Chapter 1-4

A nurse is admitting a client who is 162.6 cm (64 in) tall and weighs 68.2 kg (150 lb). Using the BMI table shown below, what should the nurse record as the client's BMI? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

The nurse should record the client's BMI as 25. BMI = 703 x Weight (Ibs)/Height^2 (in) 703 x 150/(64)^2 703 x 0.0366 BMI = 25

Which sign in a genogram indicates adoption? a. A horizontal dotted line b. A vertical dotted line c. An X in a circle d. An X in a square

b. A vertical dotted line Rationale: In a genogram, a vertical dotted line may be used to indicate adoptions. A horizontal dotted line is used to indicate the client's spouse. An X in a circle indicated a deceased female client. An X in a sqaure indicated a deceased male client.

Is the following statement true or false? Good overhead lighting is an effective substitute for sunlight during an assessment.

False It is best to use sunlight when available. However, good overhead lightning is sufficient. A portable lamp is helpful for illuminating the skin and for viewing shadows or contours.

While conducting a general survey on a client who is being admitted to a long-term care facility, a nurse is assessing the client's emotional state. Which of the following findings should the nurse record as an unexpected finding? The client is sitting in a relaxed posture. The client is cooperative in answering the nurse's questions The client tells the nurse that visits from their friends and family make them smile. The client reports they feel sad and lonely most of the time.

The client reports they feel sad and lonely most of the time.

Is the following statement true or false? A client's feelings and perceptions may be recorded as subjective data

True

A nurse is assessing a client's respirations and notes they are shallow and at a rate of 24/min. The nurse should identify this as which of the following unexpected findings? Tachypnea Bradypnea Apnea Hyperventilation

Tachypnea A client who has a breathing rate greater than 20/minute is experiencing tachypnea while a client who has a breathing rate of less than 10 to 12/min is defined as bradypnea. Apnea occurs when there is a cessation of respirations lasting for several seconds. Hyperventilation occurs when the rate and depth of a client's respirations are increased.

A nurse is caring for a client who is experiencing severe pain. Which of the following client statements indicates that the client is experiencing chronic pain? Select all that apply "The pain has been off and on for about a year now" "The pain from my car accident 2 months ago will not go away." "I have had this pain for 9 months" "I still have pain since the surgery last month, but it is getting better." "The pain isn't always in the same place."

"I have had this pain for 9 months." "The pain isn't always in the same place." "The pain has been off and on for about a year now" Unless the pain lasted for 6 months, it would be considered an acute pain. Pain is diagnosed as chronic once it has been present for 6 months or longer. Chronic pain is may also start in an unidentifiable area. For example, fibromyalgia pain can be widespread and affect different areas of the body at different times.

A nurse is preparing to obtain a client's height during a general survey. Which of the following actions should the nurse take? Deduct the client's shoe height from the measurement. Have the client gently lift their chin and look toward the ceiling. Ensure the client's feet are in contact with the wall or measuring pole. Pull up the measuring pole and extend the headpiece after the client steps on the scale.

Ensure the client's feet are in contact with the wall or measuring pole. The nurse should ensure that the client's feet, shoulders, and buttocks are in direct contact with the measuring pole or against the wall if the stadiometer is a wall-mounted device. The nurse should ask the client to remove their shoes prior to obtaining their height. The nurse should instruct the client to stand straight and look straight ahead. The nurse should pull up the measuring pole and extend the headpiece before the client steps on the scale.

Is the following statement true or false? When using the stethoscope to auscultate the lungs, the nurse should always apply pressure against the body when using the bell

False The bell of the stethoscope is used to listen to low-pitched sounds and should be held lightly against the body. If too much pressure is applied, the. bell will work like the diaphragm and the low-pitched sounds may not be detected

Is the following true or false? The nurse should use closed-ended questions to elicit the client's feelings and perceptions.

False The nurse should use open-ended questions to elicit the client's feelings and perceptions. Closed-ended questions should be used to obtain facts and to focus on specific info

Is the following statement true or false? When collecting data about the client's typical day, inquiring about dietary habits is not necessary.

False VERY IMPORTANT Many chronic conditions are related to eating and drinking habits and can reveal areas that will need to be address when planning the nursing care plan

Is the following statement true or false?​ ​ Physical medical assessment collects holistic subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgment.

False​ ​ Holistic nursing assessment collects holistic subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgment. Physical medical assessment focuses primarily on the client's physiologic development status.

Depressing the skin surface with the dominant hand and using a circular motion to palpate falls under which palpation type? A. Moderate B. Deep C. Bimanual D. Light

Moderate palpation moderate palpation involves depressing the skin surface 1 to 2 cm w/ the dominant hand and using a circular motion o feel for easily palpable body organs and masses,

A nurse is documenting a client's vital signs in the medical record following a general survey. Which of the following entries should the nurse place in the record? Fever 101 Pulse rate is tachycardic Oxygen saturation 96% on oxygen 2 L/min via nasal cannula Blood pressure 108/65 mm Hg

Oxygen saturation 96% on oxygen 2 L/min via nasal cannula The nurse should record the temperature in degrees (Celsius or Fahrenheit) according to agency policy and note the location the temperature was taken (i.e., axillary, oral). The nurse should record the measured pulse rate and indicate the rate, rhythm, and force of the pulse. The nurse should record the percentage of the client's oxygen saturation and indicate whether the client is on room air or is receiving oxygen. If the client is on oxygen, the nurse should record the type of the device and the rate at which oxygen is being delivered. The nurse should record blood pressure as well as the location of cuff placement.

A nurse is having difficulty obtaining a pulse oximetry reading from a client. The nurse should identify which of the following factors as possibly interfering with obtaining a pulse oximetry reading? Hypertension Fever Recent scan with contrast dye Thin, brittle nails

Recent scan w/ contrast dye Rationale: It makes sense for all the answer choices to pose difficulty for a nurse who is trying to obtain pulse oximetry readings, but C is the best answer because the dye can alter the transmission of the LED light used by the pulse oximetry sensor.

A nurse is obtaining a client's pulse and notes a regular rhythm with a rate of 110/min. The nurse should identify this as which of the following unexpected findings? Bradycardia Tachycardia Fasciculation Tachypnea

Tachycardia A heart rate of greater than 100/min is considered tachycardia. Bradycardia is indicated by a heart rate of less than 50/min. Fasciculation is the alteration in muscle movement seen as a continuous, rapid twitching of a muscle at rest Tachypnea is rapid breathing, indicated by a respiratory rate greater than 20/min.

A nurse assesses a client's respiratory rate and notes that it is below the expected reference range. The nurse should identify that which of the following findings can decrease a client's respiratory rate? The client has been a chronic smoker for 10 years The client takes a narcotic pain medication for chronic pain. The client reports anxiety due to being in the hospital. The client has a history of anemia.

The client takes a narcotic pain medication for chronic pain. Some medications for pain, such as narcotics and opioid analgesics, can depress the rate as well as the depth of respirations due to depressing the central nervous system. Chronic smoking results in changes of the pulmonary airways that can cause an increased respiratory rate when the client is at rest. Anxiety can increase a client's respiratory rate and depth due to stimulation of the sympathetic nervous system. Anemia is a condition where hemoglobin levels are decreased, reducing the oxygen-carrying capacity of the blood. This results in an increased respiratory rate.

A nurse is providing teaching to a client who asks, "What are things that an affect my BP?" Which of the following info should the nurse include as factors that affect BP? Select all that apply Obesity Time of Day Smoking Height Diuretic Medication

Time of Day Obesity Smoking Diuretic Medication BP will increase during the day and begin to decrease in the later afternoon. Clients who are obese are at an increased risk of developing hypertension. Taking diuretic medication will cause a decreased BP due to the reduction of resorption of sodium & and water by the kidneys. Vasoconstriction of blood vessels occur when a person smokes, causing an increase in BP. Height does not affect BP.

Is the following statement true or false? There are times when gloves must be changed between procedures on the same client.

True Gloves must be changed between tasks and procedures on the same client after contact with material may contains a high concentration of microorganisms.

Is the following statement true or false? Sitting upright on te side of the examination table is. useful position while examining the client as it allows full expansion of the lungs.

True Sitting upright on the side of the examination table, the edge of a chair, or a bed is a good position for evaluating the head, neck, lungs, chest, back, breasts, axillae, heart, vital signs, and upper extremities. This position is also useful b/c it permits full expanision of the lungs and allow the examiner to assess symmetry of upper body parts

Is the following question true or false? The nurse should take time to ensure all data agree with the subjective and objective findings

True The nurse should always take the time to validate all assessment finds to determine if more data are needed to prevent errors in nursing care and ensure the client receives the proper care

A nurse is documenting information in a client's medical record. Which of the following information did the nurse collect during the general survey? Current medication list Past medical history Use of assistive devices Height and weight Behavior and mood

Use of assistive devices Height and weight Behavior and mood Although it is necessary for the client's current medication list and past medical history to be collected and placed in the client's medical record, it is not part of the documentation collected during the general survey.

What occurs during the assessment phase of the nursing process?​ A. Collect subjective and objective data.​ B. Determine outcome criteria and develop a plan of care.​ C. Carry out the plan.​ D. Assess whether outcome criteria have been met and revise the plan as necessary.

A. Collect subjective and objective data.​ ​ Assessment is collection of subjective and objective data. Planning is determining outcome criteria and developing a plan. Implementation is carrying out the plan. Evaluation is assessing whether outcome criteria have been met and revising the plan as necessary.

Which guideline should the nurse follow for documentation? A. Write "normal" for normal findings B. Use phrases instead of sentences C. Exclude client's understand D. Describe how data were obtained

B. Use phrases instead of sentences When documenting, the nurse should remember to use phrases intsead of sentences, avoid using the word "normal" for normal findings, include the client's understanding, and record data findings, not how they were obtained

Which is a feature of an open-ended documentation form? A. Consists of check boxes B. Promotes use by different caregivers C. Promotes rapid documentation D. Provides narrative description

D. Provides narrative description An open-ended documentation form provides a narrative description of problems. A checklist form uses check boxes and promotes rapid documentation. An integrated cued checklist and a nursing minimum data set promote use by different caregivers

Is the following statement true or false? Percussions that are used to detect tenderness over organs by placing one hand flat on the body surface and using the fist of the other hand to strike the back of the hand flat on the body surface is known as direct percussion

False Blunt percussion is used to detect tenderness over organs by placing one hand flat on the body surface and using the fist of the other hand to strike the back of the hand flat on the body surface.

A nurse is conducting a general survey on a client and notes a continuous twitching movement of a muscle in the client's left arm. Which of the following terms should the nurse use to describe this involuntary movement? Fasciculation Spasticity Tic Myoclonus

Fasciculation Fasciculation- continuous twitching motion of a muscle when the muscle is at rest Spasticity- increase in muscle tonicity; attempting to extend a joint passively will increase resistance. Tic- an involuntary, repetitive movement of a muscle group, such as a wink or facial grimace Myoclonus- sudden jerking of a muscle, such as w/ hiccups or the jerk of an arm when falling asleep

When conducting a general survey of a client, the nurse should assess

Level of consciousness, Speech, and Gait The purpose of the general survey is to obtain info regarding the client's general health

A nurse is planning to obtain orthostatic blood pressures from a client who has syncope. In what order should the nurse complete the steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Place the client in a supine position and allow them to rest for at least 3 min Take the client's BP in the supine position Keep the cuff in place and assist the client to a seated position Take the client's BP in a seated position Assist the client to stand and then obtain their BP Orthostatic hypotension is indicated by a drop in systolic pressure of greater than 20 mm Hg or in diastolic pressure of greater than 10 mm Hg after the client stands.

A nurse is caring for an adult client ho is comatose. Which of the following routes should the nurse use to obtain the most accurate core body temperature of the client? Axillary Temporal Tympanic Rectal

Rectal Rectal temperatures are considered the most accurate method for obtaining a client's core temp. Obtaining a client's tympanic temperature is noninvasive and can be done quickly, but is less accurate. Temporal artery thermometers measure body temperature by scanning the temporal artery. While convenient, the measurement can be affected by skin moisture and is considered less accurate. Axillary temperatures are obtained by placing the thermometer under the client's axillae. This type of measurement requires a longer measurement time than all other routes and is considered less accurate