EAQ 3

A student nurse is assessing the blood pressure of a client with the client's arm unsupported. Which is the expected error in the obtained reading?

1 False high reading 2 False low diastolic reading 3 False high systolic reading 4 False high diastolic reading 1-If the client's arm is unsupported, or if the arm is below the heart level, the resulting outcome is a false high reading.

Which physical assessment of the skin indicates that a client is addicted to phencyclidine?

1-Burns 2-Vasculitis 3-Diaphoresis 4-Red and dry skin 4-Red and dry skin is associated with phencyclidine abuse. A client with alcohol abuse will have burns on the skin. Vasculitis is associated with cocaine abuse. Diaphoresis is associated with chronic abuse of sedative hypnotics.

Which client is suspected to have an increased risk of hyperlipidemia? Select all that apply. One, some, or all responses may be correct. 1-Client with corneal arcus 2-Client with periorbital edema 3-Client with decreased skin turgor 4-Client with paleness of conjunctivae 5-Client with yellow lipid lesions on eyelids

1-Client with corneal arcus 5-Client with yellow lipid lesions on eyelids

After assessing the muscle functionality of a client, the nurse assigns a grade of F (fair) on the Lovett scale in the client. Which describes the muscle functionality of the client? 1-Full range of motion with gravity 2-Full range of motion with gravity eliminated 3-Full range of motion against gravity with full resistance 4-Full range of motion against gravity with some resistance

1-Full range of motion with gravity In the Lovett scale, grade F (fair) is given to clients who exhibit a full range of motion with gravity. Full range of motion in passive motion is assigned a P (poor) score. When a client exhibits full range of motion against gravity with full resistance, the client is given an N (normal) score. When a client exhibits full range of motion against gravity with marginal resistance, the client is given a score of G (good).

Which error will result in false high diastolic readings while measuring a client's blood pressure during a physical examination? 1-Inflating the cuff too slowly 2-Wrapping the cuff too loosely 3-Applying the stethoscope too firmly 4-Repeating the assessment too quickly

1-Inflating the cuff too slowly Inflating or deflating the cuff too slowly will yield false high diastolic readings.

A client suffers hypoxia and a resultant increase in deoxygenated hemoglobin in the blood. Which is/are the best site(s) to assess this condition? Select all that apply. One, some, or all responses may be correct. 1-Lips 2-Sclera 3-Mouth 4-Sacrum 5-Nail beds 6-Shoulders

1-Lips 3-Mouth 5-Nail beds

After performing an optical assessment on a client, a primary health care provider notices impaired near vision. Which other finding in this client confirms the diagnosis as presbyopia? 1-Loss of elasticity of the lens 2-Increased opacity of the lens 3-Elevated intraocular pressure 4-Noninflammatory changes in eyes

1-Loss of elasticity of the lens

Arrange the hierarchy of needs in ascending order beginning with the highest priority needs as defined by Maslow.

1.Physiological needs 2.Safety and security 3.Love and belonging needs 4.Self-esteem 5.Self-actualization

The nurse is caring for a client whose forehead feels warm to the touch. The nurse uses a thermometer and obtains the client's temperature. Which step is the nurse doing? 1=Validation 2-Assessment 3-Interpretation 4-Documentation

1=Validation The nurse is validating the presence of fever in the client. Validation is the process of gathering more assessment data; it involves clarifying vague or unclear data.

A registered nurse (RN) is supervising a student nurse while assessing a 70-year-old client who is receiving aminoglycoside therapy. Which statement about the client's condition is incorrect? 1-"The client may have deterioration of the cochlea." 2-"The client may have thinning of the tympanic membrane." 3-"The client may have an inability to hear high-frequency sounds." 4-"The client may have an inability to differentiate between consonants."

2-"The client may have thinning of the tympanic membrane." An older adult who is on aminoglycoside antibiotic therapy is at a high risk of developing ototoxicity. The client with ototoxicity may have thickening of the tympanic membrane but not thinning of the tympanic membrane.

A client complains of sudden muscle weakness during times of anger or laughter that may occur at any time during the day. Which condition would be suspected in this client? 1-Insomnia 2-Cataplexy 3-Narcolepsy 4-Sleep apnea

2-Cataplexy Cataplexy is a condition in which muscle weakness occurs suddenly during times of intense emotion, such as anger, sadness, or laughter.

A 78-year-old client who has hypertension is beginning treatment with furosemide. Considering the client's age, which would the nurse teach the client to do? 1-Limit fluids at bedtime. 2-Change positions slowly. 3-Take the medication between meals. 4-Assess the skin for breakdown daily

2-Change positions slowly.

Which parts of the body would be assessed for temperature in clients who abuse sedatives or hypnotics? Select all that apply. One, some, or all responses may be correct. 1-Axillae 2-Thorax 3-Forehead 4-Oral cavity 5-Rectal area

2-Thorax 3-Forehead Diaphoresis (excessive perspiration) is an abnormal condition noticed in clients as a result of the substance abuse of sedatives and hypnotics. For this case, the temperature should be primarily assessed in the forehead or upper thorax

While assessing a client who experienced an accident, the nurse found that the client is unable to move the eyeballs laterally. Which nerve damage led to this condition in the client? 1-Optic nerve 2-Facial nerve 3-Abducens nerve 4-Oculomotor nerve

3-Abducens nerve The abducens nerve is the VI cranial nerve, which helps in lateral movement of the eyeballs.

Which assessment is expected when a client is placed in the lithotomy position during physical examination? 1-Heart 2-Rectum 3-Female genitalia 4-Musculoskeletal system

3-Female genitalia

While assessing a client, the nurse finds adventitious breath sounds. Upon further evaluation, the nurse finds loud, low-pitched, rumbling coarse sounds during inspiration. This sound can be clearly heard while the client is coughing. Which could be the reason behind these sounds? 1-Inflammation of the pleura 2-Reinflation of groups of alveoli 3-Muscular spasms in the larger airways 4-High-velocity airflow through an obstructed airway

3-Muscular spasms in the larger airways Adventitious breathing sounds (rhonchi) can be heard when there are loud, low-pitched, rumbling, and coarse sounds during inspiration. These sounds can also be clearly heard while the client is coughing.

While auscultating the heart, a health care provider notices S3 heart sounds in four clients. Which client is at highest risk for heart failure? 1-Child client 2-Pregnant client 3-Older adult client 4-Young adult client

3-Older adult client The S3 is the third heart sound heard after the normal "lub-dub." It is indicative of congestive heart failure in adults over 30 years old.

The nurse suspects that a client has a distended bladder. Which method is correct to assess for this condition? 1-Inspect and palpate in the epigastric region. 2-Auscultate and percuss in the inguinal areas. 3-Percuss and palpate in the hypogastric region. 4-Percuss and palpate bilaterally in the lumbar areas.

3-Percuss and palpate in the hypogastric region.

The nurse administers a pneumococcal vaccine to a 70-year-old client. The client asks, "Will I have to get this every year like I do with the flu shot?" How would the nurse respond? 1-"You need to receive the pneumococcal vaccine every other year." 2-"The pneumococcal vaccine should be received in early autumn every year." 3-"You should get the flu and pneumococcal vaccines at your annual physical examination." 4-"It is unnecessary to have any follow-up injections of the pneumococcal vaccine after this dose."

4-"It is unnecessary to have any follow-up injections of the pneumococcal vaccine after this dose." The Centers for Disease Control and Prevention recommend that adults be immunized with pneumococcal vaccine at age 65 years or older with a single dose of the vaccine.

An abscess develops in an obese adult after abdominal surgery. The wound is healing by secondary intention. Which diet would the nurse expect the health care provider to prescribe to meet this client's immediate nutritional needs? 1-Low in fat and vitamin D 2-High in calories and fiber 3-Low in residue and bland 4-High in protein and vitamin C

4-High in protein and vitamin C

Which sites would the nurse prefer while assessing for turgor in an older adult? Select all that apply. One, some, or all responses may be correct. 1-Back of the neck 2-Back of the hand 3-Palm of the hand 4-On the sternal area 5-Back of the forearm

4-On the sternal area 5-Back of the forearm

A client has relocated to a new city for work. The client 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 the client experiencing? 1-Action 2-Preparation 3-Maintenance 4-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.

Wrapping the cuff too loosely will result in false-

high systolic and diastolic values.

Repeating the assessment too quickly will result in false

high systolic readings.

Applying the stethoscope too firmly will result in false

low diastolic readings.