Final Review NR302

A female Latino client turns to her husband when the nurse asks a question about her health. The nurse realizes that this client is demonstrating which type of culture? A.Material B.Nonmaterial C.Competence D.Incomplete

B.Nonmaterial Nonmaterial culture is composed of the verbal and nonverbal language, beliefs, customs, and social structures. Material culture includes things such as dress, art, utensils, and tools and the ways they are used. Competence and incomplete are not types of culture.

A 47-year-old client comes into the clinic requesting information on smoking cessation. According to the Health Belief Model, this client is demonstrating: A.Disease treatment behavior B.Risk reduction behavior C.Cost reduction behavior D.Economic status behavior

B.Risk reduction behavior Within the Health Belief Model, health promotion and risk reduction behaviors are those that will increase client well-being. The focus of the health belief model is prevention of illness, not disease treatment behavior. The individual must weigh the physical and psychological cost versus the benefit. Cost reduction behavior is not an influence in this model. Economic status behavior is not an influence in the Health Belief Model.

A Native American tells the nurse, "The medicine man told me that I am imbalanced and gave me pellets to use every day for three weeks." The nurse realizes this client is describing: A.A health belief B.A dietary habit C.A temporal relationship D.A health practice

D.A health practice One health practice of the Native American is the use of medicine men to diagnose and treat disharmony. Health beliefs are one's beliefs about the causes of health and illness. Dietary habit information is not discussed in the question. Temporal relationships refer to an individual or group's orientation in terms of past, present, or future.

After conducting the health interview, the nurse begins to measure the client's vital signs. The nurse is collecting: A.Subjective data B.Objective data C.Secondary data D.Constant data

B.Objective data Objective data is information that is measured by a professional nurse. It is used to validate subjective data. Subjective data is information obtained from the client during the client interview. Secondary data is from secondary, not primary, sources. Constant data is information that will not change, such as age and race.

A female Chinese client states, "I will say nothing until my husband comes from parking the car." The nurse realizes this client is demonstrating: A.A temporal relationship B.A health belief C.A family pattern D.A health practice

C.A family pattern The family pattern within Chinese Americans is one of male dominance. Family patterns include role and relationship patterns within a family. Temporal relationship refers to time orientation (past, present, future). Health beliefs include magico-religious, biomedical, and holistic beliefs. Health practices are influenced by the individual's health beliefs, knowledge, and culture.

A client comes into the clinic with acute right lower quadrant abdominal pain. During the abdominal assessment of this client, the nurse realizes that: A.This area should be palpated first. B.This area should be palpated last. C.This area should be assessed using deep palpation techniques. D.This area should not be palpated.

B.This area should be palpated last. Known-painful areas of the body are usually the last areas to be palpated. Deep palpation should be used with caution, especially if one suspects that there is inflammation, peritonitis, or ectopic pregnancy. The area should be assessed using light to moderate palpation.

During a clinic visit, a school-age child tells the nurse he has no real interests and his parents are rarely home. The nurse realizes that this child might be at risk for: A.A disturbed parent-child relationship B.For gang recruitment C.Study time conflicts D.Environmental deprivation

D.Environmental deprivation Children who lack hobbies or cannot think of any accomplishments may be environmentally deprived. Caregivers who speak negatively about their child likely have a disturbed parent-child relationship. These children are at risk for gang behavior and drug use. This child is not demonstrating study time conflicts.

The nurse is documenting the findings from a health assessment. Which of the following demonstrates the documentation of subjective information? A."It hurts when I put weight on my leg." B.Abdomen soft and nontender to palpation C.Blood pressure 110/68 D."Pulses present in lower extremities"

A."It hurts when I put weight on my leg." When documenting subjective data, quotes are to be used. Subjective data is information obtained from the client during the interview. It is information that the client states to the nurse. Abdomen, soft and nontender is objective data. Objective data is assessment data obtained by the nurse. Blood pressure 110/68 is an example of objective data. "Pulses present in lower extremities" is incorrect use of quotes in the documentation of objective data.

The nurse notices that a client has extremely dry and brittle hair. Which of the following questions would be the most appropriate to ask this client? A."What do you use to style your hair?" B."Are you exposed to excessive sunlight?" C."What medications are you taking?" D."Do you have a history of thyroid problems?"

A."What do you use to style your hair?" Excessive washing or washing with harsh chemicals can dry the hair. The use of styling products can dry or damage the hair as can the use of hair dryers, curling irons, and heated rollers. Sunlight, medications, and thyroid disease all can cause changes in the texture of the hair. However, they are not the most common cause of dry, brittle hair.

A Cuban American client tells the nurse, "The remedy didn't work so I am here to find more help." The nurse realizes this client is demonstrating: A.A health belief B.A health practice C.A dietary habit D.A temporal relationship

A.A health belief The health beliefs of many Cuban Americans include the use of herbs, rituals, and ceremonies to diagnose and cure illnesses. Health practices are influenced by an individual's health beliefs as well as culture and knowledge. Dietary habit information is not discussed in the question. Temporal relationships refer to an individual's or group's orientation in terms of past, present, or future.

A client tells the nurse, "I recently had a family member in the hospital for three weeks and can't tell you the last time I ate dinner." The nurse realizes that this client might be experiencing: A.A negative impact of stress on her health B.An extreme level of physical fitness C.High self-concept D.Low self-esteem

A.A negative impact of stress on her health During periods of stress or change, individuals are less likely to attend to habits that promote health such as eating nutritious meals or following an exercise routine. Alterations in eating patterns do not relate to an extreme level of physical fitness or high self-concept. This client's comments demonstrate response to stress, not low self-esteem.

The client tells the nurse, "I can't tell my mother that my children take riding lessons because she doesn't think children should do this." The nurse realizes that this client might be demonstrating: A.Altered role development B.Altered self-concept C.Altered body image D.Altered self-esteem

A.Altered role development Individuals who have experienced family stress have conflicting views of role expectations or are unclear on social norms. They often experience frustration or a sense of inadequacy associated with fear or negative judgment from others if their performance is not in accordance with expectations for new or changing roles. Self-concept refers to the beliefs and feelings one holds about oneself. Body image is the way one thinks about physical appearance. Self-esteem refers to an individual's sense of worth or self-respect.

During the course of an assessment, the nurse learns that the client smokes. Which of the following clinician guidelines for smoking cessation did the nurse implement? A.Ask B.Accommodate C.Assist D.Arrange

A.Ask The guidelines for smoking cessation include the five As: ask, advise, assess, assist, and arrange. This nurse was doing an assessment and therefore was asking about smoking. The five As should be implemented as follows: 1. Ask about smoking at every health visit. 2. Advise (that is, urge) all smokers to stop. 3. Assess the client's willingness to stop. 4. Assist or aid the client in quitting. Work with the client to develop a plan to quit while providing counseling, recommending pharmacotherapy, and providing resource materials. 5. Arrange for follow-up to determine progress or the need for further assistance.

A male client tells the nurse, "I have to make sure my parents don't find out about my friends and what I do after school. It would be disgraceful." The nurse realizes this client is demonstrating: A.Assimilation B.Diversity C.Race D.Ethnocentrism

A.Assimilation Assimilation refers to the adoption and incorporation of characteristics, customs, and values of the dominant culture by those new to that culture. Assimilation occurs more easily in second-generation immigrants. Diversity is the state of being different. Race refers to the identification of an individual or group by shared genetic heritage and biological and physical characteristics. Ethnocentrism is the tendency to believe that one's own beliefs are superior to those of others.

During the health assessment of a 79-year-old female client, the nurse learns the client used to bowl and play cards with her friends. Because of chronic back pain, the client now spends most of her time in isolation. Which of the following might be an appropriate intervention for the nurse to make? A.Discuss various pain control options with the client. B.Recommend the client goes to the bowling alley and participates until inhibited by the pain. C.Find out the different types of card games that she knows. D.Identify activities that the client likes to participate in, such as dancing.

A.Discuss various pain control options with the client. Pain may be preventing this client from socializing and being active as she had been in previous years. Until the client's pain is manageable, discussing past activities and health promotion is not appropriate. The priority is pain management.

The nurse is planning to assess a client's level of self-concept. Which of the following questions would the nurse ask to gather this information? A.Do you like to be alone? B.Can you describe your chronic illnesses? C.Do you use alcohol or drugs? D.Do you have an eating problem?

A.Do you like to be alone? Clients with a positive self-concept enjoy spending time by themselves, but those who indicate that they would rather be alone most of the time may be experiencing emotional problems. Questions about any chronic illnesses, use of alcohol and drugs, and eating disorders are all important questions to ask in a psychosocial assessment, but are not specific to self-concept.

A nurse is working in a community health center teaching wellness classes based on Healthy People 2020. The goal of these classes is: A.Elimination of preventable diseases and promotion of healthy behaviors B.Increasing length and quality of life C.Identification of health indicators D.Changing social environments

A.Elimination of preventable diseases and promotion of healthy behaviors Elimination of preventable diseases, disability, injury, and premature death; achieving health equity; and creating environments that promote good health and healthy development and behaviors across the life span are the goals of Healthy People 2020. Increasing the length and quality of life was a goal of Healthy People 2010. Identification of leading health indicators was the focus of Healthy People 2010. Changing the social environment may play a role in the implementation of Healthy People 2020, but is not an overall goal.

A client has an area of inflammation due to a localized infection. Which of the following assessment findings is the nurse most likely to note on examination? A.Erythema B.Pallor C.Cyanosis D.Absence of color

A.Erythema Erythema, or increased redness of the skin, is due to hyperemia, which causes dilation and congestion of blood in superficial arteries. This can be due to fever, localized inflammation, emotions, or a warm environment. Pallor, or loss of color of the skin due to the absence of oxygenated hemoglobin, can be caused by peripheral vasoconstriction. Cyanosis, the mottled blue color of the skin, is due to inadequate tissue perfusion with oxygenated blood. Vitiligo is the absence of melanin pigment in patchy areas on the body.

During a clinic visit, the nurse notices that a mother of a three-month-old infant does not look at the baby and doesn't smile or talk to the infant. The nurse realizes that this behavior might be an indication of: A.Failure to engage B.Healthy attachment C.Negative response mechanism D.Normal infant behavior

A.Failure to engage Failure to engage an infant through eye contact, conversation, or smiles limits opportunities for the caregiver to receive positive feedback from the infant. The infant finds efforts to engage the parent frustrating, leading to decreased attempts to interact. A negative pattern is quickly established. This behavior doesn't exhibit healthy attachment, positive response, or normal behavior.

The mother of an infant is distressed because her "baby has such a bad complexion with all of those whiteheads on her face." Which of the following would be an appropriate response for the nurse to make to this client? A."This is baby acne that will disappear soon." B."This is called milia and will disappear in a few weeks." C."These are Mongolian spots and will usually disappear at about one year of age." D."This is called lanugo and will disappear in a few months."

B."This is called milia and will disappear in a few weeks." ilia are tiny white facial papules and usually disappear spontaneously within a few weeks of birth. Milia are due to sebum that collects in the openings of the hair follicles and are not baby acne. Mongolian spots are gray, blue, or purple spots on the sacral and buttocks area of newborns. Lanugo is the fine, downy hair of the newborn that is replaced within a few months by vellus hair.

The nurse is assessing a client's smoking behavior. During the interview, the nurse learns that the client wants to stop smoking but needs help with this behavior change. Which nursing theory would best support the care this client needs? A.Health promotion model B.Ecologic model C.Clinical model D.Eudaemonistic model

A.Health promotion model In the health promotion model, health is the actualization of inherent and acquired human potential through goal-directed behavior. This client is requesting help to change behaviors, which exemplifies goal-directed behavior change. The ecologic model examines the interaction of agent, host, and environment. Health is present when these three variables are in harmony. When harmony is disrupted, illness and disease occur. In the clinical model, health is the absence of disease, and the aim of care by the health professional is to relieve signs and symptoms of the disease. The eudaemonistic model views health as the actualization of a person's potential.

The nurse is preparing to use a stethoscope while assessing a client. The bell is going to be placed on the client. Which of the following would the nurse assess with the bell of the stethoscope? A.Heart murmur B.Lung sounds C.Normal heart sounds D.Abdominal sounds

A.Heart murmur The bell detects low-frequency sounds such as heart murmurs. Lung sounds, normal heart sounds, and abdominal sounds are all considered high-pitched sounds and would be assessed using the diaphragm of the stethoscope.

The nurse is preparing to assess a 55-year-old female. Which of the following will the nurse do first? A.Inspection B.Percussion C.Palpation D.Auscultation

A.Inspection Inspection always precedes the other assessment skills and is never rushed. The order of assessment techniques is: inspection, palpation, percussion, and auscultation, except when assessing the abdomen, where the techniques are inspection, auscultation, percussion, and palpation.

A flat lesion measuring less than 1.0 cm would be classified as a: A.Macule B.Papule C.Patch D.Plaque

A.Macule A macule is a flat lesion, less than 1.0 cm. Papules are raised lesions less than 0.5 cm. Patches are flat lesions greater than 1.0 cm. Plaques are elevated lesions greater than 0.5 cm.

The nurse notes that a client's nails have a slight convex curve with the angle from the skin to the nail base about 160 degrees. What condition of the client's nails is this nurse seeing? A.Normal nails B.Clubbing of the nails C.Spoon nails D.A fungal infection of the nails

A.Normal nails Normal nails form a slight convex curve or lie flat on the nail bed. When viewed laterally, the angle between the skin and the nail base should be approximately 160 degrees. Clubbing is present when the angle of the nail is 160 degrees or greater. This condition is present when there is hypoxia over a long period of time. Spoon nails form a concave curve and are associated with iron deficiency. A fungal infection of the nails would present with separation of the nail from the nail bed and thickened, yellow nails.

A client with cardiovascular disease is being seen at the clinic. The nurse anticipates that which of the following immunizations may be needed in this individual? Select all that apply. A.Pneumococcal B.Tetanus C.Hepatitis B D.Influenza

A.Pneumococcal D.Influenza A client with a chronic disease such as cardiovascular disease should receive influenza and pneumococcal vaccines. These immunizations are recommended for individuals with chronic disorders of the cardiovascular or pulmonary systems, renal or hepatic dysfunction, immunocompromised conditions, and diabetes. Tetanus immunization is recommended for those at risk for the development of tetanus, possibly through a cut or wound. Hepatitis B is transmitted via blood and body fluids and is not recommended in this client's condition.

While in the clinic, the nurse instructs a client about immunizations. In which level of prevention is this nurse providing care? A.Primary B.Secondary C.Tertiary D.Restorative

A.Primary Primary prevention implies health and a high level of wellness for the individual. Immunizations, health diet, health teaching, and workplace safety are all primary prevention strategies. In secondary prevention the emphasis is on resolving health problems and preventing serious consequences. Screenings, blood tests, and dental care are all examples of secondary prevention. Tertiary prevention is aimed at restoring the individual to the highest possible level of health and functioning. Rehabilitation is the focus for tertiary prevention. Restorative is not a level of prevention.

Prior to measuring a client's height and weight, the client states, "I am 5 feet 10 inches tall and weigh 160 pounds." Upon assessment, the nurse finds the client is shorter and weighs 15 pounds more. What can the nurse surmise from this finding? A.The client might have a self-image disturbance. B.The client is lying. C.The client is embarrassed about his/her weight. D.The client hasn't been weighed or measured in a long time.

A.The client might have a self-image disturbance. Discrepancies between the stated height and weight and the actual measurements may provide clues to the client's self-image. Not enough information is provided to determine if the client is lying, is embarrassed about their height and weight, or has not had a height and weight assessment recently. Discrepancies in weight may also indicate the client's lack of awareness of sudden weight change that may be due to illness.

The nurse notices a slightly musky odor during the interview of a 14-year-old teenager. Which of the following could explain this odor? A.This is normal functioning of the apocrine glands. B.This is normal functioning of the eccrine glands. C.This is normal functioning of the dermis. D.This is normal functioning of the hypodermis

A.This is normal functioning of the apocrine glands. Apocrine glands are found in the axillary and anogenital regions. They are dormant until the onset of puberty. When apocrine sweat mixes with bacteria on the skin surface, it assumes a musky odor. The eccrine glands produce clear perspiration made up of water and salts. The dermis contains a variety of structures including nerves, blood vessels, lymphatic vessels, hair follicles, and sweat and oil glands. The hypodermis is the subcutaneous tissue that stores fat cells.

The nurse is preparing to conduct a physical assessment on a 20-year-old male client with a gaping wound on his right forearm. Which of the following should the nurse do before beginning this examination? A.Wash hands B.Put on goggles C.Put on a sterile gown D.Put on a face mask

A.Wash hands The first thing that the nurse should do before beginning the physical examination of any client is to wash the hands. The other items are not necessary for the examination of this client.

The staff on a rehabilitation unit is attending an educational session to review the newest treatment options for clients with knee injuries. This program is most likely being presented by: A.A nurse researcher B.A clinical nurse specialist C.A nurse practitioner D.A nurse administrator

B.A clinical nurse specialist Clinical nurse specialists have advanced education and degrees in a specific aspect of practice. They provide direct client care, direct and teach other team members providing care, and conduct nursing research within the area of specialization. The nurse researcher identifies problems regarding client care, designs plans of study, develops tools, analyzes findings, and disseminates knowledge. Nurse practitioners provide client care independently in a variety of settings. Nurse administrators have a variety of responsibilities including staffing, budgets, client care, and consulting.

A female client tells the nurse, "I see how people look at me with my crooked back and short leg. No one has to tell me that I'm not pretty." The nurse realizes this client is exhibiting: A.A well-developed self-concept B.A low self-concept C.An overactive imagination D.An overinflated self-esteem

B.A low self-concept Repeated responses of a positive or negative nature can impact one's developing self-concept and self-esteem as well as overall behavior and interaction with others. This client has had negative responses to her physical appearance and therefore is exhibiting low self-concept. A person with a well-developed self-concept has a positive body image and self-esteem. This client is not demonstrating an overactive imagination or overinflated self-esteem.

A client tells the nurse that he started an exercise program because he believes it will help with cholesterol control. The nurse realizes this client is demonstrating which variable of the reasoned action/planned behavior theory? A.Subjective norms B.Attitudes C.Self-efficacy D.Intention

B.Attitudes This client is demonstrating the variable of attitudes. Attitude refers to the value of a behavior. The theory of reasoned action/planned behavior holds that the intention to perform a behavior is a determinant in the performance of the behavior. Three variables affect the intention to perform a behavior: subjective norms, attitudes, and self-efficacy. Subjective norms refer to what others will perceive about the changed behavior. Self-efficacy refers to a person's ability to perform the behavior. Intention is not a variable in this model.

A Spanish-speaking client needs educational materials about hepatitis. Which of the following would be the best action for the nurse to take to help this client? A.Provide the client with the instructions written in English. B.Contact an interpreter to read the printed English instructions to the client in Spanish. C.Tell the client that instructions do not exist for that health problem. D.Determine that the client does not need the information.

B.Contact an interpreter to read the printed English instructions to the client in Spanish. According to the National Standards for Culturally and Linguistically Appropriate Services in Healthcare, Standard 6 states that all clients with limited English proficiency (LEP) are to be provided access to bilingual staff or interpretation services. The instructions are not available written in Spanish, so the next best thing is to ask an interpreter to read the English instructions to the client in Spanish. Providing the instructions in English, telling the client that instructions are not available for that health problem, or deciding that the client doesn't need this information are not appropriate nursing actions in this situation.

During an admission assessment on a 79-year-old client, the nurse learns the client has been taking four different medications, all for the same health condition. What should the nurse do with this information? A.Document it in the medical record. B.Contact the primary care physician. C.Send an order for the medications to the pharmacy. D.Nothing. This is typical for clients in this age range.

B.Contact the primary care physician. Older adults often consume several prescription medications. Overmedication may occur because older adults seek care from multiple health care providers without collaboration regarding treatment. Multiple medications for the same condition may combine to produce dangerous side effects. The nurse would document the medications in the medical record; however, the priority intervention is to call the physician and verify that they are aware of the situation. Sending an order to the pharmacy and doing nothing are not appropriate. The nurse needs more information about the prescribed medications.

A 27-year-old female is scheduled to be seen in the clinic for a routine health checkup. Which of the following can the nurse anticipate will be provided during this health appointment? A.Counseling on injury prevention B.Counseling on diet and exercise C.Counseling on daily fluoride supplement D.Receive second MMR vaccination

B.Counseling on diet and exercise Interventions for periodic health examination for ages 25 to 64 years include counseling on diet and exercise. The other options are for periodic health examination for ages 11 to 24 years. Counseling on injury prevention, fluoride supplementation and MMR vaccinations are appropriate for younger clients.

The nurse is looking at the information collected during the health interview in an effort to cluster or group the data together. The nurse is demonstrating which phase of the nursing process? A.Assessment B.Diagnosis C.Planning D.Evaluation

B.Diagnosis After the data is collected, the nurse uses critical thinking skills to cluster, or group together, data in order to create a nursing diagnosis. Assessment is the first step of the nursing process and includes the collection, organization, and validation of the subjective and objective data. In the planning phase of the nursing process the nurse is setting priorities, stating client goals, and selecting nursing interventions. The final step of the nursing process is evaluation. The nurse compares the present client status to achievement of the stated goals or outcomes.

The nurse is observed talking rudely to a client of a non-American culture. When approached about this behavior, the nurse responds, "These people should stay in their own country." This nurse is demonstrating: A.Competent cultural care B.Ethnocentrism C.Material culture D.Nonmaterial culture

B.Ethnocentrism Ethnocentrism is the tendency to believe that one's own beliefs, way of life, values, and customs are superior to those of others. This can interfere with collection and interpretation of data as well as the development of plans of care to meet client needs. Competent cultural care includes understanding and planning for the needs of culturally diverse clients or groups. Material culture includes objects such as art and dress. Nonmaterial culture is composed of language, beliefs, customs, and social structures.

The parents of a 14-year-old male teenager are complaining about their child's behavior problems. Which of the following assessment tools might the nurse discuss with the parents to assess this teenager? A.Ages and Stages Questionnaire B.Eyeberg Child Behavior Inventory C.Family Psychosocial Screening D.The Child Development Inventory

B.Eyeberg Child Behavior Inventory The Eyeberg Child Behavior Inventory is a parent report scale of conduct problem behaviors in children ages two to 16 years. The Ages and Stages Questionnaire covers developmental, gross, and fine motor skills and problem solving. The Family Psychosocial Screening identifies developmental problems related to parental history of physical and substance abuse. The Child Development Inventory is for children up to the age of 6.

During the health interview, the nurse observes the client jumping from topic to topic, unable to finish a thought. The nurse realizes that this client is demonstrating: A.Circumlocution B.Flight of ideas C.Neologisms D.Clanging

B.Flight of ideas Flight of ideas is the jumping from one subject to another. Circumlocution is the inability to communicate an idea due to numerous digressions. Neologisms consist of new words that have symbolic meaning to the client. Clanging is a rhyming conversation.

A male client who is 10 pounds overweight has been advised by his health care provider to begin a moderately intense exercise program. For which activities can the nurse provide instruction for this client? A.Jogging B.Golf C.Running D.Mountain climbing

B.Golf Golf is considered a moderately intense physical activity. Other moderately intense activities include walking, hiking, stationary cycling, and recreational swimming. Jogging, running, and mountain climbing are classified as vigorously intense activities.

A client complaining of a sore elbow is being assessed by the nurse. Which of the following would help the nurse assess this client? A.Skin-fold calipers B.Goniometer C.Penlight D.Reflex hammer

B.Goniometer A goniometer measures the degree of joint flexion and extension. Skin-fold calipers are used to determine body fat. A penlight is used to examine the pupils, mouth, and pharynx. A reflex hammer is used to assess deep tendon reflexes.

During the health interview, the client mentions that she is "very stressed about her home situation." The nurse sees this information as impacting the client's level of pain control. Which approach is the nurse using during the health interview? A.Cultural B.Holistic C.Developmental D.Communication

B.Holistic The nurse is considering more than the physiologic health status of the client. Holism includes all factors that impact the client's physical and emotional well-being. There is no information in the question that links the client's culture and home situation with pain. The developmental level has an impact on health assessment. However, there is no information in the question that links the client's developmental level and home situation with pain. Communication refers to the exchange of information.

When performing an assessment the nurse tells the client, "Push with both arms against my hands so that I can compare the strength of your right and left arms." The nurse is demonstrating an example of: A.Formal teaching B.Informal teaching C.Learning needs D.Goal identification

B.Informal teaching Informal teaching occurs as a natural part of a client encounter. This type of teaching may be to provide instructions, to explain a question or procedure, or to reduce anxiety. Formal teaching occurs in response to an identified learning need of a client or group. Teaching plans are developed for formal teaching sessions. Identification of learning needs, or knowledge deficits, is the first step in the formal teaching process. The goal of formal teaching is a broad statement of the expected outcome of the learning process.

The nurse begins to document approximately three hours after completing the health and physical assessment of a client admitted with acute right lower quadrant abdominal pain. Which of the following might be true about this documentation? A.It will be highly accurate because the nurse has had more time to interact with the client. B.It may not be as detailed due to the time that has elapsed since the assessment. C.It will be focused and concise. D.It will be thorough and complete.

B.It may not be as detailed due to the time that has elapsed since the assessment. Documentation of data collected in a health assessment should be completed as soon as possible. With the delay of three hours, there is a chance that the information will not be highly accurate, focused, concise, thorough, or complete. Ideally, the nurse should document sooner than three hours after the assessment.

During the assessment of a preschooler the nurse notices that the child clings to his mother and won't make eye contact. The nurse recognizes this behavior might be an indication of: A.Poor communication skills B.Lack of trust development C.Fear and guilt D.Total detachment

B.Lack of trust development A clinging, frightened preschooler in a nonthreatening situation may be a child who lacks trust. The child is not demonstrating lack of communication skills, fear, guilt, or detachment.

A Vietnamese American is two hours late for her clinic appointment and tells the nurse, "I wrote down one when the person on the phone told me to write down one. When she said it two times I thought she was just making sure I got the number right." The nurse realizes this miscommunication error is an example of: A.A health belief B.Language difference C.Nonverbal communication D.A health practice

B.Language difference Language differences can result in the inability to make telephone contact and to understand dates, times, and locations for appointments. Health beliefs are one's beliefs about the causes of health and illness. Nonverbal communication consists of gestures, facial expressions, and mannerisms that occur during interactions with others. Health practices are what the individual does to promote health. They are influenced by health beliefs, knowledge, and culture.

During the spiritual assessment, the nurse asks the client what spiritual practices are most helpful to him. Within the HOPE assessment, the nurse is assessing this client's: A.H: Spiritual resources B.O: Organized religion C.P: Personal spirituality D.E: Effects on care

B.O: Organized religion The HOPE questions are used as a formal spiritual assessment in the client interview. Under the O for Organized religion, the questions include: "Are you a member of an organized religion? What religious practices are important to you?" "H" refers to spiritual resources. "P" includes personal spiritual practices. "E" refers to the effects of health care and end-of-life care.

The nurse is instructing a client about the need to reduce fat intake in his diet. The client doesn't feel that he will be successful and "won't stick with a lower-fat diet." Using Pender's health promotion model, the nurse identifies that the client is demonstrating which of the following variables? A.Perceived benefits of action B.Perceived self-efficacy C.Perceived barriers to action D.Activity-related affect

B.Perceived self-efficacy Perceived self-efficacy is a judgment of one's ability to successfully participate in a health-promoting activity to achieve a desired outcome. Perceived benefits of action are determined by the belief that the behavior is beneficial or results in a positive outcome. Health promoting behavior is the expected behavioral outcome. Perceived barriers to action include perceptions about expense, convenience, difficulty, and time required for the activity. Activity-related affect refers to subjective feelings before, during, and after an activity.

The nurse is assessing a baby and notices that the individual fingers do not always move independently. Which principle of growth and development is this nurse seeing? A.Cephalocaudal B.Proximal-to-distal C.Simple-to-complex D.Generalized-to-specific

B.Proximal-to-distal Growth and development occur in a proximal-to-distal direction, for example, learning to use the whole hand before controlling individual fingers. Cephalocaudal development is a head-to-toe direction. Generalized-to-specific or simple-to-complex development requires integrated movement such as putting something in the mouth.

An adult client is being seen in the emergency department after a motor vehicle crash. Which of the following immunizations might this client need? A.Influenza B.Tetanus booster C.Hepatitis A D.Varicella

B.Tetanus booster Adults should have a one-time dose of Tdap, then a tetanus (Td) booster every 10 years. Since this client was in a motor vehicle accident, the need for a tetanus booster is evident. Influenza vaccines are recommended annually for the prevention of seasonal influenza. Hepatitis A is primarily transmitted via the fecal/oral route. An individual in a car accident is not at increased risk of developing Hepatitis A. Varicella (chicken pox) vaccine is not indicated in this situation.

The nurse notices that a client being seen in the clinic for advancing upper lateral chest and back pain has a rash in a straight line. Which of the following would be appropriate for the nurse to document about this finding? A.The client has a polycyclic lesion. B.The client has a zosteriform lesion. C.The client has an annular lesion. D.The client has a grouped lesion.

B.The client has a zosteriform lesion. Zosteriform lesions are arranged in a linear manner along a nerve route. Polycyclic lesions are circular but united. An annular lesion is circular in shape. Grouped lesions are lesions that appear in clusters.

The nurse notices flat, red, minute hemorrhages over a client's hands, arms, and face. Which of the following might be an appropriate question for the nurse to ask this client? A."Have you been drinking adequate amounts of fluids?" B."Tell me about your calcium intake." C."Are you taking anticoagulant medications?" D."Your blood pressure medication likely caused these spots."

C."Are you taking anticoagulant medications?" Petechiae are flat red or purple rounded "freckles" approximately 1 to 3 mm in diameter. They are minute hemorrhages that can be caused by anticoagulant therapy, vitamin C or K deficiency, liver disease, or septicemia. Fluid intake might be related to dehydration or edema. Calcium intake does not have an effect on this skin condition. Antihypertensive medications do not affect the development of petechiae.

During a physical assessment, the nurse notices several small scabs along the inner aspects of both of the client's lower extremities. Which of the following would be appropriate for the nurse to say to this client? A."You really did a job on yourself while shaving!" B."Are you in an abusive situation at home?" C."Can you tell me what caused all of these scabs on your legs?" D."Those scabs look painful. What happened to you?"

C."Can you tell me what caused all of these scabs on your legs?" The nurse is identifying a physical cue that is present during the physical examination. The nurse is attempting to validate the finding, without assuming the cause of the cue. In this case, the nurse is gathering more information about the cause of the scabs. The other options represent assumptions on the nurse's part as far as the cause of the lesions.

The father of a two-year-old toddler is concerned that the child is showing no interest in the new tricycle he bought for him. Which of the following would be an appropriate response for the nurse to make to this parent? A."I would be concerned since riding a tricycle is something that should be done by age 15 months." B."I would not be concerned since riding a tricycle is something that is done around age five." C."I would not be concerned since riding a tricycle is something that is done around age three." D."I would be concerned since riding a tricycle is something that should be done immediately after learning to walk."

C."I would not be concerned since riding a tricycle is something that is done around age three." Gross and fine motor development continues through the toddler years. By three years of age, the child should be able to ride a tricycle.

An elderly client tells the nurse that she is worried about dark freckles on her hands and arms. Which of the following can the nurse say to this client? A."This is a cutaneous tag and is something to tell the doctor about." B."This is a cutaneous horn, which will need further evaluation." C."These are senile lentigines and are completely normal." D."This is a cherry angioma and is a normal change of aging."

C."These are senile lentigines and are completely normal." Senile lentigines look like hyperpigmented freckles and are commonly found on the backs of the hands and the arms. Cutaneous skin tags are common in the elderly and occur on the neck and upper chest (Figure 11.9). Cutaneous horns occur on the face (Figure 11.10). Cherry angiomas are small, red spots common in older adults.

A 79-year-old male client tells the nurse, "I swim with my friends three days a week, attend lodge meetings, and go to church when I'm not shopping, cooking, and cleaning." The nurse responds: A."You might need some cognitive stimulation." B."Have you had your eyes checked for night vision changes?" C."You must have been an active man when you were younger." D."Maybe you would like to talk to your health care provider about your feelings of being rushed?"

C."You must have been an active man when you were younger." The lifestyle of later years is often formulated in youth. The person who was once gregarious and spent time with people will continue to do so. The alternate responses are not appropriate in this situation. This client is active and doesn't report problems with vision or feelings of being rushed.

The mother of a three-month-old is concerned that her baby is not yet able to sit up alone. An appropriate response for the nurse to make to this mother would be: A."You are seeing a delay of development that could indicate an abnormality in your child." B."Let me speak with the health care provider about referring your baby for a hearing examination." C."Your baby is still too young to be able to do that alone." D."Your baby will need to try to walk before being able to sit up alone."

C."Your baby is still too young to be able to do that alone." Developmentally, sitting alone does not occur until approximately age eight months. This baby is too young for the mother to expect this level of functioning. The baby is not demonstrating an abnormality.

During the assessment of an Arab American client, the nurse is told, "I am sick because that man on the bus gave me the evil eye." The nurse realizes this client is demonstrating: A.A temporal relationship B.A communication pattern C.A health belief D.A health practice

C.A health belief Within the Arab American culture, one health belief is that illness is caused by the evil eye. This is an example of a magico-religious belief system. A temporal relationship refers to time orientation such as past, present, or future. Health practices are influenced by health beliefs, knowledge, and culture. Communication patterns refer to verbal and nonverbal communication methods.

A 68-year-old client tells the nurse, "I will not worry about getting sick because it is all in God's will." The nurse realizes this client is demonstrating: A.A holistic health belief B.A temporal relationship C.A magico-religious health belief D.A biomedical health belief

C.A magico-religious health belief In a magico-religious belief system, health and illness are believed to be controlled supernaturally or are seen as "God's will." In a holistic health belief system, one holds that human life must be in harmony with nature and that illness results from disharmony between the two. The biomedical health belief model considers illness to be caused by physiological processes. Temporal relationships relate to the individual's past, present, and future orientation.

During a health interview, the client states that she becomes increasingly short of breath when sitting in city traffic. The nurse views this information as: A.A cultural factor B.An internal environmental factor C.An external environmental factor D.An emotional factor

C.An external environmental factor External factors include but are not limited to inhaled toxins, including smoke, chemicals, and fumes; irritants that can be inhaled, ingested, or contacted through the skin; and noise, light, motion, and any objects or substances one may encounter in the home, schools, or workplaces, or while shopping, traveling, or carrying out normal activities. Cultural factors impact language, expression, emotional and physical well-being, and health practices. Internal environmental factors include emotional state, response to medication and treatment, and physiological alterations. Emotional factors include things such as anxiety and depression.

The nurse notes the presence of vitiligo on the neck and forearms of an African-American client. Which of the following is most appropriate for the nurse to do in this situation? A.Nothing since this is a normal finding. B.Document the presence of a skin rash. C.Ask the client how long their skin color has been different in these areas. D.Discuss the client's feelings regarding the skin discoloration.

C.Ask the client how long their skin color has been different in these areas. Patchy depigmented areas over the face, neck, hands, feet, and body folds are termed vitiligo. This can occur in all races but seems to occur more often in dark-skinned people. This condition has no known cause but can create severe body image disturbances in clients with the condition. The nurse should discuss the vitiligo and document its presence. Discussing the client's feelings about the skin discoloration does not take precedence over obtaining information about the symptom.

A client in the clinic begins to cry and pace around the room while waiting to be seen. Which of the following approaches would be most appropriate for the nurse to implement at this time? A.Review the client's medical record. B.Review the client's current medical problems. C.Begin a psychosocial focused interview. D.Begin a HOPE assessment.

C.Begin a psychosocial focused interview. The nurse conducts an interview focused on psychosocial well-being when the client's behavior during the initial interview is anxious, depressed, erratic, or bizarre. The nurse may review the medical record and current medical problems after conducting the psychosocial interview, which is the priority intervention in this situation. A HOPE assessment is used to gather data for a spiritual assessment.

A client reports that they consume large quantities of carrots on a routine basis. Which of the following physical findings is the nurse most likely to observe during the assessment? A.Pallor B.Cyanosis C.Carotenemia D.Jaundice

C.Carotenemia Carotenemia is a yellow-orange tinge due to ingestion of foods high in carotene such as carrots. Pallor is the loss of color in the skin due to the absence of oxygenated hemoglobin. Cyanosis is a blue color in the skin due to inadequate tissue perfusion with oxygenated blood. Jaundice is a yellow undertone due to increased bilirubin in the blood.

A client with diabetes tells the nurse that they have been feeling sad and are experiencing sleep difficulties. Which of the following is the most appropriate action for the nurse to take in this situation? A.Ask about a history of substance abuse B.Obtain information about how the client has been managing his diabetes C.Complete a depression screen D.Discuss techniques to help facilitate sleep

C.Complete a depression screen The nurse should screen for depression, which may coexist with other chronic diseases such as diabetes. Obtaining information about substance abuse and how the client manages his diabetes is important; however, the client is demonstrating signs of potential depression, and this should be evaluated first. Discussion of sleep techniques may also be discussed, but obtaining information about depression is the first action by the nurse.

After auscultating the bowel sounds of a client, the nurse realizes the sounds were long. Which of the following would be appropriate for the nurse to use to document this finding? A.Intensity B.Pitch C.Duration D.Quality

C.Duration Duration refers to the length of time of the produced sound. This time frame ranges from very short to very long with variation in between. Intensity refers to the softness or loudness of the sound. Pitch refers to the number of vibrations of sound per second. Quality refers to the overtones produced by the vibration such as clear, hollow, muffled, or dull.

After completing the health history, the nurse begins to ask more detailed questions to clarify points and follow up on concerns expressed by the client during the interview. This portion of the health assessment is: A.Informal teaching B.Objective data C.Focused interview D.Interpretation of findings

C.Focused interview The focused interview is used to clarify points, obtain missing information, and follow up on verbal and nonverbal clues identified in the health history. A prepared set of questions is not used. Informal teaching occurs as a natural part of the client encounter. The nurse may provide instructions or explain a question or procedure. Objective data is observed or measured by the nurse and is used to validate the subjective data. Interpretation of findings is defined as making determinations about all of the data collected in the health assessment process.

The nurse notices that a client walks with a limp and has long legs. Which of the following aspects of the general survey is this nurse assessing? A.Physical appearance B.Mental status C.Mobility D.Behavior

C.Mobility The nurse observes the client's gait, posture, and range of motion when assessing mobility in the general survey. Physical appearance, mental status, and behavior are the other components of the general survey. Difficulty with gait and posture, such as limping, calls for further evaluation.

A client comes into the clinic with the complaint of swollen ankles. The nurse will utilize which assessment technique to find out more information about this complaint? A.Inspection B.Percussion C.Palpation D.Auscultation

C.Palpation Palpation is the use of touch to assess specific body characteristics, which include size, shape, location, mobility, position, vibration, temperature, texture, moisture, tenderness, and edema. Palpating the ankle will give the nurse information about tenderness, temperature, mobility, and edema characteristics. Visual inspection is also included in the assessment of the ankles, but palpation will yield the most information. Percussion and auscultation are not techniques used to assess the ankles.

An eight-year-old obese child is seen in the clinic. The mother of the child tells the nurse, "I don't know what to do to help him lose some weight." Which of the following would be appropriate instruction for the nurse to provide to this mother? A.Eating fast foods should be limited to twice per week. B.Television watching should be limited to one hour per day. C.Physical activity should be increased to one hour per day. D.Dairy products should be eliminated from the diet.

C.Physical activity should be increased to one hour per day. Children should have one hour of exercise each day according to Healthy People 2020. Recommended dietary guidelines include eating a variety of foods that are low in sugar and saturated fats. Limiting activities such as television is recommended, but no specific time limit is identified. Intake of dairy products in children should not be limited.

A client tells the nurse, "I'll never get married. I'm so fat and my hair just hangs." The nurse realizes this client might be experiencing: A.Poor role development B.Poor self-esteem C.Poor body image development D.Poor economic status

C.Poor body image development Body image is the way one thinks about physical appearance, size, and body functioning. Role development is the individual's capacity to identify and fulfill the social expectations related to the variety of roles assumed in a lifetime. Self-esteem is an individual's sense of worth or self-respect. Poor economic status can contribute to poor self-esteem or self-image.

The nurse is implementing the critical thinking process with the information collected during the health assessment of a client and choosing approaches to implement. In which step of the critical thinking process is this nurse engaged? A.Analysis of the situation B.Collection of information C.Selecting alternatives D.Evaluation

C.Selecting alternatives Once the data is analyzed and alternatives are generated, the nurse then selects the alternatives that would be the most appropriate for the client's care needs. Analysis of the situation includes distinguishing the data as normal or abnormal, clustering related data, identifying patterns in the data, identifying missing information, and drawing valid conclusions. Collection of information involves identifying assumptions, organizing data collection, determining the reliability of the data, identifying relevant versus irrelevant data, and identifying inconsistencies in the data. Evaluation is the last element in critical thinking and includes the skills of determining whether the expected outcomes have been achieved.

During a clinic visit, a client tells the nurse, "I don't have many friends. People bother me." The nurse realizes this client is demonstrating an imbalance in which health dimension? A.Mental B.Emotional C.Social functioning D.Spiritual

C.Social functioning Social functioning refers to the individual's ability to form relationships with others. This client is stating that he doesn't have many friends because he finds people bothersome. This is evidence of an imbalance within the social functioning dimension of health. The mental dimension of psychosocial health refers to an individual's ability to reason, to demonstrate rational thinking, and to perceive realistically. The emotional dimension includes one's feelings. The spiritual dimension includes values and beliefs that give meaning to life.

After providing a client with the Holmes Social Readjustment Scale, the nurse determines that the client's score is 323 points. Which of the following would be appropriate for the nurse to do at this time? A.Tell the client that the level of stress in their life is normal and manageable. B.Tell the client that the amount of stress in their life is moderate. C.Tell the client that the amount of stress in their life is high. D.Tell the client that they have a fifty-fifty chance of developing a serious illness brought on by stress over the next two years.

C.Tell the client that the amount of stress in their life is high. Scores over 300 indicate that the amount of stress in the client's life is high and the chances of developing a serious illness during the next two years are close to 90 percent.

A client is demonstrating an elevated heart rate, rapid respirations, and a systolic blood pressure of 150 mm Hg. During the health interview, the nurse learns that this client's husband has to relocate to Oklahoma for his job. Which of the following can the nurse surmise about this client's health status? A.The client is having marital difficulties. B.The client wants her husband to quit his job. C.The client is having physical signs of stress. D.The client has low self-esteem.

C.The client is having physical signs of stress. Positive as well as negative events may produce stress. Physical signs of stress include increased heart rate, increased respirations, and elevated blood pressure. This question doesn't state that the individual is having marital difficulties or that the husband should quit his job. Self-esteem refers to an individual's sense of worth or self-respect.

The nurse notes that the fold of epidermal skin around an adolescent client's fingernails is bleeding. Which of the following does this finding indicate about the client? A.The client will have difficulty synthesizing vitamin D. B.The client will have difficulty regulating body temperature. C.The client's nail roots can be at risk for infection. D.The client is at risk for losing viable hair follicles.

C.The client's nail roots can be at risk for infection. A fold of epidermal skin, called a cuticle, protects the root and sides of each nail. If this skin is disrupted, the client is at risk for infection. Vitamin D synthesis and temperature regulation are functions of the skin. Hair follicles are embedded in the dermis.

During the percussion of a client's abdomen, the nurse hears a loud, high-pitched, drumlike tone. The nurse would document this sound as being: A.Resonance B.Hyperresonance C.Tympany D.Flatness

C.Tympany Tympany is a loud, high-pitched, drumlike tone of medium duration commonly heard over the stomach or intestines. Resonance is a loud, low-pitched sound heard over the lungs. Hyperresonance is a loud, long sound heard when air is trapped in the lungs. Flatness is a soft, short sound heard over solid tissue such as bone.

An infant is being seen for a well child visit. The nurse learns that the mother smokes one pack of cigarettes per day. Which of the following is the most appropriate for the nurse to say in this setting? A.More people die from cigarette smoking than from AIDS or homicide. B.You are at risk for other addictions if you don't quit smoking. C.Your children are at increased risk of developing asthma and bronchitis. D.You are at increased risk for accidents and injuries.

C.Your children are at increased risk of developing asthma and bronchitis. The incidence of asthma and bronchitis is increased in children exposed to secondary smoke. More people do die from cigarette smoking than AIDS or homicide; however, this is not the most appropriate response in this situation. Discussing risks of other addictions is not an appropriate response in this situation. Smoking does not increase an individual's risk of accidents or injuries.

The nurse notes that a client from a non-American culture has multiple bruises over the upper portion of her back. Which of the following should the nurse say to this client? A."What happened to your back?" B."Areas of bruising are normal in dark-skinned clients." C."Adult abuse is very dangerous. Have you contacted the police?" D."Can you tell me how you received all of these bruises on your back?"

D."Can you tell me how you received all of these bruises on your back?" Clients from many cultures use therapies that are not part of standard Western treatment. This client could have had coining done. Coining is the rubbing of the skin of the back with a coin, which results in skin bruising. Also, pinching of the back, another nontraditional treatment, results in bruising. These treatments are thought to stimulate circulation and restore balance in children and adults with a variety of ailments. The nurse should inquire about cultural healing practices using appropriate communication techniques. Areas of bruising are not normal in dark-skinned clients. The nurse should not assume that the bruising is the result of abuse without further questioning.

The client tells the nurse, "I've just moved to this city and haven't made any new friends yet. It's been lonely but I think I'll be okay." Which of the following responses would be appropriate for the nurse to make to this client? A."Why would you leave your family?" B."What's your education level?" C."Maybe you could talk with someone of your own race." D."It sounds like you are trying to adjust."

D."It sounds like you are trying to adjust." People tend to move more frequently today and then must adjust to the culture of the new location, the loss of the familiar, and the stress of separation from family and friends. "Why" questions are typically nontherapeutic responses. Education level and racial background are not related to this question.

The mother of a four-year-old is frustrated because her daughter thinks she should always get what she wants, whenever she wants it. An appropriate response for the nurse to make to this mother would be: A."It sounds like your child is spoiled." B."It sounds like your child does not know right from wrong." C."It sounds like your child is underdeveloped." D."It sounds like your child is an average preschooler."

D."It sounds like your child is an average preschooler." Preschoolers believe that their wishes, thoughts, and gestures command the universe. They demonstrate centration by focusing on one aspect of a situation, ignoring others, resulting in illogical thinking. This child is demonstrating normal behavior. The other responses by the nurse are nontherapeutic and are not reflective of the growth and development of a preschool child.

The mother of an Appalachian infant tells the nurse that the baby has been having colic ever since she started feeding him sweet coffee. Which of the following would be an appropriate response for the nurse to make to this mother? A."Coffee to an infant?" B."The infant is too young to digest the milk in the coffee." C."How much sugar did you use?" D."Maybe the baby is too young to digest the coffee."

D."Maybe the baby is too young to digest the coffee." Rationale: One dietary habit of Appalachians is the introduction of coffee to infants at an early age. The nurse needs to recognize that this is a normal dietary custom and offer suggestions as to why the infant may not be tolerating the food item. Inquiries concerning milk and sugar do not address the reasons for the problems being experienced by the infant.

The nurse is phoning the physical therapy department to alter a client's scheduled therapy appointment. Afterward, the nurse coordinates the time for the same client's morning care and afternoon radiology appointment. This nurse is functioning as: A.A teacher B.A caregiver C.A client advocate D.A manager

D.A manager This nurse is coordinating the aspects of this client's care for one particular day. In this capacity, the nurse is managing the client's care. When functioning as a teacher, the nurse helps the client to acquire knowledge required for health maintenance or improvement. In the role of caregiver, the nurse utilizes a holistic approach to physical care of the client. As a client advocate, the nurse informs clients of their rights and encourages clients to speak for themselves.

During the health assessment, the nurse reviews the client's laboratory data. This is an example of: A.Constant data B.A primary source of information C.Subjective data D.A secondary source of information

D.A secondary source of information Laboratory data is considered a secondary source of information. Other secondary sources include charts, reports from diagnostic testing, and information from family and other members of the health team. Constant data is information that does not change over time such as race, gender, or blood type. The primary source of information is the client. Subjective data is information obtained from the client during the health history.

The nurse is going to assess a client's blood pressure. To do this, the nurse will need to have: A.A flashlight and gloves B.A stethoscope and a thermometer C.A tongue blade and a tuning fork D.A stethoscope and a sphygmomanometer

D.A stethoscope and a sphygmomanometer To measure blood pressure, the stethoscope and sphygmomanometer are used. A flashlight, gloves, thermometer, tongue blade, and tuning fork are not used in the measurement of blood pressure.

A Filipina American client sits with her arms crossed yet nods her head to the information the nurse is providing about her health care needs. The nurse realizes this client is demonstrating: A.Agreement about the plan of care B.Rude behavior to the nurse C.The need for an interpreter D.Acknowledgement that the client hears the nurse talking

D.Acknowledgement that the client hears the nurse talking Filipino Americans often nod the head during communication, which may appear to indicate agreement or understanding but may simply mean, "I hear you." Nodding of the head does not indicate agreement with the plan of care, nor demonstrate rude behavior or the need for an interpreter.

The nurse learns that a client has a long history of alcohol abuse. The most appropriate action for the nurse to take is: A.Assess for the presence of other addictive behaviors B.Discuss the increased rate of accidents related to alcohol use C.Discuss the need to avoid tobacco products D.Assess using the CAGE questionnaire

D.Assess using the CAGE questionnaire The CAGE questionnaire is used to assess for alcohol and substance abuse, which would be the next step in this situation before assessing for other addictive behaviors. There is an increased rate of accidents related to alcohol use; however, the nurse needs to obtain more information about this client's alcohol abuse. There is no information that states the client uses tobacco products.

The nurse is preparing to assess a client with flank pain and discomfort and pink-tinged urine. Which of the following assessment techniques would be appropriate for the nurse to use? A.Direct percussion B.Reflexive percussion C.Indirect percussion D.Blunt percussion

D.Blunt percussion Blunt percussion is used for assessing pain and tenderness in the gallbladder, liver, and kidneys. With blunt percussion, the palm of the nondominant hand is flat against the body and a closed fist is used to strike the hand on the body. Direct percussion is tapping the body directly to examine the sinuses or the thorax of an infant. Reflexive percussion is not an assessment technique. Indirect percussion is the most common method used to produce sounds within the body. To perform indirect percussion, the middle finger of the nondominant hand is placed firmly over the area being examined. The middle finger of the dominant hand quickly strikes the middle finger of the nondominant hand, producing vibrations and a sound.

After completing a health assessment, the nurse documents the findings on a flow sheet with check marks and short notations. The type of documentation this nurse is using is most likely: A.Narrative B.SOAP C.APIE D.Charting by exception

D.Charting by exception Charting by exception is a system in which documentation is limited to exceptions from pre-established norms or significant findings. Flow sheets with appropriate information and parameters are completed typically with a series of check marks and short notations on a flow sheet. This type of documentation eliminates much of the repetition involved in narrative and other forms of documentation. Narrative charting includes sentences and paragraphs to record information in chronological order. SOAP charting is a method of recording subjective data, objective data, assessment, and planning. The letters APIE refer to assessment, problem, intervention, and evaluation. In this method of charting, the subjective and objective data are combined. The nurse draws conclusions from the data, identifies problems, and devises a plan to address the problem.

A non-English speaking client enters the clinic and repeats the word "doctor." What can the nurse do to assist this client? A.Repeat the word "doctor" back to the client. B.Assist this client to a chair in the waiting room. C.Tell the client to sign the sign-in sheet. D.Discuss this with the health care provider

D.Discuss this with the health care provider This question demonstrates that the nurse does not have enough cultural information to assist this client. The only real choice is for the nurse to discuss this with the health care provider, who might be better able to assist the client. Repeating the word, assisting the client back to the waiting room, and having the client sign the sign-in sheet are not appropriate actions in this situation.

A client lives in a favorable environment but is in poor health. According to Dunn's model of wellness, how would this client be classified? A.Protected poor health B.Poor health C.High-level wellness D.Emergent high-level wellness

D.Emergent high-level wellness Emergent high-level wellness (in unfavorable environment). Although the client lives in a positive environment, having poor health negatively impacts this client's placement within Dunn's model. The client would fall into the protected poor health category if they had poor health in a favorable environment. Poor health occurs in an unfavorable environment. High-level wellness is the term used for an individual with good health in a favorable environment.

At a clinic, the nurse is interviewing a client and asking about his lifestyle, social support, and normal activities of daily living. This assessment is an example of: A.Disease management assessment B.Musculoskeletal assessment C.Fall-risk assessment D.Health assessment

D.Health assessment When performing a health assessment, the nurse collects data about the client's current health status, health-promoting activities, activities of daily living, social support, illness signs and symptoms, and environmental and emotional factors. The nurse focuses on obtaining a health assessment, which includes obtaining information about illness signs and symptoms, but is not focused on management of disease assessment. Musculoskeletal and fall-risk assessments are components of an entire health assessment.

A 79-year-old client currently experiencing a health crisis is demonstrating feelings of despair and acting with contempt for others in her family. The nurse realizes this client is in which stage of psychosocial development? A.Identity versus role diffusion B.Intimacy versus isolation C.Generativity versus stagnation D.Integrity versus despair

D.Integrity versus despair Integrity versus despair, stage 8, occurs from age 65 years to death. Individuals conclude life accepting death or feeling a sense of loss, despair, and contempt for others. Identity versus role diffusion is stage 5 and occurs between 12 and 18 years of age. Achieving ego identity results in the ability to make a career choice and plan for the future. Intimacy versus isolation, stage 6, occurs from 19 to 40 years of age. The individual forms an intimate relationship with another person. Isolation results in the development of impersonal relationships and avoidance of career and lifestyle commitments. Generativity versus stagnation, stage 7, occurs between 40 and 65 years of age. Resolution of this stage results in creativity and productivity. Stagnation results in selfishness and lack of interests and commitments.

What does the nurse observe when performing an assessment on a client who is diaphoretic? A.The presence of paronychia B.Clubbing of the nails C.The presence of seborrhea D.Profuse sweating

D.Profuse sweating Diaphoresis, or profuse sweating, occurs during exertion, fever, pain, and emotional stress and in the presence of some metabolic disorders such as hyperthyroidism. It may also indicate an impending medical crisis such as a myocardial infarction. Paronychia is the infection of the nail cuticle. Clubbing of the nails occurs with hypoxia. Seborrhea is a dry, flaky scalp, also called dandruff.

During the assessment of a Mexican American, the nurse notices that the client turns to her husband before answering any questions. The nurse realizes that this client is demonstrating: A.Communication B.Environmental control C.Biological variation D.Social organization

D.Social organization The category of social organization includes the assessment observation, "Does the client consult another to make health decisions?" Communication includes verbal and nonverbal methods by which individuals and groups transmit information. Environmental control includes how health is defined by the culture and whether the client uses cultural healers or healing practices. Biological variation includes variations in anatomical characteristics, dietary preferences, illnesses, or diseases that the client is at risk for because of ethnicity or race.

The mother of a three-month-old baby tells the nurse that her baby's skin is like tissue paper and scratches easily. Which of the following responses would be appropriate for the nurse to say to this mother? A.Skin is expected to easily bruise and bleed until age 2. B.This is something that the physician needs to know about. C.Don't worry, this is normal. D.The baby's skin is thin and will get thicker as the baby gets older.

D.The baby's skin is thin and will get thicker as the baby gets older. Skin is very thin at birth and thickens throughout childhood. Despite the fact that the skin is thin during infancy, it is not expected to bruise and bleed easily until the age of 2. The physician does not need to be notified of this condition. Although this is a normal finding, using false reassurance and telling the mother not to worry is not utilizing therapeutic communication.

A client tells the nurse that he is planning to stop smoking on November 1. The nurse asks the client to list his strategies. Why is this important? A.To reduce the need for competing demands B.To identify indirect situational influences in advance C.To determine the client's level of self-efficacy D.To ensure the commitment to the action plan is complete

D.To ensure the commitment to the action plan is complete Commitment to a plan of action has two components: the commitment to do an activity and the strategies to complete and reinforce the activity. Commitment without strategies can lead to good intention, but lack of success in the completion of the activity. Competing demands are alternative activities over which the individual has little control such as family or work. Identification of situational influences includes perceptions of available options. Self-efficacy is the judgment of one's ability to successfully participate in a health-promoting activity. Commitment to the action plan has two components, which include commitment to do the activity and the strategies to complete the activity.

A client with lower-extremity edema comes into the clinic. During the assessment, the nurse is unable to palpate the client's pedal pulses. Which of the following would be appropriate for the nurse to do? A.Nothing. B.Use a blood pressure cuff around the client's calf in efforts to feel the pulse. C.Use a tourniquet around the calf and then palpate the pulse. D.Use a Doppler to listen to the pulse.

D.Use a Doppler to listen to the pulse. A Doppler uses ultrasonic waves to detect sounds that are difficult to hear with a regular stethoscope such as peripheral pulses. Doing nothing is not appropriate in this situation since the nurse needs to assess circulation to the affected area. Placing a blood pressure cuff or tourniquet around the calf will likely make the edema worse and pulses even more difficult to palpate.

The nurse is preparing to assess a client new to the clinic. Which of the following questions would provide the most information about the client's cognitive status? A.What do you do for recreation? B.Do you belong to any social groups? C.Who is your closest friend? D.What would you take with you if a fire broke out?

D.What would you take with you if a fire broke out? One of the questions listed to assess a client's senses and cognition is: "What would you take with you if a fire broke out?" The other question choices assess roles, relationships, stress, and coping.