Exam 2: Assessment

A client reports chest pain and heavy breathing when exercising or when stressed. Which is a priority nursing intervention for the client diagnosed with coronary artery disease?

Assess chest pain and administer prescribed drugs and oxygen The nurse assesses the client for chest pain and administers the prescribed drugs that dilate the coronary arteries. The nurse administers oxygen to improve the oxygen supply to the heart. Assessing blood pressure or the client's physical history does not clearly indicate that the client has CAD. The nurse does not administer aspirin without a prescription from the physician.

Lesions in the temporal lobe may result in which type of agnosia?

Auditory Lesions in the temporal lobe (lateral and superior portions) may result in auditory agnosia. Lesions in the occipital lobe may result in visual agnosia. Lesions in the parietal lobe may result in tactile agnosia. Lesions in the parietal lobe (posteroinferior regions) may result in relationship and body part agnosia.

After suctioning a tracheostomy tube, the nurse assesses the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent?

Effective breathing at a rate of 16 breaths/minute through the established airway Proper suctioning should produce a patent airway, as demonstrated by effective breathing through the airway at a normal respiratory rate of 12 to 20 breaths/minute. The other options suggest ineffective suctioning. A respiratory rate of 28 breaths/minute and accessory muscle use may indicate mild respiratory distress. Increased pulse rate, rapid respirations, and cyanosis are signs of hypoxia. Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds indicate respiratory secretion accumulation.

When the nurse notes that, after cardiac surgery, the client demonstrates low urine output (less than 25 mL/h) with high specific gravity (greater than 1.025), the nurse suspects which condition?

Inadequate fluid volume Urine output less than 0.5 mL/kg/h may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine, which occurs with inadequate fluid volume. Indices of normal glomerular filtration are output of 0.5 mL/kg/h or more and specific gravity between 1.010 and 1.025. Overhydration is manifested by high urine output with low specific gravity. The anuric client does not produce urine.

The nurse is assessing a client who is in post-anesthetic recovery from surgery with midazolam. What is a priority nursing assessment?

Respiratory rate Clients receiving midazolam should be monitored for respiratory depression and CNS suppression. For most clients, this is a priority over temperature, pupil response and urine output.

What is the micturition reflex?

The act of bladder contraction and perceived need to void. Several words are used to describe the process of excreting urine from the body, including urination, voiding, and micturition.

A nurse is caring for a client who had gastric bypass surgery two days ago. Which assessment finding requires immediate intervention?

The client's right lower leg is red, swollen, and warm to touch. A red, swollen extremity is a possible sign of a thromboembolism, a common complication after gastric surgery. The nurse should inform the physician of the finding. Pain at the surgical site upon rising is normal, but splinting should be reinforced. A reddened surgical site is concerning, but the red, swollen leg is a higher priority. Abdominal bloating occurs due to the carbon dioxide used during the laparoscopy and will lessen when it gets absorbed. Additional teaching is needed to be sure the client does not strain at the toilet.

When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. Aphthous stomatitis is best described as

a canker sore of the oral soft tissues. Aphthous stomatitis refers to a canker sore of the oral soft tissues, including the lips, tongue, and inside of the cheeks. Aphthous stomatitis isn't an acute stomach infection, acid indigestion, or early sign of peptic ulcer disease.

A client with schizophrenia hears a voice saying the client is evil and must die. The nurse understands that this client is experiencing:

a hallucination. A hallucination is a sensory perception, such as hearing voices and seeing objects, that only the client experiences. A delusion is a false belief. Flight of ideas refers to a speech pattern in which a client skips from one unrelated subject to another. Ideas of reference refers to the mistaken belief that someone or something outside the client is controlling the client's ideas or behavior.

A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode?

compliance with the prescribed medication regimen The most common cause of status epilepticus is sudden withdraw of anticonvulsant therapy. The type of medication prescribed, the client's stress level, and weight change don't contribute to this condition.

A nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates an emergency cesarean birth may be necessary at this time?

fetal heart rate of 80 beats/minute A drop in fetal heart rate signals fetal distress and may indicate the need for a cesarean birth to prevent neonatal death. Maternal blood pressure, pulse rate, respiratory rate, intake and output, and description of vaginal bleeding are all important assessment factors; however, changes in these factors don't always necessitate the delivery of the neonate.

A client has been diagnosed with a basal skull fracture following a motor vehicle accident and now presents with increasing drowsiness and is febrile. The nurse knows that the client is most at risk for developing which condition?

meningitis Head trauma and fractures place an individual at high risk for meningitis. A client who is febrile with increasing drowsiness should be investigated for posttraumatic meningitis. It is unlikely that pneumonia, renal failure, or a paralytic ileus would occur as a result of a basal skull fracture.

A nurse is caring for a client with schizophrenia who states, "I can't handle the voices anymore! It's over! I've done all I can." Which statement by the nurse is best?

"Are you thinking of hurting yourself?" Risk of suicide is greater in patients with a serious illness, including mental or emotional disorders. The nurse should recognize the client's statement as a warning for possible self-harm. With this concern, the nurse should ask the client a yes/no question regarding self-harm. Using an open-ended question is therapeutic, but assessing the risk of self-harm requires a more direct approach. Asking about medications or past feelings should wait until after the risk for self-harm is determined.

The nurse makes the following assessment: A middle-age client reports falling asleep frequently at his job during the day, feels like he is not getting enough sleep at night even though the number of hours of sleep are unchanged, and continues to feel tired and is not able to think clearly. Also, the client reports his wife believes he is irritable upon awakening. The nurse further assesses by asking:

"Have you had any recent head injury?" The client is experiencing sleep difficulties, and these symptoms may be hypersomnia. The nurse assesses for a cause for hypersomnia. Head trauma or other injury to the central nervous system may cause this. Other causes include obesity and depression. When experiencing hypersomnia, the client may exhibit slower speech.

A mother calls a clinic nurse to ask if her infant born prematurely should receive the seasonal influenza vaccine. The nurse's next question should be:

"How old is your baby?" Flu vaccine and all other vaccines are administered according to chronological age. Flu vaccine is recommended for all infants at 6 months of age and given yearly thereafter. An underlying respiratory problem makes flu vaccine important. Awareness of allergies is also necessary, but the first question is chronological age to determine if the infant is old enough to receive the vaccine.

A client with a malignant glioma is scheduled for surgery. The client demonstrates a need for additional teaching about the surgery when he states which of the following?

"The surgeon will be able to remove all of the tumor." For clients with malignant gliomas, complete removal of the tumor and cure are not possible but the rationale for resection includes relief of increased intracranial pressure, removal of any necrotic tissue, and reduction in the bulk of the tumor, which theoretically leaves behind fewer cells to become resistant to radiation or chemotherapy.

Coarctation of the aorta demonstrates few symptoms in newborns. What is an important assessment to make on all newborns to help reveal this condition?

Assessing for the presence of femoral pulses Coarctation of the aorta is a defect where there is narrowing of the aorta, which is the largest vessel carrying oxygenated blood to the body. As a result of this narrowing, blood flow is impeded causing pressure to increase in the area proximal to the defect and decrease distal to the defect. As a result, the blood pressure will be higher in the upper part of the body and decreased in the lower part of the body. The pulses will be full or bounding in the upper part of the body and weak or absent in the lower part of the body. When assessing an infant with coarctation there may be weak or absent femoral pulses. There will also be differences in the blood pressure readings. These infants may or may not have a murmur and will be no more fussy than other babies.

Which is a diagnostic marker for inflammation of vascular endothelium?

C-reactive protein (CRP) CRP is a marker for inflammation of the vascular endothelium. LDL, HDL, and triglycerides are not markers of vascular endothelial inflammation. They are elements of fat metabolism.

A 21-year-old man experienced massive trauma and blood loss during a motorcycle accident and has been started on a dopamine infusion upon his arrival at the hospital. In light of this drug treatment, what assessment should the care team prioritize?

Cardiac monitoring The high potential for adverse effects that is associated with the use of dopamine necessitates vigilant cardiac monitoring. Respiratory assessment, ABGs, and monitoring of ICP are likely indicated by the patient's injuries, but these are not directly related to the use of dopamine.

A nurse is overseeing the care of a young man whose ulcerative colitis is being treated with oral prednisone. Which action should the nurse take in order to minimize the potential for risks associated with prednisone treatment?

Carefully assess the client for infections. It is important to monitor clients who are taking prednisone carefully for signs of infection, because prednisone's immunologic activity may mask the symptoms of infection. Antacids may normally be used alongside prednisone. Headaches are not associated with the use of prednisone and IV administration is not typical.

The nurse is evaluating the client's understanding of diet teaching aimed at promoting wound healing following surgery. The nurse would conclude teaching was ineffective if the client selects which of the following?

Cheeseburger, french fries, coleslaw, and ice cream Important nutrients for wound healing include protein; vitamins A, B-complex, C, and K; arginine, magnesium, copper, and zinc; and water. The diet should be sufficient in carbohydrates and low to moderate in fats. The cheeseburger option is high in fat and low in vitamin C.

Which of the following causes should the nurse suspect in a client diagnosed with intrarenal failure?

Glomerulonephritis Intrarenal causes of renal failure include prolonged renal ischemia, nephrotoxic agents, and infectious processes such as acute glomerulonephritis.

To obtain information about the chief complaint and medical history of an older client, the nurse asks the client about any medication history. Why is obtaining a medication history important?

It may indicate multiple medications taken by the client. The nurse should obtain information about a client's medication history because the older client, in particular, may be taking multiple medications that may affect their renal function. The medication history in general indicates the probable risk factors of renal or urologic disorders. The medication history of an older client is not used to obtain information about the client's general health, childhood and family illnesses, or drugs that are contraindicated for use by the client.

The nurse is performing a physical examination of a patient and observes a well-healed old scar on the right shoulder. The scar is hypertrophied, elevated, and irregular without any redness or irritation. The patient states, "I had shoulder surgery about 5 years ago." The nurse documents this finding as which of the following?

Keloid The hypertrophied, elevated, irregular scar would be documented as a keloid. Lichenification refers to thickening and roughening of the skin or accentuated skin markings that may be due to repeated rubbing, irritation, or scratching. A nodule refers to an elevated, palpable solid mass that extends into the dermis. Cicatrix is another term used to denote a scar.

An infant is breastfed. When assessing the stools, which findings would be typical?

Less constipation than bottle-fed infants The first stool of the infant is meconium. It is the result of digestion of amniotic fluid and it is black-green color and sticky. Following that, in 1 to 2 days the infant's stools change to a yellowish-tan color. The stools of breastfed infants tend to be yellow-tan. They are looser in texture and appear "seedy." The stool of a bottle-fed baby has the consistency of peanut butter. The stools of breastfed babies generally have no odor since all milk is digested. Some babies will have a bowel movement with every feeding but it is small. Bottle-fed babies have less stools each day but they are larger and more likely to have an associated odor.

The pulmonologist sees many patients daily who suffer from a variety of respiratory disorders. What are some of the common signs and symptoms many of these patients present? (Select all that apply.)

Mucosal congestion Cough Increased secretions Common signs and symptoms of respiratory disorders include cough, increased secretions, mucosal congestion, and bronchospasm. Increased temperature is not common among respiratory disorders unless infection is involved.

An infant is diagnosed with a congenital hip dislocation. On assessment, the nurse expects to note:

Ortolani's sign. In a child with a congenital hip dislocation, assessment typically reveals Ortolani's sign, asymmetrical thigh and gluteal folds, limited hip abduction, femoral shortening, and Trendelenburg's sign.

A client diagnosed with acute pancreatitis is being transferred to another facility. The nurse caring for the client completes the transfer summary, which includes information about the client's drinking history and other assessment findings. Which assessment findings confirm the diagnosis of acute pancreatitis?

Pain with abdominal distention and hypotension Assessment findings associated with pancreatitis include pain with abdominal distention and hypotension. Blood in stools and recent hypertension aren't associated with pancreatitis; fatty diarrhea and hypotension are usually present. Presence of easy bruising and bradycardia aren't found with pancreatitis; the client typically experiences tachycardia, not bradycardia. Adventitious breath sounds and hypertension aren't associated with pancreatitis.

The newborn nursery nurse is preparing to perform a required neonatal screening for congenital hypothyroidism. What should the nurse do to obtain the necessary sample?

Perform a heel stick to obtain a drop of blood for a T4 and TSH. Screening is usually done in the hospital nursery. In this test, a drop of blood is taken from the infant's heel and analyzed for T4 and TSH.

Which term is used to describe stone formation in a salivary gland, usually the submandibular gland?

Sialolithiasis Salivary stones are formed mainly from calcium phosphate. Parotitis refers to inflammation of the parotid gland. Sialadenitis refers to inflammation of the salivary glands. Stomatitis refers to inflammation of the oral mucosa.

A client describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a client's description of pain in the right leg?

Subjective Cues may be signs (objective) or symptoms (subjective). Objective cues, called signs, are observable, perceptible, and measurable by someone other than the person experiencing them. Subjective cues, called symptoms, are only observable, perceptible, and measurable by the person experiencing them. The pain described by the client in this question is a subjective cue, as only the client is able to perceive it. Explanatory suggests that the client would offer an explanation or comparison to describe the pain in the right leg. Severe is an adjective that might be the equivalent of 8/10 on the pain scale as reported by the client.

A group of students is reviewing various methods for assessing pain. The students demonstrate understanding of the material when they identify what as the most reliable method?

Using a pain rating scale A pain rating scale is the most reliable method because it provides measurable evidence of pain severity. A client's description of pain is useful, but does not provide objective or quantifiable data over time. Although percussing or palpating provides information, it would increase the client's pain and be inappropriate. Vital sign changes occur for numerous reasons and are not the best indicator of pain in clients who can speak.

A child is receiving peritoneal dialysis to treat renal failure. To detect early signs of peritonitis, the nurse should stay alert for

abdominal tenderness. The nurse should stay alert for abdominal tenderness because it's an early sign of peritonitis. Redness at the catheter site indicates a skin infection. Abdominal fullness is expected during dialysate infusion. Headache isn't associated with peritonitis.

The nurse is providing care for an adult client whose current medication regimen includes calcitonin and a bisphosphonate. The nurse should recognize the likely need for:

bone density testing on a scheduled basis. Calcitonin and bisphosphonates are commonly used in the treatment of osteoporosis, in order to slow bone resorption; individuals with osteoporosis are encouraged to undergo regular bone density testing. Weight-bearing exercise is beneficial, provided it is performed within safe limits. Surgery is not normally indicated. Genu varum and genu valgum are congenital misalignments of the knee joint that do not affect bone resorption.

Assessment of a client in active labor reveals meconium-stained amniotic fluid and fetal heart sounds in the upper right quadrant. What is the most likely cause of this situation?

breech position Fetal heart sounds in the upper right quadrant and meconium-stained amniotic fluid indicate a breech presentation. The staining is usually caused by the squeezing actions of the uterus on a fetus in the breech position, although late decelerations, entrance into the second stage of labor, and multiple gestation may contribute to meconium-stained amniotic fluid.

The nurse is assessing a client admitted with a myocardial infarction with the following assessment: dyspnea, heart rate of 140 bpm, and crackles in the posterior chest. The nurse would interpret these findings as which condition?

development of congestive heart failure Crackles probably signify pulmonary edema, which occurs when there is left-sided congestive heart failure. The client is very dyspneic, and the heart appears to be compensating (increased rate because of respiratory congestion). Initiation of measures to help strengthen the heartbeat is a very important priority. Signs and symptoms do not indicate hypoglycemic reaction or renal failure. Heart block would be indicated by bradycardia.

A nurse is assessing a neonate. When maternal estrogen has been transferred to the fetus which sign will the nurse see in the neonate?

enlarged breast tissue It's common to see enlarged breast tissue in both male and female neonates in the first few days of life because of maternal estrogen transmitted to the fetus. Weak sucking response isn't related to estrogen. Soft skin and vernix caseosa are signs of full-term, well-developed neonates and aren't related to estrogen.

A physician orders a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance?

hypokalemia A loop diuretic removes water and, along with it, sodium and potassium. This may result in hypokalemia, hypovolemia, and hyponatremia.

Early signs of hypervolemia include

increased breathing effort and weight gain. Early signs of hypervolemia are weight gain, elevated blood pressure, and increased breathing effort. Eventually, fluid congestion in the lungs leads to moist breath sounds. One of the earliest symptoms of hypovolemia is thirst.

A Black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the:

mucous membranes. Skin color doesn't affect the mucous membranes. Therefore, the nurse can assess for cyanosis by inspecting the client's mucous membranes. The lips, nail beds, and earlobes are less-reliable indicators of cyanosis because they're affected by skin color.

A client tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client's lump is cancerous?

nonmobile mass with irregular edges Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges. A mobile mass that is soft and easily delineated is most commonly a fluid-filled benign cyst. Axillary lymph nodes may or may not be palpable on initial detection of a cancerous mass. Nipple retraction — not eversion — may be a sign of cancer.

A fracture is considered pathologic when it

occurs through an area of diseased bone. Pathologic fractures can occur without the trauma of a fall. An avulsion fracture results in a fragment of bone being pulled away by a ligament or tendon and its attachment. A greenstick fracture presents as one side of the bone being broken and the other side being bent. A compound fracture involves damage to the skin or mucous membranes.

A 2-year-old child is being examined in the emergency department for epiglottitis. Which assessment finding supports this diagnosis?

tripod position The child being in the tripod position (sitting up and leaning forward) supports the diagnosis of epiglottitis because this position facilitates breathing. Epiglottitis presents with a sudden onset of signs and symptoms, such as high fever, muffled speech, inspiratory stridor, and drooling.