Fundamentals EAQs: Health Assessment

A client with recent history of head trauma is at risk of orthostatic hypotension. Which assessment findings would help to diagnose the condition? Select all that apply.

Correct1 Fainting 2 Headache Correct3 Weakness Correct4 Light headedness 5 Shortness of breath R: Head trauma may cause blood loss. Clients with recent blood loss are at risk of orthostatic hypotension. While obtaining the orthostatic measurements, the nurse should check for fainting, light-headedness, and weakness. Headaches and shortness of breath are the symptoms of hypertension.

While assessing a client with dehydration, the nurse notices diminished skin elasticity. Which portion of the hand is used to perform this assessment?

Correct1 Fingertips 2 Pads of fingertips 3 Ulnar surface of hand 4 Palmer surface of finger pads R: The fingertips are used to palpate the skin for elasticity. The pads of the fingertips are used to palpate pulse amplitude. The ulnar surface of the hand is used to detect fremitus. The palmer surface of the fingertips is used to examine the thorax.

A nurse notices cyanosis in a client with heart disease. Which site would the nurse assess to confirm cyanosis?

Correct1 Lips 2 Sclera 3 Conjunctiva 4 Mucus membrane R: The lips and nail beds are the best sites to assess for cyanosis. The sclera and mucous membrane are assessed in jaundice. The conjunctiva is assessed for the presence of pallor.

A registered nurse is teaching a nursing student about skin assessment. Which statement made by the nursing student indicates the need for further teaching?

1 "Skin assessments are best performed in daylight." 2 "Skin assessments performed at cool room temperatures can result in cyanosis." 3 "Skin assessment performed at warm room temperatures can result in vasodilatation." Correct4 "In the absence of sunlight, skin assessments are performed best with other sources of light instead of fluorescent light." R: Though skin assessments are best conducted in daylight, in the absence of sunlight, they are best performed in fluorescent lighting. Skin exposure during skin assessments in cool room temperature can result in cyanosis. Skin exposure during skin assessments made in warm room temperature can result in vasodilatation.

The nurse is preparing to teach a client about self-injection of insulin. Which action by the nurse will increase the effectiveness of the teaching session?

1 Wait until a family member is also present. Correct2 Assess the client's barriers to learning self-injection techniques. 3 Begin with simple written instructions describing the technique. 4 Wait until the client has accepted the new diagnosis of type 1 diabetes mellitus. R: Before a teaching plan can be developed, the factors that interfere with learning must be identified. Although family members can be helpful, client involvement in care is most important for promoting independence and self-esteem. Assessment comes before intervention; written instructions may not be the most appropriate teaching modality. The client may never accept the change but must learn to manage care; this may be an unrealistic expectation.

Which feature is characteristic of a risk nursing diagnosis?

Correct1 The diagnosis does not have related factors. 2 The diagnosis can be used in any health state. 3 The defining characteristics support the diagnostic judgment. 4 The defining characteristics are supported by a client's readiness. R: A risk nursing diagnosis describes human responses to health conditions that may develop in a vulnerable individual, family, or community. Risk diagnoses do not have related factors or defining characteristics because they have not occurred yet. A risk diagnosis has risk factors that help the nurse plan preventive measures. A health promotion nursing diagnosis can be applied to any individual with a desire to enhance health behaviors in any health state. An actual diagnosis is formed when the defining characteristics support the diagnostic judgment. There must be sufficient nursing assessment data to establish an actual diagnosis. A health promotion nursing diagnosis is a clinical judgment of an individual's readiness to increase well-being.

The nurse is caring for a client whose forehead feels warm to the touch. The nurse uses a thermometer and obtains the client's temperature. What is the nurse doing?

Correct1 Validation 2 Assessment 3 Interpretation 4 Documentation R: The nurse is validating the presence of fever in the client. Validation is the process of gathering more assessment data. It involves clarifying vague or unclear data. Assessment is the first step of the nursing process. It involves collecting information from the client and secondary sources. During interpretation, the nurse recognizes that further observations are needed to clarify information. Data documentation is the last part of a complete assessment. The nurse must document facts in a timely, thorough, and accurate manner to prevent information from getting lost.

A registered nurse is teaching a nursing student how to assess for edema. Which statement made by the student indicates the need for further education?

1 "Edema results in the separation of skin from pigmented and vascular tissue." 2 "Pitting edema leaves an indentation on the site of application of pressure." 3 "Trauma or impaired venous return should be suspected in clients with edema." Correct4 "If the pressure on an edematous site leaves an indentation of 2 mm, a score of 2+ is given." R: The depth of indentation left after applying pressure to an edematous site determines the degree of edema. A 1+ score is given if the depth of indentation is 2 mm. A 2+ is the score given if the depth of edema indentation is 4 mm. An accumulation of edematous fluid will result in the separation of skin and underlying vasculature. Edema is classified as pitting if the application of pressure on the edematous site will leave an indentation for some time. Edema results from a direct trauma to the tissue or by impaired venous return.

Which client body temperatures are indicative of moderate hypothermia? Select all that apply.

1 80° F (26.7° C) 2 84° F (28.9° C) Correct3 88° F (31.1° C) Correct4 92° F (33.3° C) 5 96° F (35.6° C) R: Moderate hypothermia is a body temperature between 86°F and 93.2°F (30° C to 34° C). Therefore clients with body temperatures between 88°F and 92°F (31.1° C to 33.3° C) have moderate hypothermia. Mild hypothermia is a body temperature between 93.2°F and 96.8°F (34° C to 36° C). Therefore clients with body temperatures of 96°F (35.6° C) have mild hypothermia. Body temperature below 86°F (30° C) indicates severe hypothermia.

A nurse is teaching a parenting class. What should the nurse suggest about managing the behavior of a young school-age child?

1 Avoid answering questions. 2 Give the child a list of expectations. Correct3 Be consistent about established rules. 4 Allow the child to plan the day's activities. R: Because of a short attention span and distractibility, consistent limit setting is essential toward providing an environment that promotes concentration, prevents confusion, and minimizes conflicts. Questions should be answered, but the answers should not be judgmental. A list of expectations may be overwhelming at this age. Parents need to assist children with routine tasks; children this age may not be concerned with time frames.

The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply.

1 Dyspnea Correct2 Flushed face 3 Precordial pain Correct4 Increased pulse rate 5 Increased blood pressure R: Increased body heat dilates blood vessels, causing a flushed face. The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may not cause difficult breathing. Pain is not related to fever. Blood pressure is not expected to increase with fever.

The nurse is preparing to assess the four abdominal quadrants of a client who complains of stomach pain. When determining the order of the assessment, the nurse recognizes that it is important to assess the symptomatic quadrant when?

1 First 2 Second 3 Third Correct4 Last R: The nurse should systematically assess the abdomen concluding with the symptomatic area. Pain may be elicited in the symptomatic area if assessed first, second, or third, causing the muscles in other abdominal areas to tighten. This would interfere with the assessment.

While assessing a client, a nurse finds adventitious breath sounds. Upon further evaluation, the nurse finds loud, low-pitched, rumbling coarse sounds during inspiration. This sound can be clearly heard while the client is coughing. What could be the reason behind these sounds?

1 Inflammation of the pleura 2 Reinflation of groups of alveoli Correct3 Muscular spasms in the larger airways 4 High-velocity airflow through an obstructed airway R: Adventitious breathing sounds (rhonchi) can be heard when there are loud, low-pitched, rumbling, and coarse sounds during inspiration. These sounds can also be clearly heard while the client is coughing. Rhonchi may be caused by muscular spasms in the larger airways. Inflammation of the pleura may lead to a pleural friction rub sound. A crackling sound can be heard when there is a reinflation of groups of alveoli. In case of high-velocity airflow through an obstructed airway, wheezes or sibilant wheeze sounds may be heard.Test-Taking Tip: Adventitious breath sounds are the abnormal sounds heard during respiration.

A nurse is assigned to care for a newly admitted client. The nurse performs a physical assessment and reviews the admission form and the primary healthcare provider's prescriptions. What should the nurse identify as the priorities in this client's plan of care?

1 Intake and output 2 Diet and nutrition Correct3 Hygiene and comfort Incorrect4 Body mechanics and posture R: Because the client's condition is terminal, the nursing priority should be directed toward providing basic care and comfort. Although intake and output, diet and nutrition, and body mechanics and posture are important aspects of nursing care, provision of comfort is the priority when caring for a dying client.

The nurse at a community healthcare center focuses on providing primary preventive care. What is the focus of primary preventive care?

1 Rehabilitating the client 2 Treating early stages of disease 3 Preventing complications from illness Correct4 Promoting health in healthy individuals R: Primary prevention precedes disease or dysfunction and is applied to clients considered physically and emotionally healthy. Health education programs, immunizations, and physical and nutritional fitness activities are primary prevention activities. Tertiary preventive care occurs when an individual has a permanent or irreversible disability. The client undergoing rehabilitation is receiving tertiary preventive care. Secondary preventive care focuses on individuals who are experiencing health problems. Secondary preventive care involves treating clients in the early stages of disease. It also focuses on preventing complications from illness.

Which diagnosis made by the nurse is helpful in providing the right nursing interventions for the client?

1 The nurse understands that the client has pain due to a tracheostomy. 2 The nurse identifies that the client is anxious about the cardiac catheterization. 3 The nurse realizes that the client has diarrhea and needs the bedpan frequently. Correct4 The nurse identifies that the client is not aware of perineal care and has impaired skin integrity. R: The nurse observes that the client has impaired skin integrity due to lack of knowledge about perineal care. The nurse identifies the need for educating the client about perineal care. This nursing diagnosis is correct as it will help enhance the client's health outcomes. The nursing diagnosis should identify the problem caused by a treatment such as tracheostomy, not the treatment itself. A tracheostomy is a medical condition and should not be included in the nursing diagnosis. This client is likely to have pain following the trauma of the surgical incision. The nursing diagnosis should contain the client's response to the medical procedure rather than the medical procedure itself. The client is probably anxious due to lack of knowledge about the need for cardiac catheterization or the outcome of the procedure rather than the catheterization itself. A correct diagnosis helps the nurse put the client at ease by providing necessary teaching. The nurse should plan nursing interventions after identifying the client's problem. Therefore, the nurse should identify that the client has diarrhea due to food intolerance. This helps the nurse select appropriate interventions rather than just one intervention of offering bedpan.

While assessing a client's range of motion, the nurse explains adduction to the nursing student. Which statement made by the nursing student indicates effective learning?

Correct1 "I will ask the client to move his or her arm towards the body." 2 "I will ask the client to bend his or her limb by decreasing the angle." 3 "I will ask the client to move his or her hand so that the ventral surface faces downward." 4 "I will ask the client to move his or her head beyond its normal resting extended position." R: Adduction is moving the arm towards the body. Assessing the range of motion by bending the limb and decreasing the angle indicates flexion. Moving the hand by facing the ventral surface downwards indicates pronation. The movement of the head beyond the normal resting extended position indicates hyperextension.

The nurse is caring for an elderly client with dementia. Which client need should the nurse prioritize while providing care?

Correct1 Safety 2 Self-esteem 3 Self-actualization 4 Love and belonging R: An elderly client with dementia has impaired cognition. Therefore the nurse should make arrangements such as applying bed side rails to ensure that the client's safety needs are met first. At this stage, self-esteem or factors that enhance confidence and self-worth are not as important as safety. Self-actualization is the ability to solve problems and being able to cope realistically, which is beyond the capacity of the client with dementia. All clients need to feel love and belonging; however, safety is the first priority for this client.

A client suspected to have a prostate disorder is encouraged to have a rectal examination. What position of the client will facilitate a rectal examination by the registered nurse (RN)?

Correct1 Sims position 2 Prone position 3 Dorsal recumbent position 4 Lateral recumbent position R: In Sims position, hips and knees are flexed, which results in exposure of the rectal area. Therefore Sims position is most suitable for performing rectal examinations. A prone position helps in assessing extension of hips, skin, and buttocks. The dorsal recumbent position is predominantly indicated for abdominal assessment because it promotes abdominal muscle relaxation. The lateral recumbent position is indicated for detecting heart murmurs.

A nurse is caring for a client who has been admitted with right-sided heart failure. The nurse notes that the client has dependent edema around the area of the feet and ankles. To characterize the severity of the edema, the nurse presses the medial malleolus area, noting an 8 mm depression after release. How should the edema be documented?

1 1+ 2 2+ 3 3+ Correct4 4+ R: Dependent edema around the area of feet and ankles often indicates right-sided heart failure or venous insufficiency. The nurse should assess for pitting edema by pressing firmly for several seconds, then releasing to assess for any depression left on the skin. The grading of 1+ to 4+ characterizes the severity of the edema. A grade of 4+ indicates an 8 mm depression. A grade of 1+ indicates a 2 mm depression. A grade of 2+ indicates a 4 mm depression. A grade of 3+ indicates a 6 mm depression.

A client who sustained head injuries is admitted to the hospital. During assessment of cranial nerves, the nurse notices that the client lost the perception of taste, especially in the anterior portion of the tongue. Which cranial nerve might have been injured in this client?

1 Cranial nerve X 2 Cranial nerve IX 3 Cranial nerve XII Correct4 Cranial nerve VII R: Cranial nerve VII is the facial nerve. Injury to the facial nerve limits the sensory impulses from the anterior two-thirds of the tongue, along with altered facial expressions. Cranial nerve X is the vagus nerve, injury to which causes limitation of palatal movements. Cranial nerve IX is the glossopharyngeal nerve. Injury to this nerve results in loss of taste impulses from the posterior one-third of the tongue. Cranial nerve XII is the hypoglossal nerve, damage of which results in improper movements of the tongue.

An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult, the nurse recalls what expected sensory losses associated with aging? Select all that apply.

1 Difficulty in swallowing Correct2 Diminished sensation of pain 3 Heightened response to stimuli Correct4 Impaired hearing of high frequency sounds 5 Increased ability to tolerate environmental heat R: Because of aging of the nervous system, an older adult has a diminished sensation of pain and may be unaware of a serious illness, thermal extremes, or excessive pressure. As people age they experience atrophy of the organ of Corti and cochlear neurons, loss of the sensory hair cells, and degeneration of the stria vascularis, which affects an older person's ability to perceive high frequency sounds. An interference with swallowing is a motor loss, not a sensory loss, and it is not an expected response to aging. There is a decreased, not heightened, response to stimuli in older adults. There is a decreased, not increased, ability to physiologically adjust to extremes in environmental temperature.

The nurse is performing a weight assessment for different people in a community. Which question should the nurse ask a client to determine a disease-related change in weight?

1 Do you follow a strict calorie intake? 2 Have you notices any changes in the social aspects of eating? 3 Are you taking diuretics or insulin? Correct4 Have you noticed any unintentional weight loss in the past six months? R:Unintentional or undesired weight loss during a certain period of time may indicate a weight change due to a disease, such as gastrointestinal problems. A strict calorie intake in a permitted limit is not related to any disease. Assessing the social aspects of a client's eating habits determines any lifestyle changes that may cause a weight change. Diuretics and insulin may cause weight loss or weight gain; this change is not disease-related.

The community nurse is assessing an elderly client who lives alone at home. The nurse finds that the client refrains from physical activity for fear of falling when walking. Which interventions by the nurse are most beneficial to promote a healthy lifestyle? Select all that apply.

1 Instruct the client to apply bed side rails. Correct2 Encourage the client to wear nonskid shoes. Correct3 Suggest that the client use an assistive device. 4 Ask the client to install hand rails in the bathroom. Correct5 Help the client rearrange furniture in the house. R: The nurse should encourage the client to wear nonskid shoes that will provide a firm grip while walking and help reduce the chance of falls. The nurse should suggest that the client use an assistive device such as a cane or walker for support while walking. The nurse should make environmental changes by helping the client rearrange the furniture in the house. This will help reduce the incidence of falls within the house. These interventions reduce the fear of falling and encourage the client to participate in physical activity indoors and outdoors. The bed side rails protect the client from falling from the bed. The hand rails in the bathroom assist provide support while using the bathroom.

After an eye assessment, the nurse finds that both of the client's eyes are not focusing on an object simultaneously and appear crossed. What could be the cause for this condition?

1 Loss of elasticity of the lens Correct2 Impairment of the extraocular muscles 3 Obstruction of the aqueous humor outflow 4 Progressive degeneration of the center of the retina R: Strabismus is a condition where the eyes appear crossed; this condition is caused by the impairment of the extraocular muscles. A loss of lens elasticity may lead to presbyopia, which causes impaired near vision. An obstruction of the aqueous humor outflow may lead to glaucoma. The progressive degeneration of the center of the retina indicates macular degeneration and leads to blurred central vision.

A mother is worried about the sudden behavioral changes in her child. The child has suddenly developed a fear of certain people and places. The child's school performance is declining rapidly, and the child has developed poor relationships with his or her peers. After assessing the physical findings of the child, the nurse suspects child abuse. Which physical findings might have led the nurse to this suspicion?

1 Sunken eyes and loss of weight 2 Uncommunicative and uninteractive with others Correct3 Foreign bodies in the rectum, urethra, or vagina 4 Strangulation marks on neck from rope burns or bruises R: One of the physical findings that may be required to confirm child abuse is the presence of foreign bodies in the rectum, urethra, or vagina. Weight loss and sunken eyes may be a physical finding for older adult abuse. When the abuse is related to an intimate partner, the nurse may observe strangulation marks on the neck from rope burns or bruises. Staying isolated and not communicating with others are behavioral findings that may be related to older adult abuse.

A nursing student is recording the radial pulse rate in a client with dysrhythmias and documented a radial pulse of 80 beats per minute. The registered nurse reassesses the client and notices a pulse deficit of 15. What is the client's apical pulse?

Correct1 95 2 85 3 75 4 65 R: Dysrhythmias are often associated with pulse deficits. A pulse deficit is the difference between the apical and radial pulse rates. Thus, when the radial pulse (80) and the pulse deficit (15) are added together, the apical pulse would be 95.

A 16-year-old client has a blood pressure reading of 119/75. What is the approximate pulse pressure? Record your answer using a whole number. __________ mm Hg

The difference between the systolic and diastolic pressure is called the pulse pressure. The given blood pressure is 119/75. The difference between 119 and 75 is 44.

While performing a physical assessment of a client, a nurse notices patchy areas with loss of pigmentation on the skin, hands, and arms. What is the probable etiology for this condition?

1 Anemia 2 Pregnancy 3 Lung disease Correct4 Autoimmune disease R: Patchy areas with loss of pigmentation on skin, hands, and arms are due to vitiligo, which is caused by an autoimmune or congenital disease. Anemia results in pallor due to a reduced amount of oxyhemoglobin. A tan-brown color of the skin is noticed in pregnancy due to an increased amount of melanin. Lung disease or heart failure can cause cyanosis due to an increased amount of deoxygenated hemoglobin.

The nurse noticed the breathing rate as regular and slow while assessing a client for respiration. What could be the condition of the client?

1 Apnea Correct2 Bradypnea 3 Tachypnea 4 Hyperpnea R: In bradypnea the breathing rate is regular, but it is abnormally slow. Respirations cease for several seconds in apnea. The rate of breathing is regular, but abnormally rapid in tachypnea. In hyperpnea, the respirations are labored, the depth is increased, and the rate is increased.

The student nurse prepares a concept map while caring for a client recovering from surgery. What is the first step that the student nurse should take when preparing the concept map?

1 Assess the client and gather information. Correct2 Arrange cues into clusters that form patterns. 3 Identify patterns reflecting the client's problem. 4 Identify specific nursing diagnoses for the client. R: A concept map is a visual representation of the connection between the client's many health problems. The first step is to arrange all the cues into clusters that form patterns. This helps the nurse identify specific nursing diagnoses for the client. During the assessment stage, the nurse assesses the client and gathers information. This step is performed before preparing the concept map. After placing all cues into clusters, the nurse begins to identify patterns reflecting the client's problem. The concept map helps the nurse obtain a holistic view of the client's needs. The next step is to identify specific diagnoses so that appropriate nursing interventions can be provided.

Which client assessment finding should the nurse document as subjective data?

1 Blood pressure 120/82 beats/min Correct2 Pain rating of 5 3 Potassium 4.0 mEq 4 Pulse oximetry reading of 96% R: Subjective data are obtained directly from a client. Subjective data are often recorded as direct quotations that reflect the client's feelings about a situation. Vital signs, laboratory results, and pulse oximetry are examples of objective data.Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options. Example: If the item relates to and identifies stroke rehabilitation as its focus and only one of the options contains the word stroke in relation to rehabilitation, you are safe in identifying this choice as the correct response.

A nurse is assessing clients with gastrointestinal problems. Which client does the nurse suspect to have shigellosis?

1 Client 1 Correct2 Client 2 3 Client 3 4 Client 4 R: Shigellosis is a food-borne disease and may be due to the ingestion of milk products, seafood, or salad. The symptoms of infection include abdominal cramps and severe diarrhea and can occur 12 hours after ingestion. Therefore, shigellosis is suspected in client 2. Client 1, who has symptoms of severe abdominal cramps, pain, vomiting, diarrhea, perspiration, headache, and fever after consuming custard or processed meats, may have a Staphylococcus infection. These symptoms may appear 3 days after ingestion contaminated foods. Client 3, who has symptoms of severe diarrhea, fever, headache, and breathing difficulty after consuming soft cheese, meat, or unpasteurized milk, may have an Escherichia coli infection. These symptoms may appear 3 days after ingestion of contaminated food. Client 4 with symptoms of severe diarrhea, cramps, and vomiting after consuming milk, custards, egg dishes, or sandwich fillings may have salmonellosis. These symptoms may appear 4 days after ingestion of those foods.

What are physiologic symptoms assessed in a client with sleep deprivation? Select all that apply.

1 Correct: Ptosis and blurred vision 2 Agitation and hyperactivity 3 Confusion and disorientation 4 Increased sensitivity to pain 5 Correct: Decreased auditory alertness R: Ptosis may result from a loss of elasticity of the eyelids, which is a physiologic symptom of sleep deprivation. Decreased auditory alertness and blurred vision are also physiologic symptoms of sleep deprivation. Agitation, hyperactivity, confusion, disorientation, and increased sensitivity to pain are psychologic symptoms of sleep deprivation.

A client complains of sudden muscle weakness during times of anger or laughter that may occur at any time during the day. Which condition should be suspected in this client?

1 Insomnia Correct2 Cataplexy 3 Narcolepsy 4 Sleep apnea R: Cataplexy is a condition in which muscle weakness occurs suddenly during times of intense emotion, such as anger, sadness, or laughter. A cataplexic attack may occur at any time during the day. Insomnia is a condition in which a person has chronic difficulty falling asleep. A person with narcolepsy also experiences frequent awakenings from sleep, short periods of sleep or nonrestorative sleep, or some combination thereof. Narcolepsy is a dysfunction of the mechanisms that regulate sleeping and waking states. Sleep apnea is a disorder characterized by a lack of airflow through the nose and mouth for periods of 10 seconds or longer during sleep.

A 78-year-old client who has hypertension is beginning treatment with furosemide. Considering the client's age, what should the nurse teach the client to do?

1 Limit fluids at bedtime. Correct2 Change positions slowly. 3 Take the medication between meals. 4 Assess the skin for breakdown daily. R: With aging there is a decreased vasomotor response and diminished elasticity of blood vessels, which therefore do not respond quickly to changes from horizontal to vertical; orthostatic hypotension may occur. Changing positions slowly allows the body to adjust, which prevents dizziness and loss of balance. Usual fluid intake patterns can be maintained. Furosemide should be taken with meals to prevent gastric irritation. It is best to take it in the morning rather than at night so that sleep is not interrupted with the need to void. There is no link between furosemide and skin breakdown.

Three days after bariatric surgery, the client puts the call light on and states, "I felt a 'pop' in my belly after I had a coughing spell." The nurse assesses the client's incision site for signs of dehiscence. Which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence?

1 Loosening of the sutures Correct2 Sharp increase in serosanguineous drainage 3 Purplish color of the incision 4 Protrusion of organs through an open incision R: Serosanguineous drainage from the wound or on the dressing forewarns separation of the wound edges (dehiscence); dehiscence may progress to movement of abdominal organs outside of the abdominal cavity (evisceration). Loosening of sutures may occur after the initial wound edema subsides, but is not a sign of failure of the suture line. A purplish incision is the expected coloration of a healing wound.

The nurse is aware that the nursing diagnosis should follow the North American Nursing Diagnosis Association International (NANDA-I) label. How should the nurse document the nursing diagnosis in a three-part format?

1 NANDA-I label, related factor, and etiologies 2 NANDA-I label, risk factor, and nursing interventions 3 NANDA-I label, related factor, and nursing interventions Correct4 NANDA-I label, related factor, and defining characteristics R: The three-part nursing diagnosis label consists of the NANDA-I label, related factor, and defining characteristics. This format is also known as the problem, etiology, and symptoms (PES) format. The nurse does not document the nursing diagnosis as NANDA-I label, related factor, and etiologies. A related factor is a condition or etiology that gives a context for the defining characteristics. The nurse does not document the nursing diagnosis as NANDA-I label, risk factor, and nursing interventions. A risk for nursing diagnosis uses the risk factor instead of related factor. Nursing interventions are not included in a nursing diagnosis. Therefore, the nurse does not document the nursing diagnosis as NANDA-I label, related factor, nursing interventions.

A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes?

1 Skeletal and nervous 2 Circulatory and urinary Correct3 Respiratory and urinary 4 Muscular and endocrine R: Increased respirations blow off carbon dioxide (CO2), which decreases the hydrogen ion concentration and the pH increases (less acidity). Decreased respirations result in CO2 buildup, which increases hydrogen ion concentration and the pH falls (more acidity). The kidneys either conserve or excrete bicarbonate and hydrogen ions, which helps to adjust the body's pH. The buffering capacity of the renal system is greater than that of the pulmonary system, but the pulmonary system is quicker to respond. Skeletal and nervous systems do not maintain the pH, nor do muscular and endocrine systems. Although the circulatory system carries fluids and electrolytes to the kidneys, it does not interact with the urinary system to regulate plasma pH.

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client?

1 Skin turgor 2 Intake and output results 3 Client's report about fluid intake Correct4 Blood lab results R: Blood lab results provide objective data about fluid and electrolyte status, as well as about hemoglobin and hematocrit. Skin turgor is not a reliable indicator of hydration status for the elderly client because it is generally decreased with age. Intake and output results provide data only about fluid balance, but do not present a comprehensive picture of the client's fluid and electrolyte status; therefore this is not the best answer. The client's report about fluid intake is subjective data in general and not reliable because this client has dementia and therefore has memory problems.

A client presents with bilateral leg pain and cramping in the lower extremities. The client has a history of cardiovascular disease, diabetes, and varicose veins. To guide the assessment of the pain and cramping, the nurse should include which question when completing the initial assessment?

Correct1 "Does walking for long periods of time increase your pain?" 2 "Does standing without moving decrease your pain?" 3 "Have you had your potassium level checked recently?" 4 "Have you had any broken bones in your lower extremities?" R: Clients with a medical history of heart disease, hypertension, phlebitis, diabetes, or varicose veins often develop vascular-related complications. The nurse should recognize that the relationship of symptoms to exercise will clarify whether the presenting problem is vascular or musculoskeletal. Pain caused by a vascular condition tends to increase with activity. Musculoskeletal pain is not usually relieved when exercise ends. Low potassium levels can cause cramping in the lower extremities; however, given the client's health history, vascular insufficiency should be suspected. Previously healed broken bones do not cause cramping and pain.

A registered nurse is teaching a nursing student about when a client with high blood pressure should follow up with the primary healthcare provider. Which statement made by the nursing student indicates effective learning?

Correct1 "I will advise a client with a blood pressure of 130/80 mm Hg to follow up in a year." 2 "I will advise a client with a blood pressure of 110/70 mm Hg to follow up in a year." 3 "I will advise a client with a blood pressure of 150/90 mm Hg to follow up in a month." 4 "I will advise a client with a blood pressure of 185/115 mm Hg to follow up in a month." R: A client with prehypertension tends to have a blood pressure (BP) between 120/80 and 139/89 mm Hg. These clients should be rechecked in a year. Clients with BP less than 120/80 mm Hg are considered normal. These clients should be rechecked in two years. Clients with stage 1 hypertension have a BP between 140/90 and 159/99 mm Hg. These clients should be rechecked in two months to confirm stage 1 hypertension. Clients with stage 2 hypertension have a BP greater than 160/100 mm Hg. These clients should be rechecked in one month. If a client's BP is greater than 180/110 mm Hg, then he or she should be treated immediately or within 1 week.

A nurse is assessing a client who was admitted with a head injury that occurred 4 days ago and is diagnosed with an injury to the speech center in the cerebral cortex. Upon further assessment, the nurse finds that the client is unable to understand written or verbal speech. Which condition does the nurse suspect?

Correct1 Aphasia 2 Dysarthria 3 Borborygmi 4 Tactile fremitus R: Aphasia of the receptive type is a condition in which the client cannot understand written or verbal speech. This may be due to injury to the cerebral cortex. Dysarthria is a motor speech disorder in which the client has difficulty speaking caused by impairment of the muscles used in speech. Borborygmi are rumbling noises made by the movement of fluid and gas in the intestine. Tactile fremitus is the vibration created during speech by the vocal cords when sound is transmitted through the lung to the chest wall.

he nurse is assessing a client who arrived at the healthcare facility for an appointment. Which action by the nurse will be beneficial during the interview?

Correct1 Asking about the client's current concerns 2 Ensuring the interview follows a strict agenda 3 Asking questions that promote short responses by the client 4 Telling the client what he or she should expect from the visit R: The nurse should begin the interview by gathering information about the client's current concerns to encourage the client to express his or her chief problems. The nurse then sets an agenda for the interview. However, the nurse must remember that the best interview focuses on the client and not the nurse's agenda. The nurse must ask open-ended questions that allow the client to describe his or her concerns more clearly. The nurse should ask the client to describe his or her healthcare expectations to help the client understand that the nurse is genuinely interested in the client's health.

An older adult client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which nursing actions have specific gerontologic implications the nurse must consider? Select all that apply.

Correct1 Assessment of skin turgor 2 Documentation of vital signs 3 Assessment of intake and output Correct4 Administration of antiemetic drugs Correct5 Replacement of fluid and electrolytes R: When skin turgor is assessed, the presence of tenting may be related to loss of subcutaneous tissue associated with aging rather than to dehydration; skin over the sternum should be used instead of skin on the arm for checking turgor. Older adults are susceptible to central nervous system side effects, such as confusion, associated with antiemetic drugs; dosages must be reduced, and responses must be evaluated closely. Because many older adults have delicate fluid balance and may have cardiac and renal disease, replacement of fluid and electrolytes may result in adverse consequences, such as hypervolemia, pulmonary edema, and electrolyte imbalance. Vital signs can be obtained as with any other adult. Intake and output can be measured accurately in older adults.

Which clients should be considered for assessing the carotid pulse? Select all that apply.

Correct1 Client with cardiac arrest 2 Client indicated for Allen test Correct3 Client under physiologic shock 4 Client with impaired circulation to foot 5 Client with impaired circulation to hand R: Carotid pulse is indicated in clients with physiologic shock or cardiac arrest when other sites are not palpable in the client. Assessment of the ulnar pulse is indicated in clients requiring an Allen test. Assessment of posterior tibial pulse and dorsalis pedis pulse is indicated in clients with impaired circulation to the feet. Assessment of the radial and ulnar pulse is indicated in clients with impaired circulation to the hands.

Which features distinguish nursing diagnoses from medical diagnoses? Select all that apply.

Correct1 Nursing diagnoses involve the client when possible. 2 Nursing diagnoses are based on results of diagnostic tests and procedures. 3 Nursing diagnoses are the identification of a disease condition in the client. Correct4 Nursing diagnoses involve the sorting of health problems within the nursing domain. Correct5 R: Nursing diagnoses involve clinical judgment about the client's response to health problems. Establishing a nursing diagnosis is the second step in the nursing process. It is unique and involves the client's participation in the process. Nursing diagnoses classify health problems to be treated primarily by nurses. The nurse reviews the client assessment, sees cues and patterns in the data, and identifies the client's specific health care problems. The nursing diagnosis is a clinical judgment about the client's actual or potential health problems that the nurse is licensed to treat. A medical diagnosis is based on results of diagnostic tests and procedures, whereas a nursing diagnosis is based on the results of the nursing assessment. A medical diagnosis identifies a disease condition in the client.