to noisy neighborhood and inability to sleep. chronic fatigue syndrome related to excessive levels of noise in neighborhood. readiness for enhanced sleep related to control of noise level in the home.

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

A nurse works at a dermatologist's office and is assessing a client for skin conditions. Which of the following forms should the nurse use? Focused Assessment flow chart Progress notes Nursing minimum data set

focused

An assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a(n) ongoing or partial assessment. focused or problem-oriented assessment. emergency assessment. initial comprehensive assessment.

focused or problem-oriented assessment

A client is unable to recall the last time an immunization was received. Which part of the client's health should the nurse realize is being the most impacted by this practice? risk factors health maintenance screening test completion compliance with treatment

health maintenance

A female client tells the nurse it has been 5 years since her last pap smear examination. Where should the nurse document this information? physical examination health maintenance personal and social history review of systems

health maintenance

The nurse wants to elicit a sound from a client's abdomen. Which technique should the nurse use? direct palpation direct percussion indirect palpation indirect percussion

indirect percussion

The nurse has elicited a positive Murphy sign. What does the nurse recognize this indicates? Inflammation of the gallbladder Appendicitis Kidney pain Peritonitis

inflammation of the gallbladder

Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV. 1intact, firm skin with redness 2ulceration involving the dermis 3full-thickness skin loss 4necrosis with damage to underlying muscle

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

The nurse is assessing the abdomen of an adult client and observes a purple discoloration at the flanks. The nurse should refer the client to a physician for possible liver disease. abdominal distention. Cushing syndrome. internal bleeding.

internal bleeding

nurse is working with a client who has a history of chronic obstructive pulmonary disease (COPD). While bathing the client, the nurse senses that something is not quite right and takes the client's vital signs and obtains an oxygen saturation reading. The nurse is acting on which of the following? scientific rationale intuition knowledge prior history

intuition

A client with a zosteriform rash has a rash that has lesions distributed over a large body area appears with a single lesion in close proximity to a larger lesion, as if "orbiting" the larger lesion is distributed along a dermatome is distributed equally on both sides of the body

is distributed along a dermatome

A nurse is using the FLACC (Face, Legs, Activity, Cry, Consolability) scale for pediatric pain assessment to assess for pain in a 6-month-old client. Which of the following findings on this assessment tool would indicate the strongest pain in the client? Occasional grimace or frown Whimpering Lying quietly Kicking

kicking

For a nurse to be therapeutic with clients when dealing with sensitive issues such as terminal illness or sexuality, the nurse should have advanced preparation in this area. experience in dealing with these types of clients. knowledge of his or her own thoughts and feelings about these issues. personal experiences with death, dying, and sexuality.

knowledge of his or her own thoughts and feelings about these issues.

An older client cannot recall the date of a surgical procedure but the adult daughter interjects with the exact date because it occurred a week before her wedding. How should the nurse document this information? adult daughter controlling the interview unable to recall exact date of last surgery last surgery date validated by adult daughter confused regarding dates of surgical procedures

last surgery date validated by adult daughter

To palpate the spleen of an adult client, the nurse should begin the abdominal assessment of the client at the left lower quadrant. left upper quadrant. right upper quadrant. right lower quadrant.

left upper quadrant

A nurse assesses a client who reports abdominal pain. Which technique should the nurse use during the physical examination to detect tenderness? light palpation deep palpation percussion auscultation

light palpation

A client visits the clinic for a routine physical examination. The nurse prepares to assess the client's skin. The nurse asks the client if there is a family history of skin cancer and should explain to the client that there is a genetic component with skin cancer, especially basal cell carcinoma. actinic keratoses. squamous cell carcinoma. malignant melanoma.

malignant melanoma.

The clavicles extend from the acromion of the scapula to the part of the sternum termed the body. xiphoid process. angle. manubrium.

manubrium.

While assessing an adult client's abdomen, the nurse observes that the client's umbilicus is deviated to the left. The nurse should refer the client to a physician for possible gallbladder disease. cachexia. kidney trauma. masses.

masses

One advantage for an institution to use an integrated cued/checklist type of assessment data form is that it allows a comprehensive and thorough picture of the client's symptoms. may be easily used by different levels of caregivers, which enhances communication. provides for easy and rapid documentation across clinical settings and populations. includes the 11 health care patterns in an easily readable format.

may be easily used by different levels of caregivers, which enhances communication.

A client describes pain in the soles of both feet as constantly burning. Which type of pain should the nurse suspect this client is experiencing? somatic referred visceral neuropathic

neuropathic

A client with diabetes is admitted to the medical unit for the fifth time in 6 months because of elevated blood glucose level. The nurse caring for the client immediately states, "I knew she would be back. It was just a matter of time. She is so noncompliant." This is an example of which of the following? clustering unrelated clues not hypothesizing several diagnoses taking too much time to process data learning what is going on with the client

not hypothesizing several diagnoses

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's physiologic status. holistic wellness status. developmental history. level of functioning.

physiologic status.

A 47-year-old receptionist comes to the office with fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only worsened despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol level. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. Examination reveals a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated at 101 degrees Fahrenheit. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examination are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms? Spontaneous pneumothorax Chronic obstructive pulmonary disease (COPD) Asthma Pneumonia

pneumonia

A client is brought to the emergency department by ambulance after being involved in a motor vehicle accident. The nurse finds that he has decreased breath sounds over the left lung fields. What might the nurse suspect is the cause? Pneumothorax Atelectasis Muscular weakness Asthma

pneumothorax

The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form prevents missed questions during data collection. covers all the data that a client may provide. clusters the assessment data with nursing diagnoses. establishes comparability of data across populations.

prevents missed questions during data collection.

The nurse assesses the client's vital signs as follows: respirations 20 breaths/minute, tympanic temperature 100.9°F, pulse 88 beats/minute, and blood pressure 104/64 mm Hg. The nurse should record the vital signs. instruct the client to drink more fluids. refer the client to a primary care provider. administer Tylenol.

record the vital signs.

During a health history a client recalls the date when being first diagnosed with hypertension. Which term should the nurse use to categorize the quality of the client's data? reliable puzzling concerning questionable

reliable

The nurse is preparing to measure the triceps skinfold of an adult client. The nurse should ask the client to assume a sitting position. measure the triceps skinfold in the dominant arm. repeat the procedure three times and average the measurements. pull the skin toward the muscle mass of the arm.

repeat the procedure three times and average the measurements.

One disadvantage of the open-ended assessment form is that it does not allow for individualization. asks standardized questions. requires a lot of time to complete. does not provide a total picture of the client.

requires a lot of time to complete.

To palpate an adult client's appendix, the nurse should begin the abdominal assessment at the client's left upper quadrant. left lower quadrant. right upper quadrant. right lower quadrant.

right lower quad

To percuss the liver of an adult client, the nurse should begin the abdominal assessment at the client's right upper quadrant. right lower quadrant. left upper quadrant. left lower quadrant.

right upper quadrant

The nursing instructor realizes that the nursing student understands all the criteria necessary for developing expertise when making clinical professional judgments by identifying the following as being a barrier to diagnostic reasoning. knowledge experience time practice seeing things as only right or wrong

seeing things as only right or wrong

The spinous process termed the vertebra prominens is in which cervical vertebra? Fifth. Sixth. Seventh. Eighth.

seventh

The nurse has completed a health assessment on an older adult client being seen at a neighborhood clinic. What client-specific information should the nurse identify as being a priority? lives alone significantly impaired hearing widowed 2 years ago greatly concerned about cost of services

significantly impaired hearing

During an assessment, the client describes vomiting moderate amounts that "smell like poop." The nurse might suspect small bowel obstruction gastric varices hypercalcemia irritable bowel syndrome

small bowel obstruction

A client who suffers from arthritis complains of sharp pain in her knees and elbows. The nurse recognizes this is what type of pain? Visceral Somatic Cutaneous Referred

somatic

The nurse documents vesicular lung sounds upon auscultation. The nurse heard what type of sound? sound heard throughout inspiration and two thirds of expiration inspiratory and expiratory sounds equal in length expiratory sounds lasting longer than inspiratory short silence between inspiration and expiration

sound heard throughout inspiration and two thirds of expiration

An elderly farmer has sustained severe injuries after a serious accident involving a combine harvester. At the hospital, he tells the nurse that he thinks the pain he is feeling now is "payback" for living a "mean, selfish life." The nurse recognizes that this response by the man indicates which dimension of pain? Cognitive dimension Sociocultural dimension Affective dimension Spiritual dimension

spiritual dimension

A nurse performs percussion beginning along the left midaxillary line and progressing downward until the sound changes from lung resonance to splenic dullness. The client reports tenderness. The nurse recognizes this as an abnormal finding for which organ? Kidney Liver Spleen Gall bladder

spleen

Which organ that resides in the abdominal cavity stores red blood cells and platelets, produces new red blood cells and macrophages, and activates B and T lymphocytes? Spleen Pancreas Gallbladder Liver

spleen

The nurse assesses an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as stage I. stage II. stage III. stage IV.

stage II.

Connecting the skin to underlying structures is/are the papillae. sebaceous glands. dermis layer. subcutaneous tissue.

subcutaneous tissue

A client suffering from decreased muscle strength has been diagnosed with a low Vitamin D level. The nurse should recommend that the client increase intake of which vitamin source? Fortified breads Lentils Sunshine Orange juice

sunshine

A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance? To provide a record of the nurse's activities To provide a record of the actual events To provide a record of how the client was harmed To provide a record of the physician's activities

to provide a record of the actual events

The nurse is completing a comprehensive assessment with a client experiencing a lung infection. Which information is essential to document within risk factors? age tobacco use employment medications used

tobacco use

When beginning a height measurement on a 14-year-old, the nurse should instruct the client to stand on the scale with heels together. True False

true

The nurse documents information about a client's activity-exercise health pattern. Which information did the nurse most likely document? gained 15 lbs. over the last 6 months experiences panic attacks several times a week unable to go to the gym since having back surgery misses seeing friends who used to go for walks together

unable to go to the gym since having back surgery

The nurse is preparing the examination room before assessing a client. What is the purpose for a clean folded sheet on the examination table? pad the table use as a drape collect body fluids serve as a head support

use as a drape

During a physical examination of an adult client, the nurse is preparing to auscultate the client's abdomen. The nurse should palpate the abdomen before auscultation. listen in each quadrant for 15 seconds. use the diaphragm of the stethoscope. begin auscultation in the left upper quadrant.

use the diaphragm of the stethoscope.

To assess an adult client's skin turgor, the nurse should press down on the skin of the feet. use the dorsal surfaces of the hands on the client's arms. use the finger pads to palpate the skin at the sternum. use two fingers to pinch the skin under the clavicle.

use two fingers to pinch the skin under the clavicle.

The nurse is interviewing a client in the clinic for the first time. The client appears to have a very limited vocabulary. The nurse should plan to use very basic lay terminology. have a family member present during the interview. use standard medical terminology. show the client pictures of different symptoms, such as the "faces pain chart."

use very basic lay terminology.

The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should validate all data before documentation of the data. document the data after the entire examination process. record the nurse's understanding of the client's problem. use medical terms that are commonly used in health care settings.

validate all data before documentation of the data.

A client is asked to describe "something that brings the most hope." Which functional health pattern is the nurse assessing? value-belief self-perception role-relationship coping-stress-tolerance

value-belief

Short, pale, and fine hair that is present over much of the body is termed vellus. dermal. lanugo. terminal.

vellus

A nurse is assessing a client with a history of alcohol abuse. The client reports right upper quadrant pain. Which type of pain is the client experiencing? visceral parietal referred musculoskeletal

visceral

A nursing student demonstrates understanding of the different types of nursing problems when choosing the following to indicate that the client has the opportunity for an enhanced health state: wellness diagnosis risk diagnosis actual diagnosis medical diagnosis

wellness diagnosis

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus? Sunlight Artificial light Wood's light Flashlight

woods light

During the interview process, the nurse uses both open-ended and closed-ended questions. During what phase of the interview process does the nurse use these specific types of questions? Pre-interaction Beginning Working Closing

working