1120- Practice Questions- Exam 1

The nurse is reviewing the medical record of a newly admitted client to the rehabilitation center. Which subjective question should the nurse confirm with the client? "Would you prefer a bed by the window or a bed by the door?" "What would you like for lunch today?" "Are you aware of any allergies that you may have?" "Do you have family coming to visit today?"

"Are you aware of any allergies that you may have?"

A nursing instructor realizes that a student needs further teaching concerning growth and development when the student states the following: "Erikson's theory states a person cannot advance to the next stage if the previous task is not completed." "Erikson's theory is divided into eight stages." "Piaget's theory concerns cognitive development." "Erikson's theory covers the lifespan."

"Erikson's theory states a person cannot advance to the next stage if the previous task is not completed." Erikson's theory covers the lifespan and is divided into eight stages. Piaget's theory deals with cognitive development. In Erikson's theory, a person can advance to the next stage even if the previous task has not been completed.

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?" "Have you considered counseling for your mental problems? "Have you ever had a problem with mental or emotional illness?" "When was the last time you talked with a psychiatrist?"

"Have you ever had a problem with mental or emotional illness?" The nurse should begin by asking a non-threatening, open-ended question such as "Have you ever had a problem with mental or emotional illness?" Even though the nurse has information about this topic in the documentation, asking the question opens a dialogue with the client in which the client can share as feels comfortable. The question may elicit important information about the client's prior experiences seeking care for mental illness, for example. Asking specifically about medication for depression assumes the client has a history of depression. Asking about talking with a psychiatrist or counseling may cause the client to become defensive.

What statement by a middle-aged adult would most clearly suggest successful achievement of Erikson's central task during this stage of development? "Overall, my marriage is likely stronger than it was when we first got married." "I'm doing a lot of volunteering in order to give back to the community." "I socialize with my coworkers a lot more than I did when I was younger." "I've started to exercise more regularly so that I don't put on extra weight."

"I'm doing a lot of volunteering in order to give back to the community." Erikson identified the main task of middle adulthood as generativity versus stagnation. "Giving back" is a tangible indicator of generativity. Each of the other listed statements is positive, but none directly exemplifies this developmental task.

The nurse at a busy primary care clinic is analyzing the data obtained from the following clients. For which client would the nurse most likely expect to facilitate a referral? An 80-year-old client who lives with their daughter A teenager seeking information about contraception An adult presenting for an influenza vaccination A 50-year-old client newly diagnosed with diabetes

A 50-year-old client newly diagnosed with diabetes

The nurse is caring for 6-year-old Abigail. Which activity would the nurse expect Abigail to perform? Abigail can voice her own opinion. Abigail can calm herself by sucking her thumb. Abigail shares knowledge with others. Abigail draws a picture of her family.

Abigail draws a picture of her family. Abigail is in Erikson's stage of industry versus inferiority. She would be expected to plan and complete an activity, such as drawing a picture of her family. As an infant in the stage of trust versus mistrust, Abigail would learn to calm herself by sucking her thumb. Adolescents achieve identity (versus role confusion) by establishing their own opinions, views, and ideas separate from parent, peers, and others. Middle-aged adults demonstrate generativity (versus stagnation) by sharing their knowledge with younger generations.

A young adult has close personal relationships and desires a permanent love relationship. What should this indicate to the nurse about the client's development? Combating isolation Mastered generativity Achieved intimacy Struggling with role confusion

Achieved intimacy

After the physical examination of a client, a nurse disposes of the used gloves. The nurse has not come in contact with any body fluids or excretion, mucous membranes, nonintact skin, or wound dressings. The nurse's hands do not appear to be visibly soiled. What hand hygiene should the nurse perform? No washing is needed because hands are not soiled. Application of an alcohol-based hand rub Hand wash with antiseptic soap Nonantimicrobial soap and water with friction

Application of an alcohol-based hand rub

On a very busy day in the health care provider's office, Mrs. Donelan, age 81 years, comes for her usual visit to check her blood pressure. She has been on a low-dose diuretic for many years and denies any side effects. Today, her blood pressure is 118/78, which is well controlled. The client mentions that it is hard not having her husband Bill around anymore. What would the nurse do next? Hand Mrs. Donelan a prescription and make sure she has a 3-month follow-up appointment. Make sure Mrs. Donelan understands her prescription. Ask why Bill is not there. Explain that the nurse will have more time at the next visit to discuss any problems Mrs. Donelan is having.

Ask why Bill is not there Sometimes, the client's greatest need is for support and empathy. It would be inappropriate to ignore this comment today. The client may have relied heavily upon Bill for care and may be at risk. She may be depressed and even suicidal, but the nurse will not know unless the topic is explored. Most importantly, the nurse should empathize with the client by saying something like "It must be very difficult not to have him at home" and allow a pause for her to answer. The nurse may also ask "What did you rely on Bill to do for you?" Only a life-threatening crisis with another client should take the nurse out of Mrs. Donelan's room at this point; the nurse may need to adjust the office schedule to allow adequate time for this client.

When is it necessary for a nurse to change gloves? Select all that apply. When touching a noncontaminated client more than once Between taking the same client's blood pressure and temperature Between tasks and procedures on the same client After contact with material that contains a high concentration of microorganisms When going from a contaminated area to a cleaner area

Between tasks and procedures on the same client When going from a contaminated area to a cleaner area After contact with material that contains a high concentration of microorganisms

Universal precautions are primarily designed to protect the health care worker from what? Musculoskeletal injuries Respiratory diseases Blood-borne pathogens STDs

Blood-borne pathogens Universal precautions are a set of guidelines designed to prevent transmission of HIV, hepatitis B virus, and other blood-borne pathogens when providing first aid or health care.

Several hours into a shift, the nurse working on a medical-surgical unit observes a change in the client's mental status. Which action should the nurse take first? Perform a comprehensive head-to-toe assessment. Alert the critical assessment team. Notify the health care provider. Conduct a focused assessment.

Conduct a focused assessment Because a comprehensive assessment had already been conducted, the nurse would perform a focused assessment based on the observed neurological changes. The nurse would need to obtain more information before alerting the critical assessment team or contacting the health care provider; some actions would include completing the physical neurological exam, checking blood glucose, checking for changes in medications that may have contributed to the change in mental status, and reviewing the a.m. labs for abnormal sodium level.

An elderly client with terminal cancer is admitted to the medical unit. He has been told that he has only a few weeks left to live. Later that evening, he becomes very agitated and starts cursing at the nurses and visiting family members. He yells, "I am a failure. I never amounted to anything. My life was a waste. Now I have a few more weeks left. I know you all are happy. I am so scared." What stage of Erikson's is this client demonstrating? Inferiority Despair Role confusion Stagnation

Despair The client is demonstrating despair. He feels that he has been unsuccessful and is not ready to defend himself against the physical threat of death. He fears death and this results in despair. Role confusion goes with identity for the adolescent, while stagnation goes with generativity as seen in the middle-aged adult. Inferiority goes with industry and that stage is accomplished in the school-age child.

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and the temperature of the extremities. What is the purpose of this ongoing or partial assessment?

Determine any changes from the baseline Explanation: Ongoing or partial assessments help to determine any major changes from the baseline data. The nurse collects subjective data related to the client's overall health and conducts a comprehensive health assessment during the initial comprehensive assessment to determine baseline data. The nurse makes a rapid assessment for prompt treatment in life-threatening situations when an immediate diagnosis is needed to provide prompt treatment. Evaluation is done after an intervention to determine if the outcomes have been achieved.

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 Diagnosis occurs when the data has been analyzed and a professional judgment occurs. Assessment is the collection of data. Planning is determining outcome criteria and developing a plan. Evaluation assesses whether the outcome criteria have been met.

The nurse would use what part of the hand when assessing temperature during palpation? Ulnar surface Finger pads Palmar surface Dorsal surface

Dorsal surface

A nurse is preparing to perform auscultation on a client. Which guideline is most important for the nurse to keep in mind while performing this technique? Eliminate distracting noises from the environment. Use good lighting, preferably sunlight. Look and observe before touching the client. Compare appearance of symmetric body parts.

Eliminate distracting noises from the environment.

A nurse is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently underwent amputation of her lower leg. Which skill will the nurse most need to perform this assessment? Empathy Inspection Palpation Sympathy

Empathy Empathy is an intuitive awareness of what the client is going through; it helps the nurse to be effective in providing for the client's needs while remaining compassionately detached. Inspection and palpation are skills that help the nurse in collecting objective data of the client's physical characteristics. Sympathy is a feeling that would make the nurse as emotionally distraught as the client; this hampers the ability of the nurse to provide client care.

A nurse reviews the vital signs of a client: ● 0800: temperature: 99.5° F (37.5° C), heart rate: 85 regular; blood pressure: 110/60; 02 saturation: 95% room air ● 1200: temperature: 99.7° F (37.6° C), heart rate: 88 regular; blood pressure 112/62; 02 saturation: 90% room air ● 1230: temperature: 99.9° F (37.7° C), heart rate 87 regular; blood pressure 115/64; 02 saturation: 88% room air The nurse applies oxygen to the client. What action should the nurse take next? Evaluate outcome. Implement an intervention. Identify client concerns. Cluster client cues.

Evaluate outcomes Because the nurse implemented an intervention (in this case, applied oxygen), the nurse would next evaluate the effectiveness of the intervention. The first step in the nursing process is gathering data (objective and subjective) and then validating and documenting the data. The second step is analyzing the data, clustering client cues to identify client concerns and prioritize client concerns (diagnosis). The third step is developing a plan with interventions. In the fourth step the nurse implements the interventions, and in the last step the nurse evaluates the effectiveness of the interventions.

When assessing pulses, the nurse would use which part of the hand for palpation? Dorsal surface Ulnar surface Finger pads Palmar surface

Finger pads

A 38-year-old client has been admitted to the emergency department (ED) with reports of abdominal pain and vomiting for the past 6 hours. Which type of assessment will the nurse complete on this client? emergency assessment comprehensive assessment focused assessment ongoing assessment

Focused assessment A focused assessment may occur in all health care settings. It is smaller in scope than a comprehensive assessment, but more in depth related to the problem being presented. It usually involves one or two body systems. Data gathered and analyzed will determine the cause of the client's report. A comprehensive assessment includes the collection of objective data (data gathered during a step-by-step physical examination) and subjective data (the client's perception of the health of all body parts or systems, past health history, family history, lifestyle and health practices, including overall functioning). An emergency assessment is a very rapid assessment performed in life-threatening situations. In such situations (choking, cardiac arrest, drowning), an immediate assessment is needed to provide prompt treatment.

A nurse will be performing a complete physical examination of a man who has emphysema with a chronic productive cough, including an assessment of his oral cavity. Which pieces of personal protective equipment should the nurse wear? Gloves, mask, protective eye goggles, gown Mask, protective eye goggles, gown Mask, protective eye goggles Gloves, gown

Gloves, mask, protective eye goggles, gown

What action on the part of a middle-aged client would best exemplify Erikson's concept of generativity? Emphasizing the importance of one's knowledge and skill set Consistently increasing one's income Being able to accurately evaluate the merits of others' ideas Guiding and mentoring individuals who are younger

Guiding and mentoring individuals who are younger Generativity implies mentoring and giving to future generations. It is a broad concept, but it does not necessarily involve increasing one's income or emphasizing one's own knowledge and ideas over those of others.

The nurse notes that an adolescent client demonstrates confusion and the inability to focus on tasks. According to Erikson, which central task is this client having difficulty completing? Identity versus role confusion Generativity versus stagnation Intimacy versus isolation Ego integrity versus despair

Identity vs role confusion According to Erikson, an adolescent who is confused and unfocused is experiencing a negative resolution of the central task identity versus role confusion. Intimacy versus isolation is the central task of a young adult. Ego integrity versus despair is the central task of an older adult. Generativity versus stagnation is the central task of a middle-aged adult.

The nurse has just finished assessing a 48-year-old female client who is morbidly obese. The client claims that she overeats as a way to cope with stress. The client underwent a divorce 3 years ago and is currently single. She works 50 hours a week and cares for both her teenaged daughter and her elderly mother. When the nurse suggests changes to her nutrition, the client is resistant. Which of the following nursing diagnoses would be most appropriate for this client? Readiness for enhanced self-health management Social isolation Imbalanced nutrition: more than body requirements Risk for suicide

Imbalanced nutrition: more than body requirements

Which of the following techniques are used in a physical assessment? Select all that apply. Inspection Questioning Auscultation Subjectivity Palpation

Inspection Palpation Auscultation

Which of the following techniques are used in a physical assessment? Select all that apply. Questioning Palpation Subjectivity Auscultation Inspection

Inspection Palpation Subjectivity

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

Low-Frequency sounds

An older adult client has been admitted to the hospital with failure to thrive resulting from complications of diabetes. Which of the following would the nurse implement in response to a collaborative problem? Measure the client's blood glucose four times daily. Encourage the client to increase oral fluid intake. Assist the client with personal hygiene. Provide the client with a bedtime protein snack.

Measuring the client's blood glucose four times daily Collaborative problems, such as changes in blood glucose, are certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems by implementing both physician- and nurse-prescribed interventions to reduce further complications. Nutrition (oral fluids, bedtime snack) and hygiene are most often considered to be independent nursing concerns.

In Erik Erikson's stage of generativity vs. stagnation, the mature adult needs to be what? Financially secure Accepted by others Independent Needed

Needed According to Erik Erikson, the essence of generativity is that "mature man (the mature adult) needs to be needed, and maturity needs guidance as well as encouragement from what has been produced and must be taken care of." Financially secure, accepted by others, and independent are distracters to the question.

The mother of an adolescent is concerned because the client's personality "seems to be changing daily." If Erikson's theory is followed, what should the nurse include when responding to this mother? The child is confused Personality should have been completed by the age of 5 Personality evolves throughout the life span This indicates a personality disorder

Personality evolves throughout the life span According to Erikson, personality development continues to evolve throughout the life span. This child is not confused and does not have a personality disorder. According to Freud, personality is predetermined by the preschool age years.

A young Hispanic woman brings her baby into the clinic for immunizations. What type of disease-prevention strategy is this? Secondary prevention Primary prevention Tertiary prevention

Primary prevention

A client scheduled for surgery tells the nurse that he is very anxious about the surgery. What is an appropriate action by the nurse when interacting with this client? Mirror the client's feelings. Refer the client to a spiritual guide. Approach the client in an in-control manner. Provide simple and organized information.

Provide simple and organized information.

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? Tympany Resonance Hyper-resonance Dullness

Resonance Resonance is a loud, low-pitched, hollow sound normally percussed over an area that is part air and part solid, which is expected over normal lung fields. Hyper-resonance is a very loud, low-pitched sound that is normally heard in lungs with a lot of air such as in emphysema. Tympany is a very loud, high-pitched, drum-like sound that is heard over an air-filled structure, such as the stomach. Dullness is a medium-pitched, thud-like sound that is percussed over solid tissue such as the liver.

The nurse who provides care at an ambulatory clinic is preparing to meet a client and perform a comprehensive health assessment. Which of the following actions should the nurse perform first? Consult clinical resources explaining the client's diagnosis. Obtain basic biographic data. Validate information with the client. Review the client's medical record.

Review the client's medical record. Before actually beginning the health assessment, the nurse should review the client's record. It provides basic biographic data and a background about chronic diseases. It also gives clues to how a present illness may impact the client's activities of daily living. Validating the information with the client occurs during the assessment. Consulting clinical resources is not an immediate priority.

An elderly female client is accompanied by her daughter on a visit to the health care facility. The nurse observes that the client is doing quite well, except for the use of a hearing aid. How can the nurse best facilitate the interview process with this client? Direct the questions to the daughter to enhance communication Occupy a position close to the client and speak softly Speak slowly and clearly, using straightforward language Ask the client's daughter to be present during the interview

Speak slowly and clearly, using straightforward language

A student nurse is performing a head-to-toe assessment on a new client. The nurse intervenes when which of the following is observed? The diaphragm of the stethoscope is pressed firmly to the client's back when auscultating lung sounds. The bell of the stethoscope is used to auscultate bowel sounds. The bell of the stethoscope is pressed lightly against the skin to identify murmurs and extra heart sounds. The diaphragm of the stethoscope is used to auscultate normal heart sounds.

The bell of the stethoscope is used to auscultate bowel sounds The diaphragm, not the bell, of the stethoscope is used to assess bowel sounds. The diaphragm of the stethoscope is used to hear low-pitched sounds (normal heart sounds) and should be held firmly to the skin, whereas the bell of the stethoscope is used to detect high-pitched sounds (such as murmurs and extra heart sounds) and is held lightly to the skin.

The nurse is assessing a young adult client in light of Erikson's theory of psychosocial development. During this life stage, what assessment finding would most clearly suggest a lack of successful development? The client has been diagnosed with bipolar disorder. The client had a child when she was in her late teens. The client describes herself as lonely and isolated. The client is dissatisfied with her current job.

The client describes herself as lonely and isolated. According to Erikson, the young adult should have achieved self-efficacy during adolescence and is now ready to open up and become intimate with others. Loneliness and isolation suggest a failure to achieve this task. Erikson did not emphasize employment, psychiatric illness, or childbearing as central focuses of young adult development.

Which is an example of auscultation? Select all that apply. The nurse notes crackling over the individual's thorax. The nurse notes hyperresonance over the client's thorax. The nurse detects tympany over the client's lower abdomen. The nurse notes gurgling sounds over the individual's abdomen. The nurse notes a rhythmic lub-dub over the client's anterior thorax.

The nurse notes gurgling sounds over the individual's abdomen. The nurse notes crackling over the individual's thorax. The nurse notes a rhythmic lub-dub over the client's anterior thorax.

Ability to perform self-care activities (or activities of daily living; ADLs) is a component of the health history that reveals the client's quality of life. When assessing ADLs, the nurse asks if the client can grasp small objects and open jars. This is an example of assessing the client's: home maintenance mobility values and beliefs self-perception

This is an example of assessing the client's mobility. Self-perception is how the client views himself or herself. Home maintenance includes such things as housekeeping chores, cooking, shopping, and driving. Values and beliefs guide a person's choices or decisions.

A nurse performing percussion over the area of the stomach should anticipate hearing which type of sound? Dullness Hyper-resonance Tympany Resonance

Tympant (drum-like sound)

The nurse is caring for the client who is receiving heparin. The nurse plans to: Wear a mask when administering heparin to the client Perform hand hygiene with alcohol-based gel after administering the heparin Recap the needle after administering heparin to the client Wear clean gloves when administering heparin to the client

Wear clean gloves when administering heparin to the client

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

a healthy environment

After performing a comprehensive assessment on a client, the nurse notes the following. Which part of the nursing process is the nurse performing? Nursing Notes: ● Client reports pain in bilateral lower extremities when walking short distances, relieved with rest. ● Pulses are weak, barely palpable in bilateral lower extremities. ● Bilateral feet are cool to touch ● Total cholesterol > 200. ● Client smokes two packs of cigarettes daily for past 20 years.

analysis of assessment findings Explanation: The nurse is analyzing the findings by clustering the cues collected during assessment to determine if a client concern (nursing problem) exists. The notes contain both subjective and objective information related to peripheral arterial disease. The nurse would develop a problem-based plan based on these cues of impaired tissue perfusion and develop and implement interventions to improve the client's circulation. Documentation of the subjective assessment findings occurs during assessment. Once the assessment findings are analyzed, priority nursing diagnoses will be developed and interventions implemented.

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

areas in need of health adjustment

A nurse is conducting a health assessment. How will the information collected from the client be used? to facilitate nurse-client caring as a basis for the nursing process as one component of medical care to illustrate nursing competence

as a basis for the nursing process

How does a nurse best facilitate the nursing health assessment?

asking the appropriate questions

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

asking the appropriate questions

When performing the steps of the assessment phase of the nursing process, which of the following would the nurse do first? Validate the data Collect objective data Collect subjective data Document the data

collect subjective data With assessment, subjective then objective data is collected. This is followed by validation and then documentation of data.

The nurse obtains vital signs on a newly admitted client: temperature 101.1 F (38.4 C), heart rate 101 bpm, BP 88/56 mm Hg, O2 Saturation 94% on room air. The nurse administers an antipyretic. What will be the next step of the nursing process? Perform an assessment. Implement an intervention. Evaluate an outcome. Develop a nursing diagnosis.

evaluate an outcome

A nurse analyzes the data obtained from an initial assessment of a new client: weight gain of 15 lbs in 3 months, intolerance to cold, constipation, and lethargy. The nurse determines the client may have hypothyroidism and develops several nursing diagnoses with interventions to address the client concerns. Which action should the nurse take next? Implement interventions. Evaluate outcomes. Cluster cues. Reassess the client.

implement interventions

A pregnant woman comes to the physician's office for her first prenatal visit. The nurse knows the importance of performing a comprehensive health history in this case and understands the following must be included (check all that apply): family history obstetrical and gynecological history previous pregnancies information about current pregnancy food preferences

information about current pregnancy previous pregnancies obstetrical and gynecological history family history

During a comprehensive assessment, the primary technique used by the nurse throughout the examination is inspection. palpation. auscultation. percussion.

inspection nspection involves using the senses of vision, smell, and hearing to observe and detect any normal or abnormal findings. This technique is used from the moment that you meet the client and continues throughout the examination. Inspection precedes palpation, percussion, and auscultation because the latter techniques can potentially alter the appearance of what is being inspected.

The nurse is completing a physical examination of a client who reports ear pain. In order to determine if the tympanic membrane is still intact, which instrument is required? ophthalmoscope stethoscope sphygmomanometer otoscope

otoscope The nurse needs an otoscope to visualize the tympanic membrane and the inner ear. The nurse would need a sphygmomanometer to assess the client's blood pressure. The nurse would need a stethoscope to auscultate the lungs and abdomen. The nurse would need an ophthalmoscope to visualize the retina of the eye.

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? significantly impaired hearing lives alone widowed 2 years ago greatly concerned about cost of services

significantly impaired hearing As a nurse, it is vital to sift through all the client information and make decisions on what information will impact client safety and quality of care. The ability to identify what is important on a daily basis for each individual client is paramount for nursing care. Of the data provided, the client's impaired hearing poses the greatest safety risk and has the greatest impact on the client's quality of life and so has priority. While the other options could be potential factors related to quality of life and safety, the nurse will need to assess them further.

A community health nurse is assessing an older adult client in their home. When the nurse is gathering subjective data, which of the following would the nurse identify? The client's behavior The client's affect The client's posture The client's feelings of happiness

the client's feelings of happiness