HA exam 1
Which statement made by the nurse indicates that the client interview is coming to a close? A. "I have just one more question for you." B. "I hope you are comfortable and not in pain." C. "I would like to spend some time to understand your concerns." D. "I assure you that information I gather now will be confidential."
A Rationale The nurse should give the client a clue that the interview is drawing to a close. The nurse can do this by letting the client know that after one more question the interview will be over. The nurse sets the stage for the interview by ensuring that the client is comfortable and not in pain. The nurse begins the interview by stating that he or she would like to spend some time to understand the client's health concerns. The nurse informs the client at the beginning of the interview that the information shared by the client is confidential.
A nurse is performing a mental status assessment. What is being assessed when the nurse notes that the client is cooperative? a. Mood b. Affect c. Attitude d. Perception
C. Rationale Attitude relates to the approach or manner of the client during the interaction with the interviewer (e.g., cooperative, resistive, friendly, ingratiating). Mood is a feeling state reported by the client (e.g., sad, depressed, angry, anxious, happy). Affect is a person's mood, feelings, or tone, observable as an outward manifestation; it may be referred to as inappropriate, flat, or blunted. Perception is how a person views and interprets a situation; a perception may or may not be based in reality.
A farmer seeks medical care for a large crusty patch of skin on the cheek. The client states that even after using different remedies, it still bleeds easily and has not gotten better. From the client's history, the nurse suspects skin cancer. Which factor in the client's history helped the nurse form this conclusion? A. Exposure to radiation B. Location of the lesion C. Self-treatment of lesions D. Contact with soil contaminants
A. Rationale The major cause of skin cancer is exposure to the sun's ultraviolet light, a form of radiation. Farmers are susceptible to this type of cancer. The location of the lesion is not a causative factor of skin cancer. Self-treatment of a lesion is not a causative factor of skin cancer. Although environmental pollutants may have some bearing, they are not considered the major cause of skin cancer.
A client is diagnosed with Hodgkin disease. Which lymph nodes does the nurse expect to be affected first? A. Cervical B. Axillary C. Inguinal D. Mediastinal
A. Rationale Painless enlargement of the cervical lymph nodes often is the first sign of Hodgkin disease, a malignant lymphoma of unknown etiology. Axillary node enlargement occurs after cervical lymph node enlargement. Inguinal node enlargement occurs later. Mediastinal node involvement follows after the disease progresses.
What does the nurse infer from this image? <p>What does the nurse infer from this image? <br/> <img src="//eolscontent.elsevier.com/10D35D8019H/image/468_nclex-rn_integumentarysystem_g_question_7.png" alt=""/> </p> A. Actinic keratosis B. Dysplastic nevus C. Basal cell carcinoma D. Malignant melanoma
B Rationale Dysplastic nevus is clinically manifested by an irregular border (possibly notched), variegated color of tan, brown, black, red, or pink within a single mole. At least one flat portion is present, often at the edge of the mole. Actinic keratosis is clinically manifested as a flat or elevated, dry, hyperkeratotic scaly papule that appears possibly flat, rough, or verrucous (wart-like). Nodular and ulcerative basal cell carcinoma manifest as small, slowly enlarging papules with borders that are semi-translucent or pearly with overlying telangiectasia; erosion, ulceration, and depression in the center of the lesion may appear. Malignant melanoma manifest with irregular color, surface, and border with variegated color, including red, white, blue, black, gray, and brown. Malignant melanoma appears flat or elevated, eroded or ulcerated.
Which interventions should the nurse perform while collecting subjective data from a client during a focused respiratory assessment? Select all that apply. A.Palpate the chest and back for masses B.Question the client about shortness of breath C. Check the hematocrit and hemoglobin values D. Inspect the skin and nails for integrity and color E. Ask the client about color and quantity of sputum
B & E Rationale Subjective data is collected directly from the client. During the focused respiratory assessment, the nurse should ask the client about any shortness of breath and about the color and quantity of any sputum produced. Objective data is collected by the nurse through physical examination and laboratory reports. The nurse should palpate the chest and back for masses while collecting objective data during the physical examination. The nurse checks the hematocrit and hemoglobin values while collecting objective diagnostic data. The nurse inspects the client's skin and nails for integrity and color to determine oxygenation of tissues.
Which client assessment finding should the nurse document as subjective data? A. Blood pressure 120/82 beats/min B. Pain rating of 5 C.Potassium 4.0 mEq D. Pulse oximetry reading of 96%
B. Rationale 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.
A registered nurse teaches a nursing student about how to interview an adolescent. Which statements made by the nursing student indicate the need for further education? Select all that apply. a. "I should begin with less sensitive issues." b. "I should ask open-ended questions if possible." c. "I should use language that is common for adolescents." d. "I should make assumptions regarding his or her feelings." e. "I should interview an adolescent along with his or her parents."
D, and E Rationale The nurse should not make assumptions regarding an adolescent's feelings; the nurse should maintain objectivity. The nurse should be confidential and maintain an adolescent's privacy by not interviewing him or her in front of his or her parents. The nurse should begin the interview with less sensitive issues and then proceed to more sensitive ones. The nurse should ask open-ended questions if possible. The nurse should use language that is known to the adolescent so he or she can understand.
Which area is most common for the occurrence of the carcinoma represented in this image? <p>Which area is <b>most</b> common for the occurrence of the carcinoma represented in this image? <br/> <img src="//eolscontent.elsevier.com/10D35D8019H/image/527_nclex-rn_integumentarysystem_e_question_10.png" alt=""/> </p> A. Sun-exposed areas B. Sites of chronic irritation C. Area of the backs of hands D. Place where moles are evident
D. Rationale The image signifies melanoma. These pigmented cancers may arise in melanin-producing epidermal cells. Melanoma most commonly occurs at the place where moles or birthmarks are evident. Basal cell carcinomas include a pearly papule with a central crater that mostly occurs in the sun-exposed areas. The sites of such chronic irritation as scars, irradiated skin, burns, and leg ulcers may be found with squamous cell carcinomas. Actinic keratosis may develop on the areas of the back of the hands.
What nursing actions best promote communication when obtaining a nursing history? Select all that apply. A. Establishing eye contact B. Paraphrasing the client's message C. Asking "why" and "how" questions D. Using broad, open-ended statements E. Reassuring the client that there is no cause for alarm F. Asking questions that can be answered with a "yes" or "no"
A, B & D Rationale Eye contact indicates to the client that the nurse is listening and interested. Paraphrasing is an effective interviewing technique; it indicates to the client that the message was heard and invites the client to elaborate further. Open-ended statements provide a milieu in which people can verbalize their problems rather than be placed in a situation of providing a forced response. Asking "why" and "how" questions can be threatening to the client, who may not have the answer to these questions. False reassurance is detrimental to the nurse-client relationship and does not promote communication. Direct questions do not open or promote communication.
The nurse is conducting a secondary survey as part of the emergency assessment. Which is the priority nursing action during the health history portion of the assessment? A. Determining drug allergies B. Noting the general appearance C. Examining the neck for stiffness D. Auscultating for heart and lung sounds
A. rationale: The priority nursing action during the health history portion of the assessment is to determine drug allergies. Noting the general appearance, examining the neck for stiffness, and auscultating for heart and lung sounds are actions that occur during the head-to-toe physical assessment, not the health history.
The nurse is performing physical assessments for children in a daycare center. Which children should require a head circumference in order to monitor growth patterns? Select all that apply. A. A 6-month-old infant who is breastfed B. A 15-month-old toddler who has asthma C. A 3-year-old child whose birthday was the day prior D. A 5-year-old who will attend kindergarten in the fall E. An 8-year-old child who will begin playing soccer next week
A,B,&C Rationale: The nurse includes a head circumference in the physical assessment from birth to 36 months of age; therefore, the 6-month-old infant, the 15-month-old toddler, and the 3-year-old child whose birthday was the day prior will all have their head circumferences measured during the assessment. The 5-year-old and the 8-year-old will not have their head circumferences measured during the assessment process.
A nurse is assessing a client who underwent abdominal surgery 10 days ago. The client complains of pain in the abdomen. What type of pain does the client experience? A. Visceral pain B. Somatic pain C. Referred pain D. Intractable pain
A Rationale Visceral pain arises from visceral organs such as the pancreas, which results from the stimulation of pain receptors in the abdominal cavity. Somatic pain arises from bone, joint, muscle, skin, or connective tissue and is usually aching or throbbing in quality and well localized. Referred pain is experienced in clients with tumors, in which pain is felt in a part of the body other than its actual source. Intractable pain is a neuropathic pain that is severe, constant pain that is not curable.
Which strategy needs to be employed while interviewing the adolescent as a part of her health-screening? A. To start with more sensitive issues B. To explain the limits of confidentiality C. To ask more of close-ended questions D. To interview the adolescent along with her parents
B Rationale Explaining the limits of confidentiality helps to obtain reports on physical or sexual abuse. It also helps to get others involved if the client is suicidal. As per the nursing care guidelines, interview should include open-ended questions, when possible, in order to obtain detailed information about the client. As per the guidelines, interview should begin with less sensitive issues followed by more sensitive ones. In order to ensure privacy, it is preferable to interview the adolescent in the absence of parents.
A nurse is assessing the skin of an older adult. Which findings will the nurse determine are expected? Select all that apply. A. Scaly skin B. Tenting of skin C. Transparent skin D. Increased wrinkles E. Pigmented lesions
B, C, D, & E Rationale Decreased subcutaneous fat with degeneration of elastic fibers allows tenting of the skin and increased wrinkles. Decreased dermal thickness results in paper-thin, transparent skin. Pigmented lesions (liver spots, solar lentigines) increase in number, size, and distribution with aging. Scaling of the skin is more commonly associated with psoriasis than aging.
A registered nurse (RN) is performing a physical assessment of four clients with various medical conditions as shown in the chart. Which client is expected to have concavely curved nails? Client A: subacute endocarditis Client B: Iron Deficiency Heart Disease Client C: Cyanotic Heart Disease Client D: COPD
Client D Rationale: Conditions such as iron deficiency anemia and syphilis cause concave curvature of the nails, which is called koilonychia (spoon nails). Red or brown linear streaks in the nail bed are caused by minor trauma to nails, subacute endocarditis, or trichinosis. They are called splinter hemorrhages. Softening of the nail bed and enlargement of the finger tips with flattened nails are signs of clubbing of nails, which is seen in conditions of oxygen deficiency such as in heart or pulmonary diseases, cyanotic heart disease, and chronic obstructive pulmonary disease.
A nurse is obtaining a health history from the newly-admitted client who has chronic pain in the right knee. What should the nurse include in the pain assessment? Select all that apply. A. Pain history, including location, intensity, and quality of pain B. Client's purposeful body movement in arranging the papers on the bedside table C. Pain pattern, including precipitating and alleviating factors D. Vital signs, such as increased blood pressure and heart rate E. The client's family statement about increases in pain with ambulation
A & C Rationale The initial pain assessment should include information about the location, quality, intensity, onset, duration and frequency of pain, as well as factors that relieve or exacerbate the pain. Vital signs are a secondary assessment related to the initial pain assessment. Accurate pain assessment includes pain history with the client's identification of pain location, intensity, and quality and helps the nurse identify what pain means to the client. The pattern of pain includes time of onset, duration, and recurrence of pain, and its assessment helps the nurse anticipate and meet the needs of the client. Purposeless movements such as tossing and turning or involuntary movements such as a reflexive jerking may indicate pain. Assessment of the precipitating factors helps the nurse prevent the pain and determine its cause. Elevated blood pressure and heart rate are physiological responses to pain and not a direct evaluation of pain. Pain is a subjective experience, and therefore the nurse has to ask the client directly instead of accepting the statement of the family members.
The nurse is teaching a client about self-management to prevent dry skin. Which statement made by the client indicates the need for further teaching? A. "I should use nonalkaline soap for a bath." B. "I should apply rubbing alcohol to the skin." C. "I should avoid clothing that continuously rubs the skin." D. "I should use a room humidifier during the winter months."
B Rationale To prevent dry skin, rubbing alcohol is contraindicated because alcohol increases skin dryness. Use of nonalkaline soap for bathing prevents dry skin. Avoid clothing that continuously rubs the skin such as tight belts and nylon stockings. Use room humidifiers during winter months because skin is drier in winter.
The nurse is caring for four clients. Which client would the nurse anticipate to have decreased skin turgor? Client A: trauma Client B: severe dehydration Client C: anxiety Client D: Chronic eczema
B Rationale: Severe dehydration results in decreased skin turgor or elasticity due to decreased water content. Therefore client B should be assessed for skin turgor. Client A, with trauma, may have edema due to the inflammatory response. In client C, anxiety may result in increased skin moisture due to autonomic nervous system stimulation. In client D, chronic eczema results in alteration of skin texture leading to increased thickness due to irritation or friction.
A client with multiple sclerosis is informed that this is a chronic, progressive neurologic condition. The client asks the nurse, "Will I experience unbearable pain?" What is the nurse's best response? A "Tell me about your fears regarding pain." B "Analgesics will be prescribed to control the pain." C. "Some clients report feeling a tingling or burning sensation but not unbearable pain." D. "Let's make a list of the things you need to ask your healthcare provider."
C Rationale The response, "Some clients report feeling a tingling or burning sensation[1][2], but not unbearable pain," is a truthful answer that provides hope for the client. Although neuropathic pain may sometimes occur, it does not occur in all clients. These clients more typically have diminished sensitivity to pain and paresthesias (e.g., tingling, burning, crawling sensations). The response, "Tell me about your fears regarding pain," avoids the client's question and may increase anxiety. Analgesics are not commonly prescribed unless pain results from some other condition. The response, "Let's make a list of the things you need to ask your healthcare provider," avoids the client's question and abdicates the nurse's responsibility.
The nurse is getting a client out of bed to the chair for the first time since surgery 2 days ago. What assessment should the nurse should make first before moving the client? a. Assessment of appropriate foot wear b. Assessment of comfort and pain c.Assessment of wound and skin d. Assessment of urinary catheter
b Rationale Pain and comfort have to be assessed first before beginning to transfer the client. Assessment of foot wear, wound assessment, and catheter assessment are important after pain has been assessed and treated, if needed.
The 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? A. Asking about the client's current concerns B. Ensuring the interview follows a strict agenda C.Asking questions that promote short responses by the client D. Telling the client what he or she should expect from the visit
A Rationale 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.
During a newborn assessment the nurse identifies that the temperature, pulse, respirations, and other physical characteristics are within the expected range. The nurse records these findings on the clinical record. Legally, how should the nurse's action be interpreted? A. The nurse performed her role correctly. B. This is a medical diagnosis and the nurse overstepped the legal boundary. C. Nursing assessments are not equivalent to a primary healthcare provider's assessments. D. The initial assessment of the infant's physical status is the responsibility of the client's primary healthcare provider.
A Rationale: Accurate documentation of the infant's status is an integral component of nursing care. This is a physical assessment, not a medical diagnosis, and is within the nurse's role. Assessments should not differ when done by the nurse. The nurse is capable of independently performing a physical assessment.
Which actions should the nurse perform while collecting subjective data from a client during a focused urinary assessment? Select all that apply. A.Inquire about painful urination B. Ask the client about changes in characteristics of urination C. Assess the levels of blood urea nitrogen and creatinine D. Palpate the abdomen for bladder distention or masses E. Inspect the urinary meatus for inflammation or discharge
A & B Rationale While collecting subjective data from a client during the focused urinary assessment, the nurse should ask the client about painful urination and also about any changes in the characteristics of urination (diminished, excessive). This information indicates the presence or absence of urinary disorders. The nurse should palpate the abdomen for bladder distention or masses while collecting objective data during the physical examination. The blood, urea, nitrogen, and creatinine values are included in the objective diagnostic data. The nurse inspects the client's urinary meatus for inflammation or discharge while collecting objective data during the physical examination.
A nurse is taking care of a client who has chronic back pain. What nursing considerations should be made when determining the client's plan of care? Select all that apply. A. Ask the client about the acceptable level of pain. B. Eliminate all activities that precipitate the pain. C. Administer the pain medications regularly around the clock. D. Use a different pain scale each time to promote client education. E. Assess the client's pain every 15 minutes.
A & C Rationale The nurse works together with the client in order to determine the tolerable level of pain. Considering that the client has chronic, not acute, pain, the goal of pain management is to decrease pain to a tolerable level instead of eliminating pain completely. Administration of pain medications around the clock will provide a stable level of pain medication in the blood and relieve the pain. Elimination of all activities that precipitate the client's pain is not possible even though the nurse will try to minimize such activities. The same pain scale should be used for assessment of the client's pain level because it helps ensure consistency and accuracy in the pain assessment. Only management of acute pain, such as postoperative pain, requires pain assessment at frequent intervals.
The registered nurse asks a client to rate his or her pain on a scale from 0 to 10, then instructs the nursing student to perform a physical assessment. Which assessments performed by the nursing student would be appropriate? Select all that apply. A. Palpating for tenderness B. Observing nonverbal cues C. Inspecting any areas of discomfort D. Noticing if the pain localized or radiated E. Noticing if the client gives nonverbal signs of pain
A & C Rationale: To understand the severity of a client's pain, the registered nurse asks the client to rate the pain on a scale from 0 to 10. The nursing student may palpate for tenderness while assessing the severity of pain and inspecting the area of discomfort. Nonverbal cues are used to understand the nature of pain. Physical assessments of the nature of pain may involve the nurse noticing whether the pain is radiated or localized. The client should also be checked for any nonverbal signs of pain.
When should the nurse observe the client to assess his or her level of functioning? Select all that apply. A. During meal time B. When talking about pain C. When preparing medication D. During the assessment interview E. When administering insulin injections
A, C, & E Rationale: An observation of the functional level of the client often occurs during a return demonstration. The nurse may also observe the client while eating to determine if the client is able to eat without assistance. The nurse teaches the client how to prepare medications and asks for a return demonstration to assess the client's understanding. The nurse also observes the client administering insulin injections to ensure that the client is able to perform it properly. Observation of functional level differs from the observation during a physical examination. The nurse closely observes the client during the physical assessment when the client talks about pain. During the assessment interview, the nurse observes the client's facial expressions and eye contact to form accurate conclusions about the client's condition. The nurse does not assess the client's functional abilities during the subjective assessment.
A registered nurse assesses clients with dark skin. Which statement made by the registered nurse indicates the need for further teaching? A. "I should touch the skin to feel its consistency." B. "I should use a fluorescent light source to assess the skin color." C "I should place my hand on the skin to assess the temperature." D. "I should look for any changes in skin color darker than surrounding skin."
B Rationale The nurse should use natural light or a halogen light source to assess accurately the skin color. Fluorescent light casts a blue color, which can make skin assessment difficult. The nurse should touch the client's skin to feel its consistency. The nurse should assess the area for the skin temperature using his or her hand. The nurse should look for any changes in skin color that are darker than surrounding skin.
A client reports diminished sensations of pain, touch, and temperature on the skin. The nurse touches the skin and finds it cool. Which skin changes should the nurse relate to the client's findings? A. Degenerated elastic fibers B. Decreased blood flow to the skin C. Increased melanocytes in basal layer D. Decreased activity of the apocrine glands
B Rationale Decreased blood flow to the skin may cause diminished sensations of pain, touch, and temperature. The skin may also feel cold. Degeneration of elastic fibers may cause increased wrinkling and sagging of the breasts. Increased melanocytes in the basal layers may cause solar lentigines. Decreased activity of the apocrine glands may be related to uneven skin color and dry skin.
The nurse pulls up on the client's skin and releases it to determine whether the skin returns immediately to its original position. What is the nurse assessing for? A. Pain tolerance B. Skin turgor C. Ecchymosis formation D. Tissue mass
B Rationale Skin turgor is assessed by gently pinching the skin and releasing it while observing the degree of elasticity. If the skin pinch remains elevated or is slow to return to its original position, this may be an indication of dehydration or deficient fluid volume. This assessment technique is not appropriate for assessing pain tolerance, checking for ecchymosis formation, or measuring tissue mass.
A nurse is assessing a newly admitted client with the pressure ulcer indicated in the picture. Which pressure ulcer stage should the nurse document on the admission history and physical? <p>A nurse is assessing a newly admitted client with the pressure ulcer indicated in the picture. Which pressure ulcer stage should the nurse document on the admission history and physical? <br/> <img src="//eolscontent.elsevier.com/10D35D8019H/image/4777_integumentary_q116_image.png" alt=""/> </p> A. Stage I B. Stage II C. Stage III D. Stage IV
B Rationale A stage II pressure ulcer is a partial-thickness ulceration of epidermis or dermis; it presents as an abrasion, blister, or shallow crater; has a red/pink wound bed, has no tissue sloughing, and may have an intact/open serum-filled blister. A stage I ulcer has tissue injury with intact skin with nonblanchable redness of a localized area; the ulcer may appear with persistent red, blue, or purple hues. A stage III pressure ulcer has full-thickness ulceration involving the epidermis, dermis, and subcutaneous tissue; sloughing may be present. It presents as a deep crater with or without undermining, and bone, tendon, and muscle are not exposed. A stage IV pressure ulcer involves full-thickness skin loss and damage to muscle, bone, or tendon; sloughing or eschar may be present on parts of the wound bed, and it often includes undermining and tunneling.
Which nursing action can be inferred from the following figure? <p>Which nursing action can be inferred from the following figure? <br/> <img src="//eolscontent.elsevier.com/10D35D8019H/image/3020_lm_healthassessment_b_question_21.png" alt=""/> </p> A. Palpation of the submental lymph node B.Palpation of the supraclavicular lymph node C. Palpation of the submandibular lymph node D. Palpation of the external jugular lymph node
B Rationale The nurse is assessing a client by palpating the supraclavicular lymph nodes, which are found just above the clavicle. The submental lymph node is present just below the chin. The submandibular lymph node is located at the underside of the jaw on either side. The external jugular lymph node is beneath the sternocleidomastoid muscles.
A client is diagnosed with a dysfunction of the eccrine gland. Which physiologic abnormality might occur in the client? Select all that apply. A. Drying of hair B. Drying of surface cells C. Decreased synthesis of vitamin D D. Decreased efficiency to cool the body E. Decreased excretion of waste products through the skin
B, D, & E Rationale The eccrine gland is a sweat gland, the main functions of which are to moisturize the surface cells, cool the body by evaporation, and excrete waste products through the pores of the skin. Therefore dysfunction of the eccrine gland may result in drying of surface cells, decreased efficiency to cool the body, and decreased excretion of waste products through the skin. The sebaceous gland secretes sebum, which prevents drying of hair and skin. Therefore dysfunction of the sebaceous gland may lead to drying of hair and skin. Endogenous synthesis of vitamin D occurs by the action of UV light on vitamin D precursors in epidermal cells. Therefore dysfunction of the eccrine gland may not be associated with decreased vitamin D synthesis.
A client is admitted with a suspected malignant melanoma on the arm. When performing the physical assessment, what would the nurse expect to find? A. Large area of petechiae B. Red birthmark that has recently become lighter in color C. Brown or black mole with red, white, or blue areas D. Patchy loss of skin pigmentation
C Rationale Melanomas have an irregular shape and lack uniformity in color. They may appear brown or black with red, white, or blue areas. Petechiae are pinpoint red dots that indicate areas of bleeding under the skin. A red birthmark is a vascular birthmark and often fades over time. A patchy loss of skin pigmentation indicates vitiligo.
Which client is at a high risk for a rise in blood pressure based on the given data? Client A: 20 yrs, 70 bpm, stroke vol normal Client B: 30 yrs. 90bpm, stroke vol decreased Client C: 40 yrs, 40 bpm, stroke vol increased Client D: 50 yrs, 100 bpm, stroke vol normal
C Rationale The blood pressure rises when the heart rate is decreased and the stroke volume is increased. In adults, the pulse rate should be between 60 and 100 beats/min. Client C's heart rate is 40 beats/min, which is less than normal, and the stroke volume is increased. Thus, client C has a high risk of high blood pressure.
A nursing student has prepared pulse assessment plans for several clients. Which client's assessment plan is correct and will yield effective results? Client A: Ulnar pulse located at the ulnar side of forearm at the wrist with results of cardiac arrest when other sites are not palpable Client B: carotid pulse located along the medial edge of sternocleidomastoid muscle in the neck resulting in presence of ulnar blood flow Client C: Dorsalis pedis pulse located along the top of the foot resulting in the status of circulation to the foot Client D: poeterior Tibial pulse located above the medial malleolus resulting in the status of circulation to the foot
Client C Rationale: The dorsalis pedis is located along the top of the foot. This site is used to assess the status of circulation in the foot. The ulnar site, found on the ulnar side of the forearm at the wrist, is used to assess the status of circulation to the hand and to perform the Allen test. The carotid site is found along the medial edge of the sternocleidomastoid muscle of the neck. It is easily accessible in times of physiological shock or cardiac arrest when other sites are not palpable. The posterior tibial site is found below (not above) the medial malleolus. It is used to assess the status of circulation in the foot.
A client with a history of food intolerance has abdominal pain, abdominal distention, and a feeling of fullness. The client is admitted to the hospital for diagnostic testing. What specific information should the nurse collect when performing the nursing admission history and physical? A. Client's food preferences B. Presence of clay-colored stools C. Amount of splinting by the client D. Detailed characteristics of the pain
D Rationale The results of a detailed pain assessment help to differentiate among the many possible gastrointestinal problems. The actual food ingested in relation to the occurrence of pain is more important information than food preferences. Although the color of stool should be assessed, it is not the priority. Although self-splinting may help to identify the location of pain, this observation does not clarify the type or severity of the pain.
Which interview technique is the nurse using when asking a client to score the pain on a scale from 0 to 10? A. Probing B. Back channeling C. Open-ended questioning D. Closed-ended questioning
D. Rationale Asking a client to score pain on a scale of 0 to 10 is a type of closed-ended question. These types of questions specify the cause of the problem or the client's experience of the illness. Asking whether anything else is bothering the client is an example of probing. A response by the nurse such as "All right," or "Go on," when a client says something is called back channeling. This interview technique encourages a client to provide more details. The nurse asks open-ended, nonspecific questions such as "What brought you to the hospital today?" to elicit the client's side of story. Such questions are related to the client's health history and can strengthen the nurse-client relationship.
A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer? A. Stage I B. Stage II C. Stage III D. Unstageable
D. Rationale A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage III pressure ulcer involves full-thickness tissue loss with visible subcutaneous fat. Bone, tendon, and muscle are not exposed.
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? A. "Edema results in the separation of skin from pigmented and vascular tissue." B. "Pitting edema leaves an indentation on the site of application of pressure." C. "Trauma or impaired venous return should be suspected in clients with edema." D. "If the pressure on an edematous site leaves an indentation of 2 mm, a score of 2+ is given."
D. Rationale 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 responses does the nurse determine represent the highest risk for the development of pressure ulcers? A. Incontinence and inability to move independently B. Periodic diaphoresis and occasional sliding down in bed C. Reaction to just painful stimuli and receiving tube feedings D. Adequate nutritional intake and spending extensive time in a wheelchair
a Rationale Constant exposure to moisture (urine) and prolonged pressure that compresses capillary beds place a client at high risk for pressure ulcers. Although periodic exposure to moisture and occasional friction are risk factors for pressure ulcers, they do not place a client at highest risk. Although immobility places a client at risk for pressure ulcers, tube feedings should meet the client's nutritional needs and promote tissue integrity. Although being chair-bound increases a client's risk for pressure ulcers, adequate nutritional intake supports tissue integrity. If the client has upper body strength, weight can be shifted periodically to relieve pressure.
Which key feature does the nurse associate with a stage 2 pressure ulcer? A.Presence of nonintact skin B. Development of sinus tracts C. Damage to the subcutaneous tissues D. Appearance of a reddened area over a bony prominence
a Rationale The skin is nonintact in stage 2 of pressure ulcers. Sinus tracts may develop during stage 4 of pressure ulcers. The subcutaneous tissue becomes damaged or necrotic during stage 3 of pressure ulcers. A reddened area over a bony surface occurs in stage 1 of pressure ulcers.
The nurse is assessing a client who had knee replacement surgery. Which assessment finding gathered by the nurse is an example of subjective data? A. The client weighs 151 lbs (68.5 Kg). B. The client's pain is 7 on a scale of 1 to 10. C. The client's fasting blood sugar is 95 mg/dL. D. The client's blood pressure is 140/90 mm/Hg.
b Rationale Subjective data is information conveyed to the nurse by the client, such as the client's feelings, perceptions, and self-reporting of symptoms. The client rates pain as a 7 on a scale of 1 to 10, therefore it is subjective data. Objective data are observations or measurements of a client's health status. The client's weight is measured on a weighing scale; therefore, it is objective data. A laboratory result such as fasting blood sugar and blood pressure are measurable quantities.
While the nurse moves a client from a lying to standing position, the client experiences a rapid drop in blood pressure. The nurse would report this finding as what? A. Malignant hypotension B. Orthostatic dehydration C. Orthostatic hypotension D. Vasomotor instability
c Orthostatic hypotension specifically refers to an abnormally low blood pressure that occurs when an individual assumes a standing position. Orthostatic hypotension is also known as postural hypotension. It may be a result of internal bleeding, fluid depletion, or loss of neurovascular control preventing vasoconstriction from regulating blood pressure. Malignant hypotension and orthostatic dehydration are inaccurate terms that are not used. Vasomotor instability occurs during menopause and results in hot flashes and night sweats.
What should the nurse teach a client who is taking antihypertensives to do to minimize orthostatic hypotension? A. Wear support hose continuously. B. Lie down for 30 minutes after taking medication. C. Avoid tasks that require high-energy expenditure. D. Sit on the edge of the bed for 5 minutes before standing.
d Rationale Sitting on the edge of the bed before standing up gives the body a chance to adjust to the effects of gravity on circulation in the upright position. Support hose may help prevent orthostatic hypotension by increasing venous return. However, they must be applied before getting out of bed and should not be worn continuously. Laying down for 30 minutes after taking medication will not prevent episodes of orthostatic hypotension. Energetic tasks, once standing and acclimated, do not increase hypotension.
