Assessment steps/Diagnostic processes/Models

Inflating cuff too slow

false high diastolic

Poor fitting of blood pressure cuff

false low systolic and false high diastolic A BP cuff that is too large will give falsely low readings, while an overly small cuff will provide readings that are falsely high. it needs an adequate pressure to occlude artery

What are Korotkoff sounds?

sounds heard when taking blood pressure

Ulnar site is used to assess

the status of circulation to the hand and also used to perform the Allen test

When measuring a client's blood pressure during a physical examination, which error will result in false high diastolic reading? A. inflating the cuff too slowly B. wrapping the cuff too lossely C. applying the stethoscope too firmly D. repeating the assessment too quickly

A. inflating the cuff too slowly

Which site would be safer and less expensive for temperature measurement of a human? (select all that apply) A. skin B. oral C. axilla D. rectal E. tympanic membrane

A. skin C. axilla the skin and axilla are safe and inexpensive sites of the body for temperature measurement

magicoreligious belief

The basic premise is that the world is an arena in which supernatural forces dominate. Examples are voodoo, witchcraft, faith healings

Arrange the steps of the bimanual deep palpation technique 1. Place the sensing hand on the skin 2. Apply pressure on the sensing hand 3. Depress the area to be examined to 2 inches 4. Relax the sensing hand 5. Place the active hand on the sensing hand

1. Depress the area to be examined 2 inches 2. Relax the sensing hand 3. Place the sensing hand on the skin 4. Place the active hand on the sensing hand 5. Apply pressure

In which sequence of techniques would the nurse assess a client's abdomen? 1. Palpation 2. Inspection 3. Auscultation 4. Percussion

1. Inspection 2. Auscultation 3. Percussion 4. Palpation

Pulse grading

4 = bounding 3 = full or increased 2 = normal 1 = decreased, thread, barely palpable 0 = absent

collaborative problems

Collaborative problems are identified by the nurse If the client's health problem requires treatment by other disciplines, such as medical or physical therapy, the client has a collaborative problem

temporal pulse is used to measure

pulse in children

Maslow's Hierarchy of Needs

1. Basic needs 2. Psychological needs 3. Self-fulfillment needs

While assessing a client's skin, the nurse notices the client's skin is dry. Which probable cause would the nurse associate with this condition? (select all that apply) A. use of hard soap B. frequent bathing C. use of tanning pills D. presence of an allergy E. use of petroleum products

A. use of hard soap B. frequent bathing

At which site would the nurse obtain the temperature of a client admitted to a surgical unit in an unconscious state due to head trauma? A. oral B. axilla C. temporal artery D. tympanic membrane

B. axilla

Carotid pulse is measured when

a client's condition worsens suddenly

Validation

act of confirming or verifying Example: The nurse, providing care for a client whose forehead feels warm to the touch, uses a thermometer to obtain the client's temperature. Which action is the nurse taking? Answer: Validation by clarifying vague or unclear data

Clostridium difficile (C. diff)

bacterial infection, generally associated with antibiotic use, causing severe, watery loose stools

What does a 1:1 anteroposterior diameter and transverse diameter of the chest indicate?

barrel shaped chest

brachial pulse is used to measure

blood pressure

Applying the stethoscope too firmly will result in

false low diastolic readings.

Inadequately inflating the cuff

false low systolic

Deflating cuff too quickly

false low systolic and false high diastolic

Lovett scale

grading muscle strength. zero, trace, poor, fair, good, normal.

Rinne test

hearing ACUITY test performed with a vibrating tuning fork that is first placed on the mastoid process and then in front of the external auditory canal to test bone and air conduction Tuning fork placed on mastoid bone behind the ear

vasculitis

inflammation of blood vessels

Who are barrel shaped chests a characteristic feature of?

older adult who smokes and has a chronic lung disease

Hematocrit

percentage of blood volume occupied by red blood cells

diaphoresis

sweating

Radial site is commonly used to assess

the character of the pulse peripherally and to assess the status of the circulation to the hand

Brachial site is commonly used to assess

the status of circulation to the client's lower arm or the blood pressure is being auscultated

Which condition would the nurse suspect when an older adult is unable to see nearby objects? A. cataract B. glaucoma C. Hyperopia D. presbyopia E. Macular degeneration

C. Hyperopia D. Presbyopia

Which clinical indicator would the nurse expect a client with hyperkalemia to exhibit? (select all that apply) A. tetany B. seizures C. confusion D. weakness E. dysrhythmias

C. confusion D. weakness E. dysrhythmias Because of potassium's role in the sodium/potassium pump, hyperkalemia will cause confusion, weakness, and cardiac dysrhythmias

When preparing to assess a client with Clostridium difficile, which piece of personal protective equipment would the nurse put on before entering the client's room? A. head covering B. clear eye mask C. full plastic gown D. N95 respiratory mask

C. full plastic gown

Which condition would the nurse suspect upon finding a bluish coloration of the skin during an assessment? A. anemia B. liver disease C. heart disease D. autoimmune disease

C. heart disease

When assessing a client who had a thyroidectomy yesterday, which cue would the nurse associate with an initial sign of hypocalcemia? A. headache B. pallor C. paresthesias D. blurred vision

C. paresthesia's

While collecting a client's urine sample, which condition would the nurse suspect if the sample has a strong odor of ammonia? A. Malabsorption B. Bladder cancer C. Diabetic ketoacidosis D. Urinary tract infection

D. urinary tract infection (or possible renal failure) diabetic ketoacidosis usually causes a sweet/fruity odor on the breath malabsorption can cause foul-smelling stools in infants ammonia odor does not indicate bladder cancer

Arrange the sequence of events occurring during a fever in chronological order

Immune response is triggered Hypothalamus set point is raised Body temperature is increased Pyrogens are destroyed Febrile episode occurs Heat loss responses are initiated

Weber test vs Rinne test

Weber normal: no lateralization of sound Weber abnormal (conductive loss): sound lateralizes toward affected ear/impaired ear/ear with hearing loss Weber abnormal (sensorineural loss): sound lateralizes to the normal or better-hearing side Rinne normal: air conduction (AC) is heard greater than bone conduction (BC) (patient will hear fork at ear) Rinne abnormal (conductive loss): bone conduction (BC) is greater than air conduction (AC) (patient will not hear fork at ear)

The nurse performed physical assessments for four female clients during their general checkup. Which client is most at risk of developing breast cancer? A. Client A: age 60/family history of breast cancer/2 children/menopause age 45 B. Client B age 60/family history of breast cancer/no children/menopause age 50 C. Client C age 60/no family history of breast cancer/no children/menopause age 50 D. Client D age 60/no family history of breast cancer/2 children/menopause age 50

B. Client B women >40 w/ a family or personal history of breast cancer and late age menopause (after age 50) who have not had children after the age of 30 years or women with excessive oral contraceptive use are at risk of developing breast cancer

When assessing levels of consciousness, which one of the four clients would the nurse identify as having the lowest neurological function? A. spontaneous eye movement/localizes pain/inappropriate words B. eyes open upon pain/flaccid motor response/incomprehensible sounds C. spontaneous eye movement/normal flexion/oriented verbal response D. eyes open upon sound/abnormal extension motor response/confused conversation

B. opens on pain (GCS score of 2) flaccid motor response (GCS score of 1) incomprehensible sounds (GCS score of 2) Total GCS score = 5

The registered nurse notices a new employee, who is obtaining the blood pressure of a client, is deflating the cuff too rapidly. If the actual blood pressure of the client was 140/90 mm Hg, which blood pressure reading is the new employee most likely to have obtained? A. 130/80 B. 150/100 C. 140/100 D. 130/100

D. 130/100 Deflating the cuff too quickly will result in false low systolic and false high diastolic readings

When an African American client with renal failure reports the illness is a punishment for sins, which cultural health belief is the client communicating? A. Yin/Yang balance B. Biomedical belief C. Determinism belief D. Magicoreligious belief

D. Magicoreligious belief focuses on hexes or supernatural forces that cause illness Such clients may believe that illness is a punishment for sins

When preparing to assess a client with active tuberculosis, which piece of PPE would the nurse put on before entering the client's room? A. isolation gown B. surgical mask C. shoe covers D. N95 respiratory mask

D. N95 respiratory mask tuberculosis is an airborne disease

A client admitted to the hospital with chest pain, reports shortness of breath, weakness, and vomiting. The nurse suspects cardiac arrest. At which site would the nurse check the client's pulse rate? A. ulnar B. radial C. brachial D. femoral

D. femoral In a client with cardiac arrest, the other pulse sites may not be palpable at this time, so the femoral site is the most appropriate place

While performing a neck assessment, the nurse finds the client has enlarged lymph nodes, a history of intravenous drug use, and bisexual activity. Which possible diagnosis would the nurse suspect? A. Cancer B. Thyroid disease C. Tracheal displacement D. Human immunodeficiency virus (HIV) infection

D. human immunodeficiency virus (HIV) infection

Transtheoretical Model of Change

1. Precontemplation 2. Contemplation 3. Preparation 4. Action 5. Maintenance

In which order would the nurse perform the steps of the nursing diagnostic process? A. Identify the client's needs B. Cluster data C. Formulate nursing diagnoses D. Interpret the meaning of the data E. Look for defining characteristics F. Assess the client's health status G. Validate the data with other sources

1. Assess health status 2. validate data with other sources 3. interpret the meaning of the data 4. cluster data 5. look for defining characteristics 6. Identify client needs 7. formulate nursing diagnosis

In which order would the nurse apply the nursing process while providing care for clients? 1. Diagnosis 2. Planning 3. Evaluation 4. Assessment 5. Implementation

1. Assessment 2. Diagnosis 3. Planning (selecting interventions individualized to the client's diagnosis) 4. Implementation (involves performing the planned interventions) 5. Evaluation (evaluates the client's response and whether the interventions were effective)

Beginning with the highest priority needs as defined by Maslow, in which ascending order would the hierarchy of needs occur? 1. Self-actualization 2. Self-esteem 3. Safety and security 4. Physiological needs 5. Love and belonging needs

1. Physiological needs (basic) 2. Safety and security (basic) 3. Love and belonging needs (psychological) 4. Self-esteem (psychological) 5. Self-actualization (self-fulfillment)

In which sequential order would the nurse perform the assessment of a lesion? 1. observing for any exudate, odor, amount, and consistency 2. measuring each lesion for height, width, and depth 3. collecting information about its color, size, shape, type, grouping, and distribution 4. measuring the size of the lesion in centimeters by using a small, clear, flexible ruler

1. collecting information about its color, size, shape, type, grouping, and distribution 2. observing for any exudate, odor, amount, and consistency 3. measuring the size of the lesion in centimeters by using a small, clear, flexible ruler 4. measuring each lesion for height, width, and depth

In which sequential order would the nurse assess the visual level of the client? A. ask the client to report when he or she is able to see the finger B. close the opposite eye to superimpose the field of vision C. direct the client to stand or sit 60 cm away from eye level D. ask the client to close his or her left or right eye gently and look directly at the nurse's opposite eye E. move a finger equidistant between the nurse and the client outside the field of vision

1. direct the client to stand or sit 60 cm away from eye level 2. ask the client to close his or her left or right eye gently and look directly at the nurse's opposite eye 3. close the opposite eye to superimpose the field of vision 4. move a finger equidistant between the nurse and the client outside the field of vision 5. ask the client to report when he or she is able to see the finger (confrontation test)

When gathering data for a client's health history, which intellectual factor would the nurse consider as a dimension? A. Attention span B. Primary language C. Coping mechanisms D. Activity and coordination

A. Attention span

Which type of interview would the nurse utilize when admitting a client to a clinic A. Directive B. Exploratory C. Problem-solving D. Information giving

A. Directive During the initial interview a direct approach obtains specific information, such as allergies, current medications, and health history

When would the nurse observe a client to assess their level of functioning? (select all that apply) A. during mealtime B. when talking about pain C. when preparing medication D. during the assessment interview E. when administering insulin injections

A. During mealtime C. When preparing medication E. When administering insulin injections An observation of the 'level of functioning' occurs during a 'return demonstration' (seeing if the client is able to eat, perform, and talk without assistance) The nurse does not assess the client's functional abilities during the subjective assessment

When assessing a client's blood pressure, obtained via the client's unsupported left arm, which reading error would the nurse expect? A. False high reading B. False low diastolic reading C. False high systolic reading D. False high diastolic reading

A. False high reading if the client's arm is unsupported/if the arm is BELOW the heart level, the resulting outcome is a false high reading

While assessing a client with dehydration, the nurse notices diminished skin elasticity. Which portion of the nurse's hand would the nurse use to perform this assessment? A. Fingertips B. Pads of fingertips C. Ulnar surface of hand D. Palmer surface of finger pads

A. Fingertips The fingertips are used to palpate the skin for elasticity

After assessing the muscle functionality of a client, the nurse assigns a grade of F (fair) on the Lovett scale. Which statement describes the muscle functionality of this client? A. Full range of motion with gravity B. Full range of motion with gravity eliminated C. Full rage of motion against gravity with full resistance D. Full range of motion against gravity with some resistance

A. Full range of motion with gravity

While assessing a client's hair, the nurse notices the client has head lice. The nurse teaches the client about hair hygiene and lice control. Which client statement indicates an understanding of the teaching (select all that apply) A. I will clean my comb in ammonia water B. I should use lindane-containing shampoo C. I should shampoo my hair in a tub or shower D. I should use a dilute vinegar solution to loosen the nits E. I should use a shampoo treatment once every 24 hours

A. I will clean my comb in ammonia water D. I should use a dilute vinegar solution to loosen the nits E. I should use a shampoo treatment once every 24 hours

Which question would the nurse ask the client when obtaining their health history? (select all that apply) A. Tell me about your food habits B. Do you use alcohol or tobacco? C. Have you sustained any personal loss recently? D. Have you ever experienced any allergy reactions? E. Does any family member have a long-term illness?

A. Tell me about your food habits B. Do you use alcohol or tobacco? D. Have you ever experienced any allergic reactions?

When assessing risk factors, which question would the nurse ask a client who has developed pneumonia? A. are you diabetic? B. have you ever had pneumonia? C. what do you use for contraception? D. do you have a history of IV drug abuse?

A. are you diabetic?

For which client would the nurse assess the carotid pulse? (select all that apply) A. client with cardiac arrest B. client indicated for Allen test C. client under physiological shock D. client with impaired circulation to foot E. client with impaired circulation to hand

A. cardiac with cardiac arrest C. client under physiological shock Carotid pulse is indicated in clients with physiological shock or cardiac arrest when other sites are not palpable in the client

When the nurse completes a thorough assessment to identify the reason for a client's anxiety, which critical thinking attitude is involved in this situation? A. discipline B. confidence C. responsibility D. thinking independently

A. discipline The nurse shows discipline in collecting a thorough assessment to identify the source of the client's anxiety Confidence involves completing a task or goal such as performing a procedure or making a diagnostic decision Responsibility is applicable when performing a nursing skill by following standard care practices Thinking independently involves reading the nursing literature, talking with other nurses, and sharing ideas about nursing interventions

Which benefit would the nurse associate with using standard, formal, nursing diagnostic statements? (select all that apply) A. fosters development of nursing knowledge B. allows nurses to communicate with the client C. provides precise definition of the client's problem D. distinguishes the nurse's role from that of other care providers E. enables the primary health care provider to deliver effective health care

A. fosters development of nursing knowledge (important to be able to assess a client's specific risk for problems, identify them early, and take action) C. provides precise definition of the client's problem (gives the other nurses a common language for understanding the client's needs) D. distinguishes the nurse's role from that of other care providers

When measuring a client's blood pressure during a physical examination, which error will result in a false high diastolic reading? A. inflating the cuff too slowly B. wrapping the cuff too loosely C. applying the stethoscope too firmly D. repeating the assessment too quickly

A. inflating the cuff too slowly

The registered nurse measures the client's blood pressure as 130/80 mm Hg. When the unlicensed assistive personnel (UAP) measured the same client's blood pressure, the measurement was 120/90 mm Hg. Which rationale would explain the measurement difference? (select all that apply) A. poor fitting of the cuff B. inflating the cuff too slowly C. deflating the cuff too quickly D. inflating the cuff inadequately E. applying the stethoscope too firmly

A. poor fitting of the cuff C. deflating the cuff too quickly Poor fitting of the cuff or deflating the cuff too quickly causes false systolic and false high diastolic readings

Which assessment item needs to be documented on a client with restraints? (select all that apply) A. pulse near the restrained area B. temperature of the restrained area C. convenience of restraining the client D. skin integrity surrounding the restraint E. behavior leading to the need for restraint

A. pulse near the restrained area B. temperature of the restrained area D. skin integrity surrounding the restraint E. behavior leading to the need for restraint

While providing care for a client who is postoperative, the nurse observed a pulse deficit during physical assessment. Which pulses would the nurse use to assess the pulse deficit? A. radial and apical pulse B. apical and carotid pulse C. radial and brachial pulse D. apical and temporal pulse

A. radial and apical pulse pulse deficit may be associated with an abnormal rhythm pulse deficit = difference b/t the radial and apical pulse

The registered nurse reviews various sites for assessing body temperature with unlicensed assistive personnel (UAP). Which UAP's statement reflects effective learning? (select all that apply) A. the axilla is recommended to measure body temperature in unconscious clients B. the oral cavity is suitable for clients with epilepsy to measure body temperature C. the tympanic membrane is a preferred site of measuring body temperature in infants D. the rectum is a preferred sit of measuring body temperature in clients who underwent rectal surgeries E. the temporal artery is a preferred site of thermometer placement to measure rapid changes in core temperature

A. the axilla is recommended to measure body temperature in unconscious clients C. the tympanic membrane is a preferred site of measuring body temperature in infants E. the temporal artery is a preferred site of thermometer placement to measure rapid changes in core temperature

The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply. A. Dyspnea B. Flushed face C. Precordial pain D. Increased pulse rate E. Increased blood pressure

B. Flushed face D. Increased pulse rate increased body heat dilates blood vessels, causing a flushed face also, the pulse rate increases to meet increased tissue demands for oxygen in the febrile state

During orientation, a registered nurse reviews content about the third heart sound (S3) with recently employed nurses. Which participant's statement indicates INEFFECTIVE learning? A. S3 is heard in clients with heart failure B. S3 is normal in pregnant women C. S3 is abnormal in adults over 31 years of age D. S3 is normal in children and young adults

B. S3 is normal in pregnant women This sound may be common and normal in the last stages of pregnancy but not in ALL stages All other answers are true

While assessing a client, the nurse identifies the ratio of the anteroposterior diameter and transverse diameter of the chest as 1:1. Which finding supports this conclusion? (select all that apply) A. client has lordosis B. client is an older adult C. client has osteoporosis D. client has a history of smoking E. client has chronic lung disease

B. client is an older adult D. client has a history of smoking E. client has chronic lung disease

Which information obtained during a client's health history would the nurse classify as biographical information? (select all that apply) A. symptoms B. client's age C. family structure D. type of insurance E. occupation status

B. client's age D. type of insurance E. occupation status

Which client statement indicates a risk of breast cancer? (select all that apply) A. I had a late onset of menarche B. my first child was born when I was 32 C. I noticed a slight discharge from a nipple D. I perform breast self-examinations frequently E. I consume two to four glasses of alcohol a day

B. my first child was born when I was 32 C. I noticed a slight discharge from a nipple E. I consume two to four glasses of alcohol a day

When assessing an older client as they walk into the examination room, which finding would the nurse document as abnormal? A. the client is wearing extra layers of clothing B. the client is wearing an excessive amount of cologne C. the client walks smoothly with arms swinging at the side D. the client is bent over slightly with the elbows and knees bent

B. the client is wearing an excessive amount of cologne this can indicate the client is having an alteration in self-perception

A client arrives at a health clinic and reports "I am here to have my tuberculin skin test read." The nurse notes a 7- mm indurated area at the injection site. Which nurse's statement describes this result? A. the result indicates that you have active tuberculosis B. the result indicates you are infected with the tuberculosis organism C. the result indicates there are no tuberculin antibodies in your system D. the indicates you have a secondary infection related to the tuberculin organism

B. the result indicates you are infected with the tuberculosis organism

A client with a family history of diabetes mellitus has been following a diet regiment recommended by the dietician and walking for 45 minutes daily for the past 8 months. Based on the transtheoretical model of health behavior change, which stage would the nurse document for this client? A. Action B. Preparation C. Maintenance D. Contemplation

C. Maintenance Maintenance begins at least 6 months after the action has started. So since the client has been doing this for more than 6 months/half a year, the client is in the maintenance stage

Which Korotkoff sound represents the diastolic pressure for children? A. First B. Second C. Fourth D. Fifth

C. Fourth The 4th Korotkoff sound represents the diastolic pressure in children The 5th Korotkoff sound represents the diastolic pressure in adults and adolescents

A client who relocated to a new city for work is unable to continue the practice of walking for 30 minutes daily and exercising 5 days a week. Which stage of the transtheoretical model of health behavior change is this client experiencing? A. action B. preparation C. maintenance D. precontemplation

D. precontemplation the client is experiencing a relapse while attempting to make behavioral changes to his or her lifestyle when relapse occurs, the client returns to the contemplation or precontemplation stage before attempting to change again

Which characteristic would the nurse associate with collaborative problems experienced by a client? A. they are the identification of a disease condition B. they include problems treated primarily by nurses C. they are identified by the primary health care provider D. they are identified by the nurse during the nursing diagnosis stage

D. they are identified by the nurse during the nursing diagnosis stage

Weber test

Test done by placing the stem of a vibrating tuning fork on the midline of the head and having the patient indicate the LOCATION/in WHICH EAR the tone can be heard. Placed on bridge of forehead, nose, or teeth

During the assessment, which part of the hand is best for detecting vibration?

Ulnar surface of the hand