HA Exam 1

8. The nurse is planning on doing a nursing/health history on a new client by performing an interview. Which elements are considered phases of the nursing interview? Select all that apply.

>Preparatory phase >Introduction phase >Working phase >Termination phase

Question: Which assessment notation describes a client's level of consciousness?

Answer: "Client was alert and cooperative during the assessment."

Question: A female client is assessed to have a score of 6 points on the AUDIT. This would alert the nurse that this client

Answer: Has a hazardous alcohol consumption

Question: A nurse working in an emergency department (ED) uses the SAD PERSONS tool to assess a client's suicide risk. The nurse records client score as 8. What action should the nurse take?

Answer: Notify the health care provider

Question: The nurse is conducting a health history of a patient at the local community mental health clinic. Which assessment tool would the nurse administer to determine the suicide risk for the patient?

Answer: SADPERSONAS

A 3-year-old boy walks into an examination room with his mother and sees a tongue depressor. He points to it and says, "popsicle!" The nurse recognizes this as which adaptive process, as described by Piaget? Schema Assimilation Equilibrium Accommodation

Assimilation

14. 1. A nurse has completed a comprehensive assessment of a client and has begun the process of data analysis. Data analysis should allow the nurse to produce which of the following direct results? A) Outcomes evaluation B) Nursing diagnoses C) Holistic interventions D) An interdisciplinary plan of care

B) Nursing diagnoses

A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the exam, the nurse notices areas of hyperpigmentation around the neck and in the axillae. Which of the following should the nurse do next? A) Document the benign findings. B) Perform a random blood sugar test. C) Ask the client about a family history of cancer. D) Refer the client for medical follow-up

B) Perform a random blood sugar test.

When preparing to examine a client's thoracic cage, the nurse would locate which landmark as most helpful in determining where to start? A) Sternum B) Suprasternal notch C) Sternal angle D) Sternal border

C - Sternal Angle

Question: Which assessment notation describes a client's level of consciousness?

Client was alert and cooperative during assessment

Several hours into a shift, the nurse working on a medical-surgical unit observes a change in the client's mental status. Which action should the nurse take first?

Conduct a focused assessment

An older client tells the nurse "My kids still ask me to help them with their home projects." This is an example of what stage of Erikson's development?Stagnation Despair Ego integrity Generativity

Ego integrity

In what stage of Erik Erikson's model of development does the older adult come to terms with his or her life choices? Identity vs. role confusion Ego integrity vs. despair Generativity vs. stagnation Intimacy vs. isolation

Ego integrity vs. despair

The nurse obtains vital signs on a newly admitted client: temperature 101.1 F (38.4 C), heart rate 101 bpm, BP 88/56 mm Hg, O2 Saturation 94% on room air. The nurse administers an antipyretic. What will be the next step of the nursing process?

Evaluate an outcome

A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment?

Evaluation

Question: Revising the plan as needed occurs in what part of the nursing process?

Evaluation

A nurse analyzes the data obtained from an initial assessment of a new client: weight gain of 15 lbs in 3 months, intolerance to cold, constipation, and lethargy. The nurse determines the client may have hypothyroidism and develops several nursing diagnoses with interventions to address the client concerns. Which action should the nurse take next?

Implement interventions

Question: The nurse has interviewed a Hispanic client with limited English skills for the first time. The nurse observes that the client is reluctant to reveal personal information and believes in a hot-cold syndrome of disease causation. The nurse should

Indicate acceptance of the cultural differences

38. When assessing an older adult client with osteoporotic thinning and vertebral collapse, which of the following findings would the nurse expect to identify?

Kyphosis

Question: A client opens the eyes and answers questions however falls back asleep within seconds. How should the nurse document this assessment finding?

Lethargic

An older adult client had hip replacement surgery 2 days ago. The nurse enters the client's room and encourages the client to use the incentive spirometer ten times every hour. What is this action an example of?

Nursing Intervention

The nurse believes that a young adult has achieved the conventional level of moral reasoning. What behavior caused the nurse to make this decision?Obeys the law Protests injustices Does not want to "get caught" doing something wrong Ignores authority figures

Obeys the law

An instructor is emphasizing the need for nurses to be culturally sensitive and competent for which reason?

Obtain accurate assessment data

After receiving morning report the nurse prepares to assess a client who was admitted the day before. Which type of assessment will the nurse complete at this time?

Ongoing

During a health history a client states that "a tickle at the back of the throat" indicates the development of a chest cold. If Piaget's theory is applied, which concept is the client demonstrating? Equilibrium Schema Assimilation Accommodation

Schema

13. What is the nurse's best defense if a client alleges nursing negligence?

The clients record/documentation

6. What is the purpose for a comprehensive health history exam?

To collect subjective data, allowing you to perform a focused physical exam

Which of the following statements is true regarding Piaget's concept of transductive thinking? Transductive thinking is not used by adults. This type of thinking is only used by preschoolers. Transductive thinking can be used by formal operational thinkers. This type of thinking is only characteristic of 3 year olds.

Transductive thinking can be used by formal operational thinkers.

A nurse has explained her intention to conduct a Weber test and Rinne test. Which pieces of equipment will the nurse require?

Tuning Fork

Question: The nurse performs a comprehensive assessment on a new client. What is the next action of the nurse?

Validate problems and determine client goals

During the interview process, the nurse uses both open-ended and closed-ended questions. During what phase of the interview process does the nurse use these specific types of questions? A) Pre-interaction B) Beginning C) Working D) Closing

Working

Question: During the interview process, the nurse uses both open-ended and closed-ended questions. During what phase of the interview process does the nurse use these specific types of questions?

Working

While examining a client, the nurse observes the client's chest to be barrel shaped. The nurse would interpret this as indicating which of the following? a) Emphysema b) Pneumonia c) Funnel chest d) Pectus excavatum

a. Emphysema Explanation:A barrel chest is often seen in emphysema because of hyperinflation of the lungs. A change in chest shape would be rare with pneumonia. Pectus excavatum or funnel chest is a congenital malformation.

Which finding, if noted when inspecting a client's mouth, would require immediate follow-up? A) Thrush B) Leukoplakia C) Koplik spots D) Canker sore

b

When assessing a client for possible oral cancer, the nurse would closely inspect which area? A) Buccal mucosa B) Hard palate C) Area under the tongue D) Along the gum line

c

A client's electronic health record states that he has been diagnosed with sensorineural hearing loss. Which condition should the nurse most likely identify as a cause? a) Otosclerosis b) Perforated eardrum c) Otitis media d) Inner ear problem

d) Inner ear problem Explanation:Sensorineural hearing loss is related to the dysfunction of the inner ear. A perforated eardrum, otosclerosis, or otitis media would most likely cause a conductive hearing loss, since these would affect structures in the external or middle ear.

The most effective way for a nurse to learn about an ethnic group within the community in which he/she practices is: a. study transcultural nursing texts and articles about the group. b. interview the traditional healers within the group c. do a community survey of the areas where the ethnic group lives. d. spend time with a variety of individuals of that ethnic group

d. spend time with a variety of individuals of that ethnic group

12. According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:

have the right to copy their health records.

An adult client visits the clinic and tells the nurse that he has had excessive tearing in his left eye. The nurse should assess the client's eye for

lacrimal obstruction. Explanation: Excessive tearing (epiphora) is caused by exposure to irritants or obstruction of the lacrimal apparatus. Unilateral epiphora is often associated with foreign body or obstruction.

A nurse is assessing the pulses of a client's lower extremities and finds that the client's popliteal pulses are 1+. The nurse interprets this finding as: A. absent B. diminished, thready C. normal D. increased, full volume

Answer: B - Diminished, thready Rationale: Pulses that are diminished, thready, and easily obliterated are graded as 1+. Absent pulses are graded as 0. Pulses that are normal and not easily obliterated are graded as 2+. Pulses that are increased and full volume are graded as 3+.

Question: The nurse is assessing a client's respiratory rate. Which of the following should the nurse do to ensure accuracy of this assessment?

Answer: Watch chest movement before removing the stethoscope after counting the apical beat

Question : The nurse uses the SAD PERSONAS to assess the suicide risk for a patient. The total score was 3. Which interpretation by the nurse is correct? a) The patient is at high risk for suicide. b) The patient is at low risk for suicide. c) The score suggests suicide may be a problem. d) Further evaluation is needed to make a determination.

B, low risk

A nurse is talking to an 8-year-old boy who is proud of himself for washing his hands before every meal this past week. The nurse recognizes that this client is eager to please the nurse and his own parents. The nurse realizes that this boy is most likely in which level of moral development, according to Kohlberg? Conventional Latent Preconventional Postconventional

Conventional

Total parenteral nutrition (TPN) has been prescribed for a client. After several hours of infusion, the nurse checks the client's glucose and it is elevated, requiring insulin. The nurse administers the insulin as prescribed. What step in the nursing process should the nurse take next?

Evaluation

As part of assessing the client's level of consciousness, the nurse asks questions related to person, place, and time. Which of these statements is true? Orientation to person is usually lost first and orientation to time is usually lost last. Orientation to time is usually lost first and orientation to person is usually lost last. Orientation to person is usually lost first and orientation to place is usually lost last. Orientation to time is usually lost first and orientation to place is usually lost last.

Orientation to time is usually lost first and orientation to person is usually lost last.

Perform the Weber test when...

if the client reports diminished or lost hearing in one ear. Helps evaluate conduction of sound waves of the affected ear

Which statements are true when the nurse is measuring blood pressure (BP)? Select all that apply. 1- Using a BP cuff that is too small will give a higher BP measurement. 2- The client's arm should be positioned at the level of the heart. 3- Using a BP cuff that is too large will give a higher BP measurement. 4- The client's BP should be measured 1 hour before consuming alcohol .5- The client should sit quietly while BP is being measured.

1,2,5

Assessment of a client's radial pulse reveals that it is bounding and does not disappear with moderate pressure. The nurse documents the pulse amplitude as which of the following? a) 4+ b) 1+ c) 3+ d) 2+

4+

64. A client with postnasal sinus drainage is seen in the clinic. When assessing the throat, the nurse would anticipate seeing which color drainage? A) Green B) Clear C) Gray D) Yellow

D. Yellow

A client returns to the unit after a thyroidectomy. On entering the client's room, the nurse observes the client having difficulty breathing due to swelling in the neck. What type of assessment should the nurse perform at this time?

Emergency

Question: The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes?

Evidence in situations of wrongdoing

8. The nurse is reviewing the medical record before meeting a new client. In which phase of the interview process is the nurse working? A) working B) termination C) introduction D) pre-interview

Pre-interview

7. A nurse is interviewing a new client admitted to the hospital for surgery. Which action would the nurse perform in the introductory phase of the interview?

The nurse assess the client's comfort and ability to participate (introductory phase of the interview, the nurse determines if the client is going to be able to participate in the interview, gathering of information occurs during the working phase.)

A client is found to have leukoplakia, and the nurse is teaching the client about measures to reduce the client's risk. Which of the following would the nurse include in the teaching? A) "Increase your intake of foods high in iron and zinc." B) "Avoid substances that could be irritating to your mouth." C) "Make sure to get lots of vitamin from the sun." D) "Use a humidifier to increase the moisture in the environment."

b

Questions: A client's blood pressure is affected by

Answers: cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity.

Upon assessment, the nurse determines the client has a body mass index (BMI) of 45. This finding indicates the client is which of the following? a.Extremely obese b.Underweight c.Normal weight d.Obese

Extremely Obese

The nurse completes her interview of a 39-year-old female client who seems happily married with four healthy children who are doing very well in school and who works part time as a college professor. The nurse would be able to conclude that this client is in which of the following psychosocial developmental stages? Generativity Stagnation Isolation Intimacy

Generativity

A nurse palpates a client's ear and finds that the tragus is exquisitely tender. The nurse should suspect what health problem?

Otis Extena

Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media? Gray, translucent, with no retraction Pearly, translucent, with no bulging Yellowish, bulging, with fluid bubbles Red, bulging, with an absent light reflex

Red, bulging, with an absent light reflex

Which statement is true regarding children being raised in a home where they have witnessed intimate partner violence?

They are at increased risk for being abused.

The nurse obtains a client's blood pressure when standing and compares it to the measurement obtained while the client was sitting. The client's blood pressure when sitting was 122/72 mmHg. Which finding would suggest to the nurse that the client is experiencing orthostatic hypotension?

98/52 mmHg

Question: A nurse has admitted a client to the medical unit and is describing the purpose for obtaining a comprehensive health history. Which of the following purposes should the nurse describe?

Answer: "This helps us have an appropriate focus for the physical examination."

The nurse knows that she will be caring for a patient from Southern Korea who has been visiting with a family member. The nurse obtains some information about the Korean culture so that she will be able to meet the patients needs. What is the nurse demonstrating? Cultural knowledge Cultural assessment Unconscious incompetence Unconscious competence

Cultural knowledge

During a patient interview, the nurse is focusing on cultural influences particularly when assessing: (Select all that apply.) A. Health care beliefs and practices B. Employment history C. Nutrition D. Cardiovascular status E. High-risk behaviors

A,C,E

A young adult has close personal relationships and desires a permanent love relationship. What should this indicate to the nurse about the client's development? Achieved intimacy Mastered generativity Combating isolation Struggling with role confusion

Achieved intimacy

In what stage of Erik Erikson's model of development does the older adult come to terms with his or her life choices? Identity vs. role confusion Intimacy vs. isolation Generativity vs. stagnation Ego integrity vs. despair

Ego integrity vs. despair

A parent tells the nurse she is concerned that her 5 year old has an imaginary friend. The nurse understands that the child is in what stage of Piaget's cognitive development. Preoperational Concrete Formal operations Sensorimotor

Preoperational

8. A nurse assesses a client who reports the onset of a severe headache. During which phase of the nursing interview should the nurse ask the client about the history of the present health concern and the reasons for seeking care? A) Introductory B) Working C) Summary D) Closing

Working

The nurse documents a 2+ radial pulse. What assessment data indicated this result? a) diminished pulse b) brisk, expected (normal) pulse c) absent (unable to palpate) pulse d) bounding pulse

b) brisk, expected (normal) pulse

An 88-year-old woman has been admitted to the acute medical unit for the treatment of a urinary tract infection that is thought to be progressing to urosepsis. When assessing the client's orientation, how should the nurse best gauge the client's orientation to time? a- Are you able to tell me today's date? b- Are you able to tell the months and the year that we're in? c- Can you tell me approximately what time it is right now? d- Can you tell me the date and the day of the week?

b- Are you able to tell the months and the year that we're in?

12. A client made a formal request to review his or her medical records. With review, the client believes there are errors within the medical record. What is the most appropriate nursing response? "HIPAA legislation only allows access to review the medical record." "According to HIPAA, medical records cannot be changed." "HIPAA legislation allows for you to change any information." "According to HIPAA legislation, you have a right to request changes to inaccurate information."

"According to HIPAA legislation, you have a right to request changes to inaccurate information."

A nurse has been asked to assess an older adult resident of a long-term care facility. During assessment of the resident's skin, the nurse notes a break in the skin, erythema, and a small amount of serosanguineous drainage over the resident's sacrum. Inspection reveals that the area appears blister-like. The nurse should interpret this finding as indicating which stage of pressure ulcer?1 2 3 4

2

QUESTION: A nurse is evaluating a client who may have Alzheimer's disease. Which of the following are warning signs of Alzheimer's disease? Select all that apply. a. Gaining 5 pounds or more within a 2-week period b. Asking the same question over and over again c. Neglecting to bathe d. Losing one's ability to pay bills e. Sleeping longer than 12 hours in a 24-hour period f. Getting lost in familiar surroundings

ANSWER: B,C,D,F

Question: A 75-year-old male client is admitted to the hospital with confusion. The client's adult child states that their father has been becoming more confused for the past few months. The child states "they keep forgetting to pay their bills and are unable to manage a budget, and they are constantly making poor decisions. I don't know what to do." The client is able to state their name and date of birth but appears confused about where they are and why, and the current date. The client also has difficulty with word finding and carrying on a conversation. For each finding, click to specify if the finding indicates an age-related change or Alzheimer Disease. Findings may support more than one classification.

Answer: Alzheimers patients are forgetful at times, unable to make a budget, constantly making poor decisions, unable to state where they are or why or the current date, have difficulty carrying on a conversation Age related changes include being forgetful at times

Question: What are the nursing goals for the introductory phase of the nurse-client interview? (Select all that apply.)

Answer: Establishing a trusting, respectful rapport with the client AND agreeing upon the agenda for the interview

Question: A nurse is assessing a client's pain level while taking his blood pressure. Which of the following are signs of pain that the nurse should look for in the assessment? Select all that apply.

Answer: Grimacing, holding a shoulder, shallow/rapid breathing

A client tells the clinic nurse that she has sought care because she has been experiencing excessive tearing of her eyes. Which assessment should the nurse next perform?

Assess the nasolacrimal sac. Explanation:Excessive tearing is caused by exposure to irritants or obstruction of the lacrimal apparatus. Therefore the nurse should assess the nasolacrimal sac. Inspecting the palpebral conjunctiva would be done if the client complains of pain or a feeling of something in the eye. The client is not exhibiting signs of problems with muscle strength, such as drooping, so performing the eye position test, which assesses eye muscle strength and cranial nerve function, is not necessary. Testing the pupillary reaction to light evaluates pupillary response and function of the oculomotor nerve.

The nurse notes that a toddler is having issues while being toilet trained. According to Erikson, in which stage of development is this child? Autonomy versus shame and doubt Initiative versus guilt Industry versus inferiority Trust versus mistrust

Autonomy versus shame and doubt

A middle-aged client is overheard telling another person about the desire to "not get caught" performing an inappropriate action while at work. What does this indicate about the client's moral development? Evidence of achieving the conventional level of development Difficulty achieving the post-conventional level of development Solid achievement of the post-conventional level of development Tendency to become confused with the transcendence level of development

Difficulty achieving the post-conventional level of development

The nurse's assessment of an adult female client reveals the presence of excessive hair on her face and chest. The nurse should plan further evaluation of which body system? Endocrine Neurologic Cardiovascular Genitourinary

Endocrine

A nurse on a busy medical unit is aware of the importance of accurate blood pressure (BP) measurement. To ensure accuracy when assessing patients' blood pressures, the nurse should always: 1- Use a manual, rather than automated, sphygmomanometer 2- Alternate blood pressure readings between patients' right and left arms 3- Take serial blood pressure readings on each patient 4- Ensure that the correct cuff size is used for each patient

Ensure that the correct cuff size is used for each patient

The nurse notes that an adolescent client demonstrates confusion and the inability to focus on tasks. According to Erikson, which central task is this client having difficulty completing? Generativity versus stagnation Identity versus role confusion Intimacy versus isolation Ego integrity versus despair

Identity versus role confusion

All the following are stages in Erik Erikson's model of development except which one? Industry vs. inferiority Autonomy vs. shame and doubt Identity vs. isolation Trust vs. mistrust

Identity vs. isolation

14. A nurse has completed data analysis. Which of the following would the nurse identify first as the result?

Nursing diagnosis Explanation: The end result of data analysis is the identification of a nursing diagnosis, collaborative problem, or need for referral to another health care professional. After nursing diagnoses are identified, then outcomes, planning, implementation, and evaluation occur.

Question: A nurse reviews the documentation of the nurse on the previous shift and finds that the client was obtunded. The nurse anticipates that the client will respond to stimulation in what manner?

Opens eyes to a loud voice with confusion

The nurse recognizes that a child is most likely in Piaget's preoperational stage of development when observing which activity? Reacting emotionally when a behavior change is suggested Pretend play Solving verbal problems without writing them down Sorting a card collection

Pretend Play

Which diagnostic test distinguishes between conductive and sensorineural hearing loss? a) Whisper test b) Audiometry c) Weber test d) Rinne test

Rinne test Explanation:The Rinne test is useful for distinguishing between conductive and sensorineural hearing loss. The whisper test, the patient with normal acuity can correctly repeat what was whispered. Audiometry is used to detect hearing loss. The Weber test uses bones conduction to test lateralization of sound

Questions: The intensive care nurse is working with a client who has increased intracranial pressure secondary to a traumatic brain injury. The nurse is performing the hourly assessment of the client's level of consciousness and observes that the client's eyes are closed. How should the nurse first stimulate the client to assess for arousability? A) Gently shake the client's right shoulder and then his left shoulder. B) Rub the client's sternum with the knuckles. C) Speak to the client clearly from a close distance. D) Press down on one of the client's nail beds.

Speak to the client clearly from a close distance

A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on a ventilator for 3 weeks. The nurse is completing an initial assessment and evaluating the client's skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter with damage to the subcutaneous tissue. The underlying muscle is not affected. What is the stage of this pressure ulcer? 1 2 3 4

Stage 3 Explanation: A stage III ulcer is a full-thickness skin loss with damage to or necrosis of subcutaneous tissue that may extend to, but not through, the underlying muscle.

A nurse obtains the blood pressure of a client who is uncharacteristically fatigued and who is lying in bed rather than sitting in a chair. The nurse should interpret the client's blood pressure reading in light of what principle? The client's blood pressure will be slightly highly than the client's norm. Position rarely affects the client's blood pressure. The client's blood pressure will be slightly lower than standing readings. There will be questionable accuracy of the blood pressure reading.

The client's blood pressure will be slightly lower than standing readings. Explanation: When a client lies down, there is a decrease in peripheral vascular resistance, which will cause the blood pressure to be slightly lower than when the client is standing.

8. During an interview between a nurse and a client, the nurse and the client collaborate to identify problems and goals. This occurs during the phase of the interview termed A) Introductory B) Ongoing C) Working D) Closure

Working

A 53-year-old client with a sensorineural hearing loss asks the nurse how this occurred. Which of the following responses would be most appropriate? a) "Your work in the factory exposed you to loud noises over a long time." b) "You probably have a lot of wax buildup that is interfering with hearing sounds." c) "You have a history of fluid building up in your middle ear, which is responsible." d) "This is not uncommon in people your age because your eardrum is hardening."

Your work in the factory exposed you to loud noises over a long time." Explanation:Sensorineural hearing loss is most commonly associated with prolonged exposure to loud noises or the use of ototoxic medications. Conductive hearing loss is associated with cerumen buildup and fluid in the middle ear. Conductive hearing impairment is not uncommon in the older client due to a greater incidence of cerumen buildup or atrophy or sclerosis of the tympanic membrane

The nurse assesses thick white plaques on the hard palate of a client. Which of the following would the nurse do next? A) Further evaluate for AIDS. B) Refer the client for medication. C) Asses laboratory values for zinc deficiency. D) Assess the client for signs of jaundice.

b

33. Which of the following would be most appropriate for the nurse to do to determine stroke volume? a) Take the blood pressure while the client is standing. b) Add the radial pulse and the systolic blood pressure. c) Calculate the difference between the diastolic and systolic pressures. d) Measure the strength of the radial pulse.

c) Calculate the difference between the diastolic and systolic pressures.

The nurse is assessing the hearing of an older adult. Which type of hearing problem might the nurse expect to find in the older adult? a) Tinnitus b) Conductive hearing loss c) Presbycusis d) Sensorineural hearing loss

c) Presbycusis

A client with postnasal sinus drainage is seen in the clinic. When assessing the throat, the nurse would anticipate seeing which color drainage? A) Green B) Clear C) Gray D) Yellow

d

A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve? A) III B) VI C) VIII D) XII

d