Exam 1 Homeworks HA

A client who has fractured her arm is describing her pain as "excruciating." The nurse determines that the client is experiencing what type of pain?

deep somatic

When assessing an older adult client with osteoporotic thinning and vertebral collapse, which finding would the nurse expect to identify? Lordosis Increased arm swing Narrowed gait Kyphosis

Kyphosis

A nurse is providing feedback to a colleague after observing the colleague's interview of a newly admitted client. Which of the following would the nurse identify as an example of a closed-ended question or statement? "Tell me about your relationship with your children?" "Tell me what you eat in a normal day?" "Are you allergic to any medications?" "What is your typical day like?"

"Are you allergic to any medications?"

A nurse is completing a general survey of a client's health and is beginning by measuring the client's vital signs. What assessment question constitutes the "fifth vital sign"? "Can you tell me the date and month?" "Can I check your oxygen saturation level?" "Are you experiencing any shortness of breath?" "Are you having any pain right now?"

"Are you having any pain right now?"

During an eye assessment, the nurse is testing a client's visual acuity using a Snellen chart. In order to prepare the client for this component of assessment, what instruction should the nurse provide? "I'm going to ask you to slowly walk forward until the last line of the chart become clear." "Please stand at a comfortable distance from the chart and I'll get you to read each letter." "Hold this chart and start to read out the letters after covering one of your eyes." "Cover one of your eyes and then read out the letters on the chart, starting from the top."

"Cover one of your eyes and then read out the letters on the chart, starting from the top."

The nurse is preparing to perform a nutritional assessment of a newly admitted client. What question would be most appropriate for the nurse to ask when initiating the assessment? "Did you eat breakfast today?" "How many meals do you eat each day?" "What have you eaten in the last 24 hours?" "How often do you eat out?"

"What have you eaten in the last 24 hours?"

The nurse is inspecting a client's tonsils and notes that they make contact with the client's uvula. How would the nurse document this finding? 1+ 2+ 3+ 4+

#+

The nurse is preparing to test a client's eyes for accommodation. The nurse would have the client focus on an object in which sequence for this test? Far, then near Lateral, then near Near, then far Lateral, then far

Far, then near

A nurse has completed the general survey of a client who has been transferred to the unit. The information gathered during the general survey primarily provides the nurse with which of the following? Select all that apply. 1. An indication of the level of physical distress experienced by the client 2. Clues about the overall health of the client 3. A direct link to the client's medical diagnosis 4. Indications about normal variations in the status of body systems 5. Data relating to the patient's level of social support

1, 4, 5

The nurse has completed the initial assessment of a client and is now performing data analysis. The nurse obtained a blood pressure reading of 114/70 mm Hg. What is this client's pulse pressure? 44 mm Hg 92 mm Hg 114 mm Hg 184 mm Hg

44

The nurse is caring for a client diagnosed with chronic nonmalignant pain. The nurse should understand that this client has experienced this pain for at least how many months?

6

A nurse who works at an outpatient ophthalmic clinic has a large number of clients. Which client would be at the highest risk for developing cataracts? A 75-year-old client who has smoked for 50 years A 40 year old with arteriosclerosis A 30-year-old client who drinks a beer twice a week A 55-year-old client with hyperthyroidism

A 75-year-old client who has smoked for 50 years

The nurse assists a client into the dorsal recumbent position. Assessment of which area is contraindicated when the client is in this position? Chest Head Peripheral pulses Abdomen

Abdomen

Otoscopic examination of a 69-year-old client's tympanic membrane reveals that it is red, bulging, and distorted. The nurse also notes a diminished light reflex. To what should the nurse most likely attribute this assessment finding? Repeated ear infections Trauma Age-related changes Acute otitis media

Acute otitis media

A nurse is admitting a client to the postsurgical unit from the postanesthetic care unit. The nurse has transferred the client from the stretcher to a bed and asked the client if he is experiencing pain. The client acknowledges that he is in pain. What would the nurse do next? Ask the client to briefly explain his cultural background. Assess the client's pain according to COLDSPA. Assess the client's self-management skills. Assess the client's pain by obtaining a set of vital signs.

Assess the client's pain according to COLDSPA

The nurse palpates a client's pulse and notes that the rate is 71 beats/min, with an irregular rhythm. How should the nurse follow up this assessment finding? Auscultate the client's apical pulse. Palpate the client's ulnar pulse. Administer a dose of nitroglycerin. Reposition the client in a side-lying position.

Auscultate the client's apical pulse

A nurse has performed the corneal light reflex test during a client's eye examination. During this test, the nurse appraised the client's eye alignment in which way? By comparing the reflection of the light on the client's eye surface By comparing the speed of pupillary constriction By comparing how quickly the client blinks each eyelid By comparing the relative color of the sclerae before and after light exposure

By comparing the reflection of the light on the client's eye surface

The nurse is conducting an assessment of an older adult client who has a diagnosis of chronic heart failure. How can the nurse best assess the effects of the client's stroke volume? Take the blood pressure while the client is standing. Measure the strength of the radial pulse. Add the radial pulse and the systolic blood pressure. Calculate the difference between the diastolic and systolic pressures.

Calculate the difference between the diastolic and systolic pressures.

The nurse is inspecting the dominant hand of an older adult client and notes the presence of irregularly shaped brown lesions on the dorsal surface of the client's hand. What action should the nurse perform next? Obtain a tissue sample for pathology Compare the appearance of the client's other hand Palpate the lesions for tenderness and warmth Perform health promotion teaching about sun protection

Compare the appearance of the client's other hand

A nurse is preparing to assess an adult client's carotid pulses. Which action would be contraindicated? Asking the client to flex his or her neck Compressing the arteries bilaterally Performing the examination while the client is seated Asking the client to swallow water

Compressing the arteries bilaterally

A nurse is preparing a presentation for a local community group about preventing traumatic brain injury. The nurse would discuss which measure as prevention of the leading cause? Safe use of firearms Safe use of machinery Falls prevention Domestic violence prevention

Falls prevention

When preparing to assess a client's thyroid gland, the nurse should ensure that which piece of equipment is readily available? Penlight Tongue depressor Centimeter-scale ruler Cup of water

Cup of water

The nurse should prioritize assessments related to overhydration for a client experiencing which health problem? Early congestive heart failure Chronic emphysema Newly diagnosed hepatitis C virus infection Adult respiratory distress syndrome

Early congestive heart failure

The nurse's assessment of an adult client reveals the presence of excessive hair on her face and chest. The nurse should plan further evaluation of which body system? Endocrine Neurologic Cardiovascular Genitourinary

Endocrine

A nurse will complete an initial comprehensive assessment of a 60-year-old client who is new to the clinic. What goal should the nurse identify for this type of assessment? Identify the most appropriate forms of medical intervention for the client. Determine the most likely prognosis for the client's health problem. Identify the status of the client's airway, breathing, and circulation. Establish a baseline for the comparison of future health changes.

Establish a baseline for the comparison of future health changes.

The nurse is preparing to examine a client's skin. What would the nurse do next? Ensure that the room is hot to prevent chilling. Wear gloves when preparing to inspect the skin and nails. Expose only the body part that is being examined. Have the client remove clothing from the upper body.

Expose only the body part that is being examined

The nurse is assessing a client whose electronic health record notes a diagnosis of esotropia. When examining this client, the nurse should expect what finding? Eye turning outward Eye malalignment Eye turning inward Eye oscillating

Eye turning inward

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

Feeling of happiness

A client comes to the health care provider's office for a visit. The client has been seen in this office on occasion for the past 5 years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform? Comprehensive assessment Ongoing assessment Focused assessment Emergency assessment

Focused Assessment

The nurse is using a Wood's light for a client who has complaints of itching, burning, and peeling of the skin between his toes. The nurse is assessing for what etiology of the client's symptoms? Parasitic infection Fungal infection Bacterial infection Allergic reaction

Fungal

A client has sought care because she states that she has begun to see halos around headlights and streetlights when she is out at night. The nurse should recognize the need to refer the client for further assessment related to what health problem? Episcleritis Strabismus Macular degeneration Glaucoma

Glaucoma

The nurse collects vital signs on a hospital client who has recently been experiencing pain. Which finding would indicate the client is currently experiencing pain? Respiratory rate of 18 breaths/min Temperature of 37.3°C (99.1°F) Heart rate of 110 beats/min Blood pressure of 120/70 mm Hg

Heart rate of 110 beats/min

A client presents with a cluster of upper airway complaints that include rhinorrhea. Which area of assessment would yield the most pertinent information to the etiology of rhinorrhea? History of allergies Incomplete immunization record History of epistaxis (nosebleeds) Prolonged tonsillar enlargement

History of allergies

A client presents to an ambulatory clinic with purulent, bloody drainage of the ear. What would the nurse assess first? Assess the client's tympanic membrane. Palpate the client's tragus. Inspect the client's external ear canal. Perform hearing assessments.

Inspect the client's external ear canal.

A nurse is completing an assessment that will involve gathering subjective and objective data. Which assessment technique will best allow the nurse to collect objective data? Inspection Therapeutic communication Interviewing Active listening

Inspection

A nurse educator is presenting an in-service program to a group of oncology nurses. Which characteristic of cancer pain should the nurse describe? Its basis is usually chronic neuropathy. It is most often caused by a specific recent trauma. It usually appears in the first month after cancer develops. It is typically caused by compressed peripheral nerves.

It is typically caused by compressed peripheral nerves.

A nurse is conducting a focused head and neck assessment of a client. When preparing to assess the client's thyroid gland, the nurse should be aware of which principle? The thyroid gland is not normally palpable in female clients. Many clients have an additional (third) thyroid lobe. The thyroid gland is not normally palpable until clients are in their 30s or 40s. Palpation creates a risk of rupturing the thyroid gland in some older adult clients.

Many clients have an additional (third) thyroid lobe.

The nurse is assessing the face of a client with a diagnosis of Parkinson disease. What would the nurse most likely assess? Sunken face Drooping of one side Mask-like expression Asymmetry of earlobes

Mask-like expression

A nurse in the emergency department assesses a client's pupillary reaction and observes pinpoint pupils. The nurse interprets this finding as suggesting which of the following? Recent eye trauma Narcotic use Macular degeneration Recent peripheral nervous system injury

Narcotic use

While inspecting the client's tympanic membrane, the nurse notes a pearly gray and shiny appearance. The nurse would interpret this finding as what? Scarring from previous infections Otitis media Normal tympanic membrane Otitis externa

Normal tympanic membrane

A nurse palpates a client's ear and finds that the tragus is exquisitely tender. The nurse should suspect what health problem? Otitis media Otitis externa Ruptured tympanic membrane Mastoiditis

Otitis externa

While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse should recognize the presence of which of the following? Purpura Petechiae Ecchymosis Cherry angioma

Petechiae

A 66-year-old client states that he has increasing difficulty hearing high-pitched sounds. The patient's statement most likely suggests that he has what diagnosis? Vertigo Otalgia Tinnitus Presbycusis

Presbycusis

The nurse is assessing a client who has been admitted with signs and symptoms that are consistent with malnutrition. Which physiologic phenomenon would the nurse recognize as an early indicator of malnutrition? Protein stores are lower than normal Bone is metabolized to compensate for missing nutrients Calcium levels decrease Hemoglobin levels decrease

Protein stores are low

The nurse is using their fingerpads to palpate a client's body part during the physical examination. The nurse would best be able to detect which finding? Temperature Vibrations Pulses Fremitus

Pulses

The nurse is caring for a client who has been experiencing dysphagia secondary to a stroke. What risk nursing diagnosis should the nurse associate with this health problem? Risk for Injury related to potential esophageal trauma Risk for Oral Infection related to dysphagia Risk for Aspiration related to decreased swallowing ability Risk for Excess Fluid Volume related to decreased peristalsis

Risk for Aspiration related to decreased swallowing ability

The nurse is assessing a fair-skinned, Caucasian woman with red hair and freckled skin. During health promotion, the nurse should focus education on what topic? Management of dry skin Susceptibility to bruising Risks of fungal infections Risks of sun exposure

Risk sun exposure

The nurse asks the patient to rate their pain on a scale 1 -10? Character Onset Severity Pattern

Severity

The nurse is preparing to assess the peripheral pulses of a client. The nurse should place the client in which position? Sitting position Supine position Sims' position prone position

Supine

When assessing the client's ear, which finding should the nurse identify as indicating a need for further assessment and possible treatment? Darwin tubercle Red, flaky cerumen Tender tragus Pearly gray tympanic membrane

Tender tragus

The nurse is collecting data from a client about his nutrition. Which finding would the nurse document as objective data? Client states he is not eating well. Client states he is not eating well. Client complains of nausea and vomiting. Clients experiences urinary frequency. Tenting of client's skin observed upon skin pinch.

Tenting of client's skin observed upon skin pinch.

The nurse is providing care for a client with a history of chronic heart failure. The client is in bed with the head of her bed at 45 degrees, and the nurse is assessing the client's neck veins. What assessment finding would be most consistent with a nursing diagnosis of fluid volume excess related to chronic heart failure? The client's carotid arteries are not palpable. The client's jugular veins are clearly visible and firm to palpation. The client's carotid pulses are asymmetrical and difficult to palpate. The client's carotid pulses are easier to palpate than the jugular pulses.

The client's jugular veins are clearly visible and firm to palpation.

During a Weber test, the client reports lateralization of sound to the good ear. How should the nurse interpret this assessment finding? The good ear cannot receive sound vibrations. There is a dysfunction of the middle ear. The poor ear is receiving sound vibrations by air. There is a sensorineural hearing impairment.

There is a sensorineural hearing impairment. lateralization to good ear = sensorineural loss Lateralization to poor ear = conductive hearing loss

The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an "itching rash." Which question would be most important for the nurse to ask? "Are you allergic to foods, medications, or other substances?" "Does anyone else in your family have a rash like this?" "How painful is your rash?" "What have you been doing to control the itching?"

are you allergic to any foods, medications, or other substances

A nurse shines a light into one of the client's eyes during an ocular exam and the pupil of the other eye constricts. The nurse interprets this as which of the following? Direct reflex Optic chiasm Consensual response Accommodation

consensual response

The nurse is completing the general survey of a client and determines that the client's temperature is 102°F. What would the nurse also expect to find? Weak, thready pulse Heart rate greater than 100 beats/min Respiratory rate between 12 and 20 breaths/min Diastolic blood pressure 10 mm Hg greater than normal

heart rate grader 100 bpm

The nurse is evaluating the setting prior to beginning a client's physical examination. The nurse should confirm the presence of which of the following? Select all that apply. Adequate lighting Cool room temperature Quiet surroundings Soft chair or table Table for equipment Door or curtain

lighting quiet table for equipment door/curtain

Which of the following findings should the nurse document after assessing the thyroid gland of an older adult without abnormalities? Nodularity Tenderness Enlargement Bruits

nodularity

When assessing pain in an older adult client who is alert and oriented, which assessment tool would be most appropriate to use? Numeric Rating Scale Faces Pain Scale-Revised FLACC Scale Graphic Rating Scale

numerical rating scale

The nurse is performing an assessment of a hospital client at the beginning of a shift. When assessing the client's heart rate, the nurse will most likely palpate what artery?

radial pulse

A group of students is reviewing information about the salivary glands and their secretions. The students demonstrate understanding of the information when they identify which components of saliva? Select all that apply. Salts Proteins Fats Mucus Amylase

salts mucus amylase

A nurse has received a report on a client who will soon be admitted to the medical unit from the emergency department. When preparing for the assessment phase of the nursing process, what should the nurse do first? Collect objective data. Validate important data. Collect subjective data. Document the data.

subjective objective validate document

The nurse is preparing to assess a client's vital signs. Which vital sign should the nurse assess first? Temperature Pulse Respiration Blood pressure

temperature