Fundamentals-Chapter 13

C) Blood vessel changes increase the risk for high blood pressure in older people.

A 72-year-old client asks the LPN what blood pressure changes are expected with aging. Which is the most appropriate response by the LPN/LVN? A)Its expected that your blood pressure will increase when you stand up. B)Its common for blood pressure to decrease with age due to lack of exercise. C)Blood vessel changes increase the risk for high blood pressure in older people. D)The heart pumps harder with age and that will increase blood pressure.

B

A 75 year old client's resting heart is 60. 20 years ago the resting heart rate was 82. What does the LPN know about this change? A)This is r/t ongoing coronary artery disease B)This is a normal progression of aging C)This is a symptom indicating the need for a pacemaker D)This is a symptom of peripheral artery disease

C

A 90-year-old patient is having difficulty answering the nurse's questions while completing the patient history. What should the nurse keep in mind about caring for older adults? A)All older adults age at the same rate. B)The nurse should write down all of the questions and have the patient's family complete the information. C)The nurse should sit down at eye level with the patient and allow a longer period to answer each question. D)The nurse should talk more loudly and raise the pitch of the voice.

B

A patient has been admitted for dehydration after a prolonged period of diarrhea. Which finding does the nurse expect to observe in this patient? A)Skin, warm, moist, pink with good skin turgor B)Skin, warm, dry, pale with decreased skin turgor C)Skin cool, dry, pink with increased skin turgor D)Skin cook, moist, pale with decreased skin turgor

A

A patient has been admitted with acute bronchitis. When performing a lung assessment, the nurse is best able to auscultate the lower lobes by listening to what location on the body? A)Posterior B)Anterior C)Lateral D)Superior

A

An elderly male patient is admitted for chest pain. How does the nurse best document the information the patient gives about his symptoms? A)Use the patient's own words in quotation marks. B)Briefly summarize what the patient says. C)Interpret the patient's comments using medical terminology. D)Use the information for the chief complaint from the admission sheet.

A

Mr. S is complaining of pain in his chest, difficulty breathing, and a cough. What are these reports by the patient considered? A)Subjective Data B)Objective Data C)Disease process D)Observable Data

B C D

One of the first steps in gathering data about a patient is to establish the "nurse-patient relationship." What are appropriate ways to establish this relationship? SATA A) The nurse promises to return in 10 minutes but returns in 45. B)The nurse shows professionalism and competence to patients. C)The nurse introduces herself/himself to patients and answers questions the patients may have. D)The nurse communicates trust and confidentiality to patients. E)The nurse enters patient rooms without knocking and offers very little information.

A) Instruct the client to remove shoes.

The LPN assists with data collection by measuring a client's height and weight. Which action should the LPN take first? A)Instruct the client to remove shoes B)Ask the client to remove clothes C)Ensure the client stands erect D)Place client's feet together.

A

The LPN assists with data collection by measuring a client's height and weight. Which action should the LPN take first? A)Instruct the client to remove shoes B)Ask the client to remove clothes. C)Ensure the client stands erect. D)Place client's feet together.

C

The LPN cares for a client following surgery. Listening to the heart is part of the observation required. What best indicates how to auscultate the heart? A)Listen for 1 minute at the lower end of the sternum on the right side B)Listen for 2 cardiac cycles on the left medial side of the clavicle C)Listen for 1 minute at each of the four locations on the left chest D)Listen for 4 cardiac cycles in the middle of the left chest area.

A

The LPN cares for a client whose at risk to develop orthostatic hypotension. What will the LPN expect to observe if orthostatic hypotension develops? A)Decreased systolic, decreased diastolic bp, increased PR B)Decreased systolic, increased diastolic bp, decreased PR C)Decreased systolic, decreased diastolic bp, decreased PR D)Decreased systolic, decreased diastolic bp, no change in PR

B

The LPN checks the blood pressure on a client. Which is the most appropriate action for the LPN to take? A)The LPN places a stool beneath the clients feet when client is sitting in chair B)The LPN measures the blood pressure after the client has rested for 5 minutes. C)The LPN uses a blood pressure cuff that is 15% more than the upper arm diameter. D)The LPN measures 2 sets of blood pressure on minute apart.

3 Rationale: -The LPN would not notify the health care provider before notifying the RN. -Listening again doesn't provide more data, the heart rate will still be irregular. -The LPN does not auscultate the carotid artery as it is a proximal artery to the heart. Data collection for the perfusion of blood is completed by evaluating the arteries distal to the heart. -The LPN would first palpate the radial pulse while listening to make sure all heart beats are being heard and that every beat moves blood distally through the radial artery. The data collected should then be passed to the registered nurse.

The LPN is auscultating the heart of a new client and hears an irregular heart beat. What should the LPN do next? 1)Notify the health care provider. 2)Listen again for 2 minutes. 3)Palpate the radial pulse while listening apically. 4)Auscultate the carotid pulse.

C

The LPN is auscultating the heart of a new client and hears an irregular heart beat. What should the LPN do next? A)Notify the health care provider B)Listen again for 2 minutes C)Palpate the radial pulse while listening apically D)Auscultate the carotid pulse.

B

The LPN is collecting data on a newly admitted client. The LPN understands this initial data collection serves which main purpose? A)Determine physical needs of the hospitalization. B)Provide a baseline for the nursing plan of care C) Establish a relationship with the client D)Teach the client about the plan of care

3 "Have you ever had jaundice before?" Rationale: -Your stomach is not located on the right side under the ribs -appendix is located in the lower right quadrant of the abdomen, not upper -pancreas is not located under the ribs and does no enlarge with diabetes -The liver is located in the upper right abdominal area. If it is felt when palpated under the ribs, it is often diseased or enlarged and jaundice may be a symptom.

The LPN is preparing a client to have a physical examination by the health care provider. The client says, "I hate when they push under my ribs on the right side because it hurts." Which statement by the LPN would be most appropriate? 1)"Yes, it can hurt when they push on your stomach." 2)"Have you had your appendix removed yet?" 3)"Have you ever had jaundice before?" 4)"Yes, your diabetes may cause an enlarged pancreas."

B

The LPN is working on a medical floor and assisting the RN with patient assessments. A new patient is admitted to the floor and the RN takes a health history and performs an assessment. What is this considered the first step of? A)The obtaining of the chief complaint B)The nursing process C)The review of systems D)The nurse-patient relationship

A

The LPN listens to the apical heart rate for 1 minute. Which is the best description of the area to listen for the apical heart rate? A)Fifth intercostal space, midclavicular line. B)Underneath the client's left nipple. C)5 cm to the left of the midsternal area D)Third intercostal space immediately left of sternum

A

The LPN notes in the client's history the radial pulse is irregular. Which is the best procedure for the LPN to use to take the pulse? A)Monitor the apical pulse for one minute. B)Monitor the femoral pulse for fifteen seconds and multiply times four. C)Monitor the pedal pulse for thirty seconds and multiply times two. D)Monitor the radial pulse for sixty seconds.

B)Oral mucous membranes

The LPN observes for cyanosis on a dark skinned client. What is the best location to observe for cyanosis? A)Lips B)Oral mucous membranes C)Palms of hands D)Ear lobes

D

The LPN takes the apical pulse of the client before administering diltiazem. Which is the correct site to located the apical pulse? A)Second intercostal space, left sternal border. B)Second intercostal space, right sternal border C)Fourth or fifth intercostal space, left sternal border D)Fifth intercostal space, midclavicular line.

ABCE

The nurse asks the patient about which signs and symptoms experienced when reviewing the elderly patient's gastrointestinal system? SATA A)changes in bowel habits B)Pyrosis (heart burn) C)Firmness of the abdomen D)Dyspnea E)Anorexia

B

The nurse assess a vibration felt along the patient's carotid artery with palpation. How should the nurse describe the assessment finding? A)Palpation B)Thrill C)Bruit D)Aneurysm

C

The nurse documents which finding while assessing a patient with heart failure where it is noted that the lower extremities have deep indentations that remain for 30 seconds when pressed? A)Nonpitting edema B) 2+ pitting edema C) 3+ pitting edema D)4+ pitting edema

A

The nurse is auscultating breath sounds on a patient and detects adventitious breath sounds. The nurse describes them as a loud, bubbly noise heard during inspiration. The nurse is correct when using which term for documenting this finding? A)Corse crackles B)Sonorous wheezes C)Pleural friction rub D)Sibilant wheezes

D E

The nurse is documenting a patient assessment. The nurse correctly identifies which information as being objective data? SATA A)"I have a headache and feel like the room is spinning." B)"When I eat I have horrible pain in my stomach." C)"It burns when I use the bathroom; what do you think is wrong with me?" D)"It is noted that the blood pressure is high at 156/96." E) "Abdomen is distended and hypoactive bowel sounds are noted."

A,B,C,D

The nurse is performing a cardiovascular system assessment on a patient. Which is included in an assessment of the peripheral vascular system? SATA A)Assessment of the apical pulse rate by counting the pulsations for 60 seconds B)Assessment of the brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior tibial pulses C)Assessment of capillary refill in the nail beds of the fingers and toes D)Determination of the rate, rhythm, and strength of the dorsalis pedis pulse E)Assessment of the patient's skin turgor by counting the amount of time the skin remains

C

The nurse is preparing a female patient for a gynecologic examination. Which patient position best assists the health care provider in this examination? A)High Fowler's B)Dorsal recumbent C)Lithotomy D)Sims

C

The nurse is taking care of a patient with a leg wound. The nurse notices redness, swelling, and purulent drainage while completing the assessment and recognizes that these are cardinal signs of what process? A)Asthenia B)Ecchymosis C)Infection D)Pain

B

The patient asks the nurse why all of the nurses always listen to his abdomen with the stethoscope before pressing on it. Which response is correct? A)This prevents distortion of vascular sounds. B)This prevents distortion of bowel sounds. C)This determines any areas of tenderness or pain. D)This allows the patient to relax and be comfortable.

A B

The patient has been admitted to the medical unit with a wound to the left lower extremity from a mowing accident 2 days ago. The inflammatory response present at this stage includes which signs and symptoms? (SATA) A)Swelling B)Pain C)Coolness D)Purulent drainage E)Pale skin at injury site

B

The patient reports severe abdominal pain. What type of assessment should the nurse perform? A) Head to toe assessment B) Focused assessment C) System by system assessment D) Complete assessment

A

The process of listening to sounds produced by the body is which physical assessment technique? A)Auscultation B)Inspection C)Percussion D)Palpation

D

To prepare to take the blood pressure, the LPN selects a cuff that has which characteristic? A)Cuff applies enough pressure to the brachial artery of the clients arm to obscure it. B)Cuff bladder covers the entire circumference of the client's arm. C)Cuff fits tightly around the client's arm. D)Cuff width is two-thirds of client's arm length.

A

What is the first area to be assessed after taking vital signs when performing a nursing assessment? A)Assess for level of consciousness and orientation. B)Assess the skin. C)Listen to lung sounds. D)check for pitting edema.

C

What is the term used to describe a patient's respiratory rate that exceeds 36 breaths per minute? A)Sonorous B)Bradypnea C)Tachypnea D)Apnea

B

When documenting assessment findings, which of the following are examples of objective data? A)Dizziness and headache B)Redness and swelling to feet C)Leg pain and calf tenderness D)Chest pain and headache

A, B, C, E

When preparing to perform an assessment, which elements need to be included to ensure the integrity of the nurse-patient relationship? SATA A)Introduction of the nurse to the patient, which includes title (LPN/LVN) and purpose of visit B)Explanation of what the nurse will need to accomplish (i.e., vital signs, body system review) during the time with the patient. C)An estimated time frame to complete the assessment. D)Standing at the foot of the bed to get the best look at the patient and his and her responses. E)Preparation of the room for the least amount of distractions so that the patient can remain focused to questions offered by the nurse.

A

Where would the LPN locate the brachial pulse on an adult client? A)In the antecubital area B)On the inside of the wrist C)on the back of the knee D)On the top of the foot

B D

Which is a contraindication for palpating the abdomen? A)Cesarean section B)Wilms' tumor C)Constipation D)Organ transplant

C

Which is an expected percussion sound in the abdomen? A)Tympany above the organs B)Dullness above areas of tenderness C)Increased tympany with distension D)Increased resonance over bones

A

Which is the appropriate depth of light abdominal palpation? A)1-2 cm B)4-6 cm C)1-2 in D)4-6 in

C

Which is the best position for assessing the abdomen? A)Semi-fowlers B)High-fowlers C)Dorsal recumbant D)Sims

D

Which of the following is an appropriate assessment during abdominal auscultation? A)Hearing 50 audible bowel sounds in one minute B)Listening left of the umbilicus above the ileocecal valve C)Using the stethoscope diaphragm to listen for aorta bruits D)Listening for 5 minutes to determine absent bowel sounds

A)Peristalsis will be visible in infants

Which of the following is an expected finding of an abdominal inspection? A)Peristalsis will be visible in infants B)Skin color will be darker than other areas C)Abdominal breathing during pregnancy D)Scaphoid shape will be seen in older adults.

AC

Which of the following would cause protrusion of the umbilicus? A)Underlying mass B)Adipose build-up C)Hernia D)Bone abnormality

C E

Which risk factor for cardiovascular disease can be modified? SATA A)Age B)Race C)Diet D)Family history E)Smoking

B

Which skill is performed last in an abdominal assessment? A)Inspection B)Palpation C)Percussion D)Auscultation

3) The abdomen is palpated to detect masses or pain. Rationale: 1-bowel sounds are detected through auscultation 2-to detect bowel sounds, the entire abdomen is auscultated 3-masses and painful areas are detected through palpation of the entire abdomen 4-the entire abdomen is auscultated to detect bowel sounds **Note that when doing an abdominal assessment the order of examination is slightly different. 1)Inspect 2)Auscultate 3)Percuss 4)Palpate

Which statement would the LPN recognize as true regarding observations of the abdomen? 1)The abdomen is palpated to detect bowel sounds. 2)The lower two quadrants are auscultated for bowel sounds. 3)The abdomen is palpated to detect masses or pain. 4)The upper two quadrants are inspected for bowel sounds.

C

Which statement would the LPN recognize as true regarding observations of the abdomen? A)The abdomen is palpated to detect bowel sounds B)The lower two quadrants are auscultated for bowel sounds C)The abdomen is palpated to detect masses or pain D)The upper two quadrants are inspected for bowel sounds

A

Which term is described as an abnormal growth of new tissue, either malignant or benign? A)Neoplastic disease B)Infectious disease C)Metabolic disease D)Deficiency disease

A

While assessing a patient's lower extremities, the nurse notes edema around the feet and ankles. When the area is depressed, it lasts for more than 1 minute before the shape returns. How would the nurse document this edema? A)3+ pitting edema B)1+ pitting edema C)2+ pitting edema D)4+ pitting edema

CDEG

While performing a physical assessment, which findings would indicate a deviation from normal? SATA A)Bilateral lung sounds clear B)Afebrile C)Cyanosis of the fingers and toes D)Erythema of lower extremities E)Jaundice F)Capillary refill less than 3 seconds G)Apical heart rate of 110

B

While the nurse is performing a physical assessment, the patient complains of dyspnea. This symptom indicates a problem with which body system? A)Peripheral vascular B)Respiratory C)Neurologic D)Gastrointestinal