Exam 3 Fundamentals NUR 352

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply. 1. Auscultating lung sounds 2. Obtaining the client's temperature 3. Assessing the strength of peripheral pulses 4. Obtaining information about the client's respirations 5. Performing a musculoskeletal and neurological examination 6. Asking the client about a family history of any illness or disease

1, 2, 4 Rationale: A focused assessment focuses on a limited or short-term problem, such as the client's complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion, the nurse would focus on the respiratory system and the presence of an infection. A complete assessment includes a complete health history and physical examination and forms a baseline database. Assessing the strength of peripheral pulses relates to a vascular assessment, which is not related to this client's complaints. A musculoskeletal and neurological examination also is not related to this client's complaints. However, strength of peripheral pulses and a musculoskeletal and neurological examination would be included in a complete assessment. Likewise, asking the client about a family history of any illness or disease would be included in a complete assessment.

The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan? Select all that apply. 1. "The ductus arteriosus allows blood to bypass the fetal lungs." 2. "One vein carries oxygenated blood from the placenta to the fetus." 3. "The normal fetal heart tone range is 140 to 160 beats per minute in early pregnancy." 4. "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta." 5. "Two veins carry blood that is high in carbon dioxide and other waste products away from the fetus to the placenta."

1, 2, 4 Rationale: The ductus arteriosus is a unique fetal circulation structure that allows the nonfunctioning lungs to receive only a minimal amount of oxygenated blood for tissue maintenance. Oxygenated blood is transported to the fetus by one umbilical vein. The normal fetal heart tone range is considered to be 110 to 160 beats per minute. Arteries carry deoxygenated blood and waste products from the fetus, and the umbilical vein carries oxygenated blood and provides oxygen and nutrients to the fetus. Blood pumped by the embryo's heart leaves the embryo through two umbilical arteries.

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. 1. The client is aphasic. 2. The client has weakness on the right side of the body. 3. The client has complete bilateral paralysis of the arms and legs. 4. The client has weakness on the right side of the face and tongue. 5. The client has lost the ability to move the right arm but is able to walk independently. 6. The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance.

1,3,4 Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic: unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.

The home care nurse has taught a client with a problem of inadequate cardiac output about helpful lifestyle adaptations to promote health. Which statement by the client best demonstrates an understanding of the information provided? 1. "I will eat enough daily fiber to prevent straining at stool." 2. "I will try to exercise vigorously to strengthen my heart muscle." 3. "I will drink 3000 to 3500 mL of fluid daily to promote good kidney function." 4. "Drinking 2 to 3 oz of liquor each night will promote blood flow by enlarging blood vessels."

1. "I will eat enough daily fiber to prevent straining at stool." Standard home care instructions for a client with this problem include, among others, lifestyle changes such as decreased alcohol intake, avoiding activities that increase the demands on the heart, instituting a bowel regimen to prevent straining and constipation, and maintaining fluid and electrolyte balance. Consuming 3000 to 3500 mL of fluid and exercising vigorously will increase the cardiac workload.

The home care nurse has given instructions to a client who is beginning therapy with digoxin. The nurse determines a need for further teaching if the client makes which statement? 1. "If I miss a dose, I should just take 2 the next day." 2. "I shouldn't change brands without asking the health care provider first." 3. "I should call the health care provider if my daily pulse rate is under 60 or over 100." 4. "The pills should be kept in their original container so they don't get mixed up with my other medicines."

1. "If I miss a dose, I should just take 2 the next day." Rationale: Client teaching should include taking the dose exactly as prescribed each day. If the client misses a dose and more than 12 hours goes by, that dose should be omitted, and only the next scheduled dose should be taken; the client should not double-dose. The health care provider (HCP) should be consulted before changing brands because the bioavailability of another preparation of the medication may be different. A daily pulse check is necessary, and the client should know the parameters for which the HCP should be called. Clients are advised not to mix digoxin in pill boxes with other medications.

The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques? 1. "Use of an incentive spirometer will help prevent pneumonia." 2. "Close monitoring of your oxygen saturation will detect hypoxemia." 3. "Administration of intravenous fluids will prevent or treat fluid imbalance." 4. "Early ambulation and administration of blood thinners will prevent pulmonary embolism."

1. "Use of an incentive spirometer will help prevent pneumonia." Rationale: Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Use of an incentive spirometer helps to prevent pneumonia and atelectasis. Hypoxemia is an inadequate concentration of oxygen in arterial blood. While close monitoring of the oxygen saturation will help to detect hypoxemia, monitoring is not directly related to coughing and deep-breathing techniques. Fluid imbalance can be a deficit or excess related to fluid loss or overload, and surgical clients are often given intravenous fluids to prevent a deficit; however, this is not related to coughing and deep breathing. Pulmonary embolus occurs as a result of a blockage of the pulmonary artery that disrupts blood flow to 1 or more lobes of the lung; this is usually due to clot formation. Early ambulation and administration of blood thinners helps to prevent this complication; however, it is not related to coughing and deep-breathing techniques.

The nurse is talking to a client who had a below-the-knee amputation 2 days earlier. The client states, "I hate looking at this; I feel that I'm not even myself anymore." What client problem should the nurse incorporate in the plan of care based on the statement by this client? 1. Altered body image 2. Inability to care for self 3. Disruption in coping ability 4. Difficulty maintaining health

1. Altered body image Rationale: Altered body image is characterized by negative verbalizations or feelings about a body part. This is a common response after amputation. The nurse supports the client and assists the client to work through these feelings. The client also may have the other problems as listed in the remaining options, but altered body image is the client problem that correlates best with the client's statement.

A client has been experiencing difficulty with completion of daily activities because of underlying cardiovascular disease, as evidenced by exertional fatigue and increased blood pressure. Which observation by the nurse best indicates client progress in meeting goals for this problem? 1. Ambulates 10 feet (3 meters) farther each day 2. Verbalizes the benefits of increasing activity 3. Chooses a healthy diet that meets caloric needs 4. Sleeps without awakening throughout the night

1. Ambulates 10 feet (3 meters) farther each day Each of the options indicates a positive outcome on the part of the client. Both option 2 and the correct one relate to the client problem of difficulty with completion of daily activities. However, the question asks about progress. The correct option is more action-oriented and therefore is the better choice. Option 3 would most likely indicate progress if the client had a problem of inadequate nutritional intake. Option 4 would be a satisfactory outcome for a client experiencing difficulty sleeping.

The nurse has reviewed activity restrictions with a client who is being discharged after insertion of a femoral head prosthetic system. What statement by the client will help the nurse determine that the client understands the material presented? 1. Use a raised toilet seat. 2. Bend carefully to put on socks and shoes. 3. Sit in chairs without arms for better mobility. 4. Exercise the leg past the point of 90-degree flexion.

1. Use a raised toilet seat. The client who has had an insertion of a femoral head prosthesis should use a raised toilet seat. The client should avoid putting on his or her own socks and shoes for 8 weeks after surgery because it would force the leg into acute flexion. The client should sit in chairs that have arms to provide assistance in rising from the sitting position. The client also should maintain the leg in a neutral, straight position when lying, sitting, or walking. The leg should not be adducted, internally rotated, or flexed more than 90 degrees.

The nurse is developing a plan of care for a client recovering from pulmonary edema. The nurse establishes a goal to have the client participate in activities that reduce cardiac workload. The nurse should identify which client action as contributing to this goal? 1. Using a bedside commode 2. Sleeping in the supine position 3. Elevating the legs when in bed 4.

1. Using a bedside commode Rationale: Using a bedside commode decreases the work of getting to the bathroom or struggling to use the bedpan. The supine position increases respiratory effort and decreases oxygenation. Elevating the client's legs increases venous return to the heartthus increasing cardiac workload. Seasonings may be high in sodium and promote further fluid retention.

A client has been prescribed pindolol for hypertension. The nurse provides anticipatory guidance, knowing that which common side effect of this medication may decrease client compliance? 1. Impotence 2. Mood swings 3. Increased appetite 4. Difficulty swallowing

1. Impotence Rationale: A common side effect of beta-adrenergic blocking agents such as pindolol is impotence. Other common side effects include fatigue and weakness. Central nervous system side effects are rarer and include mental status changes, nervousness, depression, and insomnia. Mood swings, increased appetite, and difficulty swallowing are not side effects of this medication.

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate? 1. Do nothing, because this is an expected finding. 2. Check for an air leak, because the bubbling should be intermittent. 3. Increase the suction pressure so that the bubbling becomes vigorous. 4. Clamp the chest tube and notify the health care provider immediately.

2. Rationale: Fluctuation with inspiration and expiration, not continuous bubbling, should be noted in the water seal chamber. Intermittent bubbling may be noted if the client has a known pneumothorax, but this should decrease as time goes on and as the pneumothorax begins to resolve. Therefore, the nurse should check for an air leak. If a wet chest drainage system is used, bubbling would be continuous in the suction control chamber and not intermittent. In a dry system, there is no bubbling. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system; in addition, increasing the suction can be harmful and is not done without a specific prescription to do so if using a wet system. Dry systems will allow for only a certain amount of suction to be applied; an orange bellow will appear in the suction window, indicating that the proper amount of suction has been applied. Chest tubes should be clamped only with a health care provider's prescription.

The nurse has provided instructions to the client with hyperparathyroidism regarding home care measures to manage the symptoms of the disease. Which statement by the client indicates a need for further instruction? 1. "I should avoid bed rest." 2. "I need to avoid doing any exercise at all." 3. "I need to space activity throughout the day." 4. "I should gauge my activity level by my energy level."

2. "I need to avoid doing any exercise at all." Rationale: The client with hyperparathyroidism should pace activities throughout the day and plan for periods of uninterrupted rest. The client should plan for at least 30 minutes of walking each day to support calcium movement into the bones. The client should be instructed to avoid bed rest and use energy levels as a guide to activity. The client also should be instructed to avoid high-impact activity or contact sports.

The nurse is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary to control disease progression. Which statement by the client indicates a need for further teaching? 1. "I will avoid using table salt with meals." 2. "It is best to exercise once a week for 1 hour." 3. "I will take nitroglycerin whenever chest discomfort begins." 4. "I will use muscle relaxation to cope with stressful situations."

2. "It is best to exercise once a week for 1 hour." Rationale: Exercise is most effective when done at least 3 times a week for 20 to 30 minutes to reach a target heart rate. Other healthful habits include limiting salt and fat in the diet and using stress management techniques. The client also should be taught to take nitroglycerin before any activity that previously caused the pain and to take the medication at the first sign of chest discomfort.

Intravenous (IV) fluids have been infusing at 100 mL/hour via a central line catheter in the right internal jugular for approximately 24 hours to increase urine output and maintain the client's blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and coughing. For which additional signs of a complication should the nurse assess based on the previously known data? 1. Excessive bleeding 2. Crackles in the lungs 3. Incompatibility of the infusion 4. Chest pain radiating to the left arm

2. Crackles in the lungs Rationale: Circulatory (fluid) overload is a complication of IV therapy. Signs include rapid breathing, dyspnea, a moist cough, and crackles. Blood pressure and heart rate also increase if circulatory overload is present. Therefore, since the nurse previously noted rapid breathing and coughing, the nurse should then assess for a moist cough and crackles. Hematoma is another potential complication and is characterized by ecchymosis, swelling, and leakage at the IV insertion site, as well as hard and painful lumps at the site. Allergic reaction is a complication of administration of IV fluids or medication and is characterized by chills, fever, malaise, headache, nausea, vomiting, backache, and tachycardia; this type of reaction could also occur if the IV solutions infused are incompatible; however, there was no indication of multiple solutions being infused simultaneously in this question. Chest pain radiating to the left arm is a classic sign of cardiac compromise and is not specifically related to a complication of IV therapy.

Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement first? 1. Maintain bed rest with legs elevated. 2. Place the client in high Fowler's position. 3. Increase the rate of infusion of intravenous fluids. 4. Consult with the health care provider (HCP) regarding initiation of oxygen therapy.

2. Place the client in high Fowler's position. Rationale: New onset of tachycardia, bounding pulses, and crackles and wheezes posttransfusion is evidence of fluid overload, a complication associated with blood transfusions. Placing the client in a high Fowler's (upright) position will facilitate breathing. Measures that increase blood return to the heart, such as leg elevation and administration of IV fluids, should be avoided at this time. In addition, administration of fluids cannot be initiated without a prescription. Consulting with the HCP regarding administration of oxygen may be necessary, but positional changes take a short amount of time to do and should be initiated first.

A client with acquired immunodeficiency syndrome (AIDS) is experiencing fatigue. The nurse should plan to teach the client which strategy to conserve energy after discharge from the hospital? 1. Bathe before eating breakfast. 2. Sit for as many activities as possible. 3. Stand in the shower instead of taking a bath. 4. Group all tasks to be performed early in the morning.

2. Sit for as many activities as possible. Rationale: Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. The client is taught to conserve energy by sitting for as many activities as possible, including dressing, shaving, preparing food, and ironing. The client also should sit in a shower chair instead of standing while bathing. The client needs to prioritize activities, such as eating breakfast before bathing, and should intersperse each major activity with a period of rest.

The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instructions if the client made which statement "I need to wear a MedicAlert tag or bracelet." 2. "I need to restrict my activity while this catheter is in place." 3. "I need to keep the insertion site protected when in the shower or bath." 4. "I need to check the markings on the catheter each time the dressing is changed."

2. The client should be taught that only minor activity restrictions apply with this type of catheter. The client should carry or wear a MedicAlert identification and should protect the site during bathing to prevent infection. The client should check the markings on the catheter during each dressing change to assess for catheter migration or dislodgement.

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which? 1. Lub-dub sounds 2. Scratchy, leathery heart noise 3. A blowing or swooshing noise 4. Abrupt, high-pitched snapping noise

3. A heart murmur is an abnormal heart sound and is described as a faint or loud blowing, swooshing sound with a high, medium, or low pitch. Lub-dub sounds are normal and represent the S1 (first) heart sound and S2 (second) heart sound, respectively. A pericardial friction rub is described as a scratchy, leathery heart sound. A click is described as an abrupt, high-pitched snapping sound.

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client? 1. Stridor 2. Crackles 3. Wheezes 4. Diminished

3. Rationale: Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency. Crackles are produced by air passing over retained airway secretions or fluid, or the sudden opening of collapsed airways. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring.

The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included? 1. Out-of-bed activities as desired 2. Bed rest with the affected extremity kept flat 3. Bed rest with elevation of the affected extremity 4. Bed rest with the affected extremity in a dependent position

3. Rationale: For the client with deep vein thrombosis, elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. A flat or dependent position of the leg would not achieve this goal. Bed rest is indicated to prevent emboli and to prevent pressure fluctuations in the venous system that occur with walking.

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? 1. Weight loss and dry skin 2. Flat neck and hand veins and decreased urinary output 3. An increase in blood pressure and increased respirations 4. Weakness and decreased central venous pressure (CVP)

3. A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit.

A client has dysfunction of the cochlear division of the vestibulocochlear nerve (cranial nerve VIII). The nurse should determine that the client is adequately adapting to this problem if he or she states a plan to obtain which item? 1. A walker 2. Eyeglasses 3. A hearing aid 4. A bath thermometer

3. A hearing aid Rationale: The cochlear division of cranial nerve VIII is responsible for hearing. Clients with hearing difficulty may benefit from the use of a hearing aid. The vestibular portion of this nerve controls equilibrium; difficulty with balance caused by dysfunction of this division could be addressed with use of a walker. Eyeglasses would correct visual problems (cranial nerve II); a bath thermometer would be of use to clients with sensory deficits of peripheral nerves, such as with diabetic neuropathy.

A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit. What activity level should the nurse encourage for the client immediately after transfer? 1. Ad lib activities as tolerated 2. Strict bed rest for 24 hours after transfer 3. Bathroom privileges and self-care activities 4. Unsupervised hallway ambulation for distances up to 200 feet (60 meters)

3. Bathroom privileges and self-care activities Rationale: On transfer from CCU to an intermediate care or general medical unit, the client is allowed self-care activities and bathroom privileges. Activities ad lib as tolerated is premature at this time and potentially harmful for this client. It is unnecessary and possibly harmful to limit the client to bed rest. The client should ambulate with supervision in the hall for brief distances, with the distances being gradually increased to 50, 100, and 200 feet (15, 30 and 60 meters).

A client with a neurological impairment experiences urinary incontinence. Which nursing action would be most helpful in assisting the client to adapt to this alteration? 1. Using adult diapers 2. Inserting a Foley catheter 3. Establishing a toileting schedule 4. Padding the bed with an absorbent cotton pad

3. Establishing a toileting schedule Rationale: A bladder retraining program, such as use of a toileting schedule, may be helpful to clients experiencing urinary incontinence. A Foley catheter should be used only when necessary because of the associated risk of infection. Use of diapers or pads is the least acceptable alternative because of the risk of skin breakdown.

A client has a difficulty with the ability to flex the hips. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item? 1. Walker 2. Slider board 3. Raised toilet seat 4. Adaptive eating utensils

3. Raised toilet seat Rationale: A raised toilet seat is useful if the client does not have the mobility or ability to flex the hips. The cerebellum is responsible for balance and coordination. A walker would provide stability for the client during ambulation. A slider board is used in transferring a client from a bed to a stretcher or wheelchair. Adaptive eating utensils may be beneficial if the client has partial paralysis of the hand.

The nurse has developed a plan of care for a client in traction and documents a problem of inability to perform self-care independently. The nurse evaluates the plan of care and determines that which observation indicates a successful outcome? 1. The client refuses care. 2. The client allows the family to assist in the care. 3. The client assists in self-care as much as possible. 4. The client allows the nurse to complete the care on a daily basis.

3. The client assists in self-care as much as possible. Rationale: A successful outcome for the problem of self-care is for the client to do as much of the self-care as possible. The nurse should promote independence in the client and allow the client to perform as much self-care as is optimal, considering the client's condition. The nurse would determine that the outcome is unsuccessful if the client refused care or allowed others to do the care.

The nurse is trying to determine the ability of the client with myocardial infarction (MI) to manage independently at home after discharge. Which statement by the client is the strongest indicator of the potential for difficulty after discharge? 1. "I need to start exercising more to improve my health." 2. "I will be sure to keep my appointment with the cardiologist." 3. "I don't have anyone to help me with doing heavy housework at home." 4. "I think I have a good understanding of what all my medications are for."

3. "I don't have anyone to help me with doing heavy housework at home." To ensure the best outcome, clients should be able to comply with instructions related to activity, diet, medications, and follow-up health care on discharge from the hospital after an MI. All of the options except the correct one indicate that the client will be successful in these areas.

The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus? 1. "It connects the pulmonary artery to the aorta." 2. "It is an opening between the right and left atria." 3. "It connects the umbilical vein to the inferior vena cava." 4. "It connects the umbilical artery to the inferior vena cava."

3. Rationale: The ductus venosus connects the umbilical vein to the inferior vena cava. The foramen ovale is a temporary opening between the right and left atria. The ductus arteriosus joins the aorta and the pulmonary artery.

A client receiving tricyclic antidepressants arrives at the mental health clinic. Which observation would indicate that the client is following the medication plan correctly? 1. Client reports not going to work for the past week. 2. Client complains of not being able to "do anything" anymore. 3. Client arrives at the clinic neat and appropriate in appearance. 4. Client reports sleeping 12 hours per night and 3 to 4 hours during the day.

3. Client arrives at the clinic neat and appropriate in appearance. Depressed individuals sleep for long periods, are unable to go to work, and feel as if they cannot "do anything." When these clients have had some therapeutic effect from their medication, they report resolution of many of these complaints and exhibit an improvement in their appearance. Options 1, 2, and 4 identify continued depression.

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? 1. Inhale as rapidly as possible. 2. Keep a loose seal between the lips and the mouthpiece. 3. After maximum inspiration, hold the breath for 15 seconds and exhale. 4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

4 Rationale: For optimal lung expansion with the incentive spirometer, the client should assume the semi Fowler's or high Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly.

On review of the client's record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior? 1. Fearfulness regarding treatment measures 2. Anger and aggressiveness directed toward others 3. An understanding of the pathology and symptoms of the diagnosis 4. A willingness to participate in the planning of the care and treatment plan

4. In general, clients seek voluntary admission. If a client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program since he or she is actively seeking help. The remaining options are not characteristics of this type of admission. Fearfulness, anger, and aggressiveness are more characteristic of an involuntary admission. Voluntary admission does not guarantee that a client understands his or her illness, only the client's desire for help.

The nurse provides dietary instructions to a client with diabetes mellitus regarding the prescribed diet. Which statement, if made by the client, indicates a need for further teaching? 1. "I'll eat a balanced meal plan." 2. "I need to drink diet soft drinks." 3. "I'll snack on fruit instead of cake." 4. "I need to purchase special dietetic foods."

4. "I need to purchase special dietetic foods." Rationale: It is important to emphasize to the client and family that they are not eating a diabetic diet but rather a balanced meal plan. Adherence to nutritional principles is an important component of diabetic management, and an individualized meal plan should be developed for the client. It is not necessary for the client to purchase special dietetic foods.

The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? 1. Gets angry with family if they interrupt a task 2. Experiences bouts of depression and irritability 3. Has difficulty with using modified feeding utensils 4. Consistently uses adaptive equipment in dressing self

4. Clients are evaluated as coping successfully with lifestyle changes after a stroke if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions. Options 1 and 2 are not adaptive behaviors; option 3 indicates a not yet successful attempt to adapt.

The abdomen normally moves with breathing until the age of ____ years. 14 7 75 4

7 Abdominal breathing in children continues until the age of 7 years. Abdominal breathing in children continues until the age of 7 years.

When preparing to complete thorax and lung objective assessment of an infant or child, the nurse should do which of the following? (Select all that apply.) Select all that apply. Allow the caregiver to hold the infant. If infant is sleeping, perform auscultation before doing any other objective assessments. There is no need to change the language you use when telling the young child to breathe in and out. Warm the stethoscope between your hands before placing on the infant. Document a barrel chest shape as expected findings for a 7-year-old child.

Allow the caregiver to hold the infant. If infant is sleeping, perform auscultation before doing any other objective assessments. Warm the stethoscope between your hands before placing on the infant. Allowing the caregiver to hold the infant provides comfort for the infant and may decrease the risk for crying. Seize the opportunity with a sleeping infant to inspect breathing pattern and listen to lung sounds. This allows you to concentrate on breath sounds. Warming the stethoscope prevents involuntary reaction to cold equipment, which can irritate the infant. For young children, you should use easily understood words and help them through what you want them to do. For example, while listening to breath sounds, hold your penlight in front of them, turned on, and tell them to blow it out like they're blowing out birthday candles. A barrel chest shape is normal until age 6, but if persistent after is an indication of chronic asthma or cystic fibrosis.

Which of the following cardiac alterations occurs during pregnancy?

An increase in cardiac volume and a decrease in blood pressure During pregnancy the blood volume increases by 30% to 40%; this creates an increase in stroke volume and cardiac output and an increased pulse rate of 10 to 15 beats per minute. The arterial blood pressure decreases in pregnancy as a result of peripheral vasodilation.

High-pitched fine, short, interrupted crackling sounds heard during end of inspiration; usually not cleared with coughing. Caused by random, sudden reinflation of groups of alveoli; disruptive passage of air through small airways.

Fine Crackles. Medium crackles are lower, moister sounds heard during middle of inspiration; not cleared with coughing. Coarse crackles are loud, bubbly sounds heard during inspiration; not cleared with coughing.

Which of the following actions by the student nurse is indication that he/she does not know the correct method for assessing the carotid artery?

He/she is firmly pressing the bell of the stethoscope over the carotid artery. The student nurse who is firmly pressing the bell of the stethoscope over the carotid artery is performing incorrect procedure that could compress the artery and compromise circulation. In order to correctly assess the carotid arteries, the patient's neck should be in a neutral position; one side should be palpated at a time; and asking the patient to take a breath, exhale, and hold briefly assists so that breathing does not mask or mimic a carotid artery bruit.

The student nurse demonstrates correct technique in using the stethoscope to auscultate heart sounds when he/she does which of the following?

Makes sure earpieces fit snugly and are pointed to their nose. When auscultating, the earpieces of the stethoscope should fit snugly in the examiner's ear canal and they should be aimed forward (toward nose) to avoid air leak. The diaphragm of the stethoscope is used for higher pitched sounds and the bell for lower pitched sounds. It's important to minimize noise in order to be able to appropriately assess sounds with the stethoscope. Heart sounds should be assessed for in 5 locations using a rough Z pattern from the base of the hear across and down and over to the apex.

Dry, rubbing, or grating quality heard during inspiration or expiration; does not clear with coughing; heard loudest over lower lateral anterior surface. Caused by inflamed pleura; parietal pleura rubbing against visceral pleura.

Pleural friction rub

Which of the following is a clinical manifestation in a patient with chronic obstructive pulmonary disease (COPD)? Periodic breathing patterns Prolonged expiration Unequal chest expansion Hyperventilation

Prolonged expiration A person with chronic obstructive lung disease commonly experiences normal inspiration but prolonged expiration to overcome the increased airway resistance. Periodic breathing patterns are Cheyne-Stokes or Biot respirations. Cheyne-Stokes respirations occur in heart failure, renal failure, meningitis, drug overdose, and increased intracranial pressure; this type also normally occurs in infants and older adults during sleep. Biot respirations occur with head trauma, brain abscess, heat stroke, spinal meningitis, and encephalitis. Unequal chest expansion occurs when part of the lung is obstructed or collapsed, as with pneumonia, or with guarding to avoid postoperative incisional pain or pleurisy pain. Hyperventilation is a normal response to fever, fear, or exercise; respiration rate also increases with respiratory insufficiency, pneumonia, alkalosis, pleurisy, and lesions in the pons.

loud, low-pitched, rumbling coarse sounds heard either during inspiration or expiration; sometimes cleared by coughing. Caused by muscular spasms, fluid, or mucus in larger airways; new growth or external pressure causing turbulence.

Rhonchi

Which of the following is an appropriate position to have the patient assume when auscultating for extra heart sounds or murmurs?

Roll toward the left side. After auscultation in the supine position, the nurse should have the patient roll onto the left side; the examiner should listen at the apex with the bell for the presence of any diastolic filling sounds (i.e., S3 or S4) or murmurs that may be heard only in this position. The examiner should have the patient sit up and lean forward; the examiner should auscultate at the base with the diaphragm for a soft, high-pitched, early diastolic murmur of aortic or pulmonic regurgitation.

Which of the following guidelines may be used to identify which heart sound is S1?

S1 coincides with the carotid artery pulse. S1 is loudest at the apex of the heart. S1 coincides with the C wave of the jugular venous pulse wave. S1 coincides with the R wave (the upstroke of the QRS complex).

When auscultating lung sounds, it is important for the nurse to do which of the following? Anterior auscultation should include 9 spots on each side. Quickly move through the assessment to decrease risk for fainting or hyperventilation. Tell the patient to stop the assessment if he/she begins to feel dizzy. Complete assessment of right lung fields then move to auscultate the left lung fields.

Tell the patient to stop the assessment if he/she begins to feel dizzy. It's important to instruct the patient to let you know if they are beginning to feel dizzy during auscultation assessment as this is an early sign of hyperventilating. Must listen to full inspiration and expiration cycle and do not move quickly through the assessment as this will lead to dizziness, hyperventilation, and could cause the patient to faint. Lung sounds must be compared in each spot between both lungs. Listening to all fields in one lung prevents comparison. Anterior auscultation includes 5 spots on each side. Posterior auscultation includes 9 spots on each side.

Which of the following voice sounds would be a normal finding? Whispered "1-2-3" is audible and distinct. The voice transmission is distinct and sounds close to the ear. The whispered sound is transmitted clearly. The "eeeee" sound is clear and sounds like "eeeee."

The "eeeee" sound is clear and sounds like "eeeee." A normal finding from voice sounds is egophony—"eeeee" heard through the stethoscope clearly. A normal finding from voice sounds is bronchophony; normal voice transmission is soft, muffled, and indistinct. A normal finding from voice sounds is whispered pectoriloquy—whispered sound is faint, muffled, and almost inaudible.

Pyrosis is: a burning sensation in the upper abdomen. an abnormally sunken abdominal wall. an inflammation of the peritoneum. a congenital narrowing of the pyloric sphincter.

a burning sensation in the upper abdomen. Pyrosis (heartburn) is a burning sensation in the esophagus and stomach from reflux of gastric acid. Peritonitis is an inflammation of the peritoneum. Pyloric stenosis is a congenital narrowing of the pyloric sphincter. A scaphoid abdomen abnormally caves in or is sunken.

Older adults have: increased gastric acid secretion. increased liver size. decreased incidence of gallstones. abdominal musculature less tone.

abdominal musculature less tone. The abdominal musculature is thinner and has less tone than that of the younger adult. Aging results in decreased gastric acid secretion. Aging results in decreased liver size. Aging results in increased incidence of gallstone formation.

Ascites is defined as: an abnormal accumulation of serous fluid within the peritoneal cavity. a bowel obstruction. an abnormal enlargement of the spleen. a proximal loop of the large intestine.

an abnormal accumulation of serous fluid within the peritoneal cavity. Ascites is free fluid in the peritoneal cavity. A bowel obstruction may result in abdominal distention. The proximal loop of the large intestine is the ascending colon. Splenomegaly is the term to describe an enlarged spleen.

When auscultating the heart of a newborn within 24 hours after birth, the examiner hears a continuous sound that mimics the sound of a machine. This finding most likely indicates

an expected sound caused by nonclosure of the ductus arteriosus. The murmur of a patent ductus arteriosus is a continuous machinery murmur, which disappears by 2 to 3 days.

A water-hammer or Corrigan pulse is associated with: conduction disturbance. hyperkinetic states. aortic valve regurgitation. decreased cardiac output.

aortic valve regurgitation. A water-hammer (Corrigan) pulse occurs in aortic valve regurgitation. A full, bounding pulse is associated with hyperkinetic states (exercise, anxiety, fever). A weak, thready pulse occurs with decreased cardiac output. Pulsus bigeminus occurs with conduction disturbances.

Moles on the abdomen: are common. are uncommon. require a biopsy. are no cause for concern.

are common. Pigmented nevi (moles) are common on the abdomen. Nevi are circumscribed brown macular or papular areas. Nevi should be observed for unusual color or change in shape; biopsy or removal is indicated if nevi change, which indicates a possible malignancy. Pigmented nevi (moles) are common on the abdomen. Nevi are circumscribed brown macular or papular areas. Nevi should be observed for unusual color or change in shape; biopsy or removal is indicated if nevi change, which indicates a possible malignancy.

The symptoms occurring with lactose intolerance include hematemesis. gray stools. bloating and flatulence. anorexia.

bloating and flatulence. Lactose intolerance produces abdominal pain, bloating, and flatulence when milk products are consumed. Gray stools may occur with hepatitis. Hematemesis occurs with stomach or duodenal ulcers and esophageal varices. Anorexia is a loss of appetite and occurs with gastrointestinal disease, as a side effect of some medications, with pregnancy, or with psychological disorders.

The first heart sound (S1) is produced by the

closure of the AV valves. S1 occurs with closure of the atrioventricular valves. The second heart sound (S2) occurs with closure of the semilunar valves. Normally opening of the semilunar valves is silent, but in aortic or pulmonic stenosis, an ejection click may be heard. An ejection click occurs early in systole at the start of ejection because it results from opening of the semilunar valves. A third heart sound (S3) can be heard when the ventricles are resistant to filling during the early rapid filling phase. S3 is heard when the AV valves open and atrial blood first pours into the ventricles.

Pyloric stenosis is a(n): abnormal opening in the pyloric sphincter. congenital narrowing of the pyloric sphincter. inflammation of the pyloric sphincter. abnormal enlargement of the pyloric sphincter.

congenital narrowing of the pyloric sphincter. Pyloric stenosis is a congenital defect causing a narrowing of the pyloric sphincter. Pyloric stenosis is a congenital defect causing a narrowing of the pyloric sphincter.

The gradual loss of intra-alveolar septa and a decreased number of alveoli in the lungs of older adults cause spontaneous atelectasis. decreased dead space. hyperventilation. decreased surface area for gas exchange.

decreased surface area for gas exchange. The histologic changes result in less surface area for gas exchange.

A patient has severe bilateral lower extremity edema. The most likely cause is: Raynaud phenomenon. an aortic aneurysm. heart failure. an infection of the right great toe.

heart failure. Bilateral lower extremity edema is a result of a generalized disorder such as heart failure. An infection of only one extremity would lead to unilateral edema. Raynaud phenomenon does not result in bilateral lower extremity edema. Aneurysms do not cause bilateral lower extremity edema.

The jugular venous pressure is an indirect reflection of the

heart's efficiency as a pump. Jugular venous pressure is a reflection of the heart's ability to pump blood. If the pressure is elevated, heart failure is suspected.

Percussion of the chest is: not influenced by the overlying chest muscle and fat tissue. normal if a dull note is elicited. a useful technique for identifying small lesions in lung tissue. helpful only in identifying surface alterations of lung tissue.

helpful only in identifying surface alterations of lung tissue. Percussion detects only the outer 5 to 7 cm of tissue; it does not penetrate to reveal any change in density deeper than that. An abnormal finding must be 2 to 3 cm wide to yield an abnormal percussion note. Percussion findings (resonant notes) may be modified by a muscular chest wall of an athlete or subcutaneous tissue of an obese person. Resonance is a low-pitched, clear, hollow sound that predominates with percussion of healthy lung tissue.

An increase in the transverse diameter of the chest cage in a pregnant woman is due to a(n) increase in surfactant. increase in estrogen. increase in tidal volume. compensatory increase in respiratory parenchyma.

increase in estrogen. The increase in estrogen level during pregnancy relaxes the chest cage ligaments. This allows an increase in the transverse diameter of the chest cage by 2 cm, and the costal angle widens.

The organ in the right upper quadrant of the abdomen is the: spleen. liver. sigmoid colon. cecum.

liver. The liver is in the right upper quadrant of the abdomen. The spleen is in the left upper quadrant. The cecum is in the right lower quadrant. The sigmoid colon is in the left lower quadrant.

Palpable inguinal lymph nodes are: normal if small (less than 1 cm), movable, and nontender. abnormal and indicate the presence of malignant disease. abnormal in adults but common in children and infants. normal if fixed and tender.

normal if small (less than 1 cm), movable, and nontender. Inguinal lymph nodes may be palpable. This is a normal finding if the nodes are small (1 cm or less), movable, and nontender. Lymph nodes may be relatively large in children, and the superficial ones often are palpable even when the child is healthy. Enlarged, tender, or fixed inguinal lymph nodes are an abnormal finding.

One of the leg's deep veins is the: popliteal. great saphenous. tibial. small saphenous.

popliteal. The femoral and popliteal veins are the deep veins in the leg. The superficial veins are the great and small saphenous veins. The superficial veins are the great and small saphenous veins. The anterior tibial veins extend downward from the popliteal veins.

Methods to enhance abdominal wall relaxation during examination include: positioning the patient with the knees bent. examining painful areas first. having the patient place arms above the head. a cool environment.

positioning the patient with the knees bent. Position the patient supine, with the head on a pillow, knees bent or on a pillow, and arms at the side. Keep the room warm to avoid chilling and tensing of muscles. Avoid having arms above the head; this increases abdominal wall tension. Painful areas should be examined last to avoid muscle guarding.

In young children, the thymus gland: is small and begins to atrophy. produces B lymphocytes. produces T lymphocytes. is not important in immune function.

produces T lymphocytes. In young children, the thymus gland is important in developing the T lymphocytes of the immune system. The thymus is large in the fetus and young children and atrophies after puberty. The thymus has no function in adults. The thymus gland does not produce B lymphocytes.

Lymphedema is: an inflammation of the vein associated with thrombus formation. the swelling of an extremity caused by an obstructed lymph channel. a thickening and loss of elasticity of the arterial walls. the indentation left after the examiner depresses the skin over swollen edematous tissue.

the swelling of an extremity caused by an obstructed lymph channel. Lymphedema is swelling of the limb caused by surgical removal of lymph nodes or damage to lymph nodes and vessels. Pretibial edema (pitting) occurs if an indentation is left after the examiner depresses skin over the tibia or the medial malleolus for 5 seconds. Arteriosclerosis is the thickening and loss of elasticity of the arterial walls. In deep vein thrombosis, a deep vein is occluded by a thrombus, causing inflammation, blocked venous return, cyanosis, and edema.

high-pitched, continuous musical sounds like a squeak heard continuously during inspiration or expiration; usually louder on expiration. Caused by high-velocity airflow through severely narrowed or obstructed airways such as with asthma.

Wheezes

Claudication is caused by: arterial insufficiency. venous insufficiency. stasis ulcerations. varicose veins.

arterial insufficiency. Claudication is caused by arterial insufficiency. Varicose veins are venous in origin. Stasis ulcerations are venous in origin.

Inspiration is primarily facilitated by which of the following muscles? Internal intercostal and abdominis Diaphragm and intercostal Trapezius and sternomastoids Diaphragm and rectus abdominis

Diaphragm and intercostal The major muscle responsible for inspiration is the diaphragm. Intercostal muscles lift the sternum and elevate the ribs, making them more horizontal; this increases the anteroposterior diameter.

Increased tactile fremitus would be evident in an individual who has which of the following conditions? Crepitus Emphysema Pneumothorax Pneumonia

Pneumonia. Fremitus is a palpable vibration. Increased fremitus occurs with compression or consolidation of lung tissue (e.g., lobar pneumonia). Decreased fremitus occurs when anything obstructs transmission of vibrations (e.g., obstructed bronchus, pleural effusion or thickening, pneumothorax, or emphysema). Crepitus is a coarse crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue. Decreased fremitus occurs when anything obstructs transmission of vibrations (e.g., obstructed bronchus, pleural effusion or thickening, pneumothorax, or emphysema).

The nurse has completed a peripheral vascular assessment. Which of the following findings would he or she document as expected findings? Capillary refill <5 seconds. Radial pulses 2+ with regular rate and rhythm bilaterally Right ankle 1+ edema with no perceptible swelling of the leg. Feet pale and cool to touch.

Radial pulses 2+ with regular rate and rhythm bilaterally Radial pulses 2+ indicates normal force/amplitude and should have a regular rate and rhythm in both the right and left arms. Mild pitting edema is 1+. Unilateral edema in the ankles without swelling in the rest of the leg is not a normal finding. Feet should be pink or appropriate for race with capillary refill < 2 seconds in the toes and should not be cool to touch. Cool extremities can indicate decreased perfusion. Normal capillary refill should occur in 1 to 2 seconds.

The ability of the heart to contract independently of any signals or stimulation is due to

automaticity. The heart can contract by itself, independent of any signals or stimulation from the body; this property is termed automaticity. Depolarization is the reversal of the resting potential in excitable cardiac muscle cell membranes when stimulated. Conduction is the process by which an electrical impulse is transmitted through the heart. Repolarization is the process by which the membrane potential of a cardiac muscle cell is restored to the cell's resting potential.

In pulsus paradoxus: the rhythm is regular, but the force of the pulse varies with alternating beats. there is a deficiency of arterial blood to a body part. beats have weaker amplitude with respiratory inspiration and stronger amplitude with expiration. the rhythm is irregular; every other beat is premature.

beats have weaker amplitude with respiratory inspiration and stronger amplitude with expiration. In pulsus paradoxus, beats have weaker amplitude with inspiration and stronger amplitude with expiration. The rhythm is irregular and coupled in pulsus bigeminus; every other beat comes early or premature. A weak, thready pulse may result in a deficiency of arterial blood to a body part. The rhythm is regular in pulsus alternans, but the force varies with alternating beats of large and small amplitudes.

Arteriosclerosis refers to: thickening and loss of elasticity of the arterial walls. a sac formed by dilation in the arterial wall. deposition of fatty plaques along the intima of the arteries. a variation from the heart's normal rhythm.

thickening and loss of elasticity of the arterial walls. Arteriosclerosis is the thickening and loss of elasticity of the arterial walls. A dysrhythmia is a variation from the heart's normal rhythm. An aneurysm is a sac formed by dilation in the artery wall. Atherosclerosis is the deposition of fatty plaques on the intima of the arteries.

A bruit heard while auscultating the carotid artery of a 65-year-old patient is caused by

turbulent blood flow through the carotid artery. A carotid bruit is a blowing, swishing sound indicating blood flow turbulence. A bruit indicates atherosclerotic narrowing of the vessel.

Stridor is a high-pitched, inspiratory crowing sound commonly associated with pneumothorax. upper airway obstruction. congestive heart failure. atelectasis.

upper airway obstruction. Stridor is associated with upper airway obstruction from swollen, inflamed tissues or a lodged foreign body.

The four layers of large, flat abdominal muscles form the ventral abdominal wall. rectus abdominis. viscera. linea alba.

ventral abdominal wall. The four layers of large, flat muscles form the ventral abdominal wall. These muscles are joined at the midline by a tendinous seam, the linea alba. One set of abdominal muscles, the rectus abdominis, forms a strip extending the length of the midline. The viscera are all the internal organs inside the abdominal cavity.