Health Assessment Exam 3

A nurse is assessing the head and neck of an adult client. Which vertebra should the nurse identify as a landmark in order to locate the client's other vertebrae?

C7

The nurse is preparing to perform a nutritional assessment of a newly admitted client. Which of the following questions would be most appropriate to use when initiating the assessment?

Can you tell me what you've eaten in the last 24 hours?

A nurse who provides care in a busy, inner-city clinic performs physical examinations on clients of various cultures. In a client from which group would the nurse expect to find the greatest amount of body odor from perspiration?

Caucasian

A nursing instructor is discussing cultural variations in the size of the thorax and impact on lung capacity. Which group would the instructor identify as typically having a larger thorax?

Caucasians

The nurse is performing a respiratory assessment of a client who is palliative due to severe, uncompensated heart failure. What type of respiratory pattern should the nurse anticipate?

Cheyne-Stokes

A cardiac care nurse works with a diverse client population. The nurse would assess a client from which cultural group for an increased effect of an antihypertensive medication?

Chinese

During a nutritional assessment, the client asks the nurse for suggestions to improve her diet. The nurse identifies a nursing diagnosis of health-seeking behaviors related to desire to improve diet. Which of the following suggestions would be most appropriate?

Choose low-fat versions of milk products such as yogurt.

The nurse is preparing a client for cancer chemotherapy treatment. While talking with the nurse, the client says, "Miracles do happen, and I'm praying for one." The nurse interprets this statement as suggesting which religious preference?

Christianity

Upon entering the examination room, the nurse observes that the client is leaning forward with his arms supporting his body weight. The nurse would recognize this as a tripod position and suspect the presence of which of the following medical problems?

Chronic obstructive pulmonary disease

An older adult male client states that he has trouble cutting his toenails because they are hard and thick, and the nurse notes that they are very long and unkempt. Which system would be most important for the nurse to assess?

Circulatory

A client weighs 106 pounds and is 5 feet 5 inches tall. As a result, her ideal body weight is 120 pounds. After determining the client's percentage of ideal body weight, which of the following should the nurse conclude?

Client is mildly malnourished.

When assessing a client's spirituality, the nurse has the client complete a Brief Religious Coping Questionnaire. When reviewing the completed questionnaire, the nurse identifies which of the following as indicating positive religious coping?

Client looks to God for support in a crisis.

After having a client perform a Romberg test, which of the following would indicate to the nurse that the test is negative?

Client maintains the position during the test

Prader-Willi Syndrome

Complex, neurodevelopmental disorder identified as a genetic cause of obesity (hypothalamic pituitary) An insatiable desire for food; no loss of hunger following food intake Multiple body system involvement

A nurse is preparing to assess an adult client's carotid pulses. Which of the following actions would be contraindicated?

Compressing the arteries bilaterally

A nurse is caring for a 70-year-old client from a different culture whose breast cancer has metastasized. The nurse observes that the client tends to defer responsibility for decision making around treatment options to her eldest son. How should the nurse respond to this?

Confirm that the client wants her son to make decisions and follow those decisions accordingly.

Based on a colleague's feedback, a nurse learns that she is aware of cultural differences in a general way but does not know what the specific differences are or how to communicate with a person of a specific culture. This nurse exhibits which of the following?

Conscious incompetence

A nurse is participating in an educational exercise in which she is conducting a self- examination of her own biases. This activity addresses what construct of cultural competence?

Cultural awareness

A group of students is reviewing material on cultural competence. The students demonstrate understanding of this concept when they identify which of the following as the starting point?

Cultural desire

A nurse admits to a colleague, I sometimes tend to avoid clients from other cultures because it's awkward and it's usually frustrating for me and for the client. This nurse is likely lacking in what construct of cultural competency?

Cultural desire

The nurse attends a Native-American Alcoholic Anonymous support group and develops close relationships with three group members. The nurse is demonstrating which of the following?

Cultural encounter

When preparing to assess a client's thyroid gland, the nurse should ensure that which piece of equipment is readily available?

Cup of water

Moon-shaped face with reddened cheeks and increased facial hair may indicate

Cushing syndrome

A 12-year-old boy has been brought to the emergency department after being hit in the head with a pitch during a baseball game. The emergency department nurse's comprehensive assessment includes examination of the boy's ears with an otoscope. What assessment finding would suggest trauma to the middle ear or inner ear?

Dark red or bluish tympanic membrane

A nurse has completed the assessment of an older adult client's head and neck and is now analyzing the assessment findings. Which of the following findings should the nurse attribute to age-related physiological changes?

Decreased strength of temporal artery pulsations

Assessment of a client's skin reveals several individual and distinct 2-mm lesions on the client's back. The nurse would document the configuration as which of the following?

Discrete

A nurse is assessing a client for possible fluid overload. Which of the following assessment findings is most consistent with this diagnosis?

Distended neck veins with head elevated at 45 degrees

During a new client's nutritional assessment, the nurse asks the client's height and usual weight. The client states that he has no idea how much he weighs. How should the nurse respond?

Do you feel like your weight has increased, decreased, or stayed the same lately?

A client describes her frequent headaches as being severe and lasting for days. The client's positive response to what question would most clearly suggest to the nurse that these headaches are migraines?

Do you have any visual changes before the headache?

The nurse is assessing a middle-aged female client who is new to the clinic. The nurse observes the presence of significant facial hair that is uncharacteristic of the client's ethnicity. What assessment question should the nurse consequently ask?

Do you take steroid medications on a regular basis?

A nurse is assessing a client of East Asian descent. Which biological variation would the nurse expect?

Dry cerumen in the client's ears

The nurse should prioritize assessments related to overhydration for a client experiencing which of the following health problems?

Early congestive heart failure

An older adult client has a body mass index of 15.5 and is consequently considered to be underweight. The client lives alone and states that she has never been a heavy eater. How can the nurse most accurately assess the client's nutritional habits?

Elicit the client's 24-hour food recall.

A male Hispanic client describes the fact that he mixed hot and cold foods, causing them to lump together and get stuck in his intestines, causing diarrhea and abdominal pain. The nurse would document this as which of the following?

Empacho

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

A nurse's reflection of his practice reveals that he tends to see his own culture as the ìgold standardî to which all other cultures should aspire. This nurse should create learning goals to address what phenomenon?

Ethnocentrism

A nurse is admitting a client who is from another culture. Prior to caring for a client from another culture, the nurse should place primary importance on which action?

Examining personal biases and prejudices

The nurse is preparing to examine a client's skin. Which of the following actions would be most important for the nurse to do?

Expose only the body part that is being examined.

A group of students is reviewing material related to the role of religion and spirituality in health care choices. The students demonstrate understanding when they identify which of the following situations as the most prominent ethical dilemma that involves religion?

Failure to seek timely medical care

A nurse interviews a pregnant client and learns that her beliefs around health care do not involve participation in comprehensive prenatal care. To which religious view would the client most likely adhere?

Faith Assembly of Indiana

An African-American woman collapses at the funeral of her mother and later states that she could hear everything people were saying to her but, for a brief period, she could not move. The nurse interprets this as which of the following?

Falling out

A nurse is preparing a presentation for a local community group about preventing traumatic brain injury. The nurse would discuss which measure as prevention of the leading cause?

Falls prevention

When percussing the scapula of a client, which of the following would the nurse expect to hear?

Flatness

A nurse at a long-term care facility is completing the nutrition assessment of a man who has just moved to the facility. The nurse has lowered the client's arm and observed how long it takes for venous filling, then raised the same arm and watched how long it takes to empty. After determining that venous filling and emptying each take approximately 10 seconds, the nurse should perform further assessments related to what health problem?

Fluid volume deficit

Which of the following, if obtained during the health history, would alert the nurse to a possible risk factor for ear-related problems?

Frequent use of cotton-tipped applicators inside the ear

The nurse is assessing a client who has been admitted for the treatment of severe dehydration. What might the nurse expect to hear when auscultating the lungs of a client with this fluid volume deficit?

Friction rub

What eight bones are composed in the cranium?

Frontal Parietal Temporal Occipital Ethmoid Sphenoid

Stage 4 Pressure Ulcer

Full-thickness tissue loss with exposed bone, muscle, or tendon

Stage 3 Pressure Ulcer

Full-thickness ulcer; extends into subcutaneous tissue

Spirituality assessment tool

HOPE

While auscultating a client's lungs, the nurse notes the presence of adventitious sounds. Which of the following actions should the nurse do first?

Have the client cough, then listen again.

A nurse is assessing an adult client's neck. Which of the following would be most appropriate when auscultating the client's thyroid gland for bruits?

Have the client hold his or her breath.

A clinic client's primary complaint is earache (otalgia). Consequently, the nurse's assessment is focusing on potential causes of the client's pain. What question should the nurse include in the health interview?

Have you been swimming lately?

A nurse is assessing a 49-year-old client who questions the nurse's need to know about sunburns he experienced as a child. How should the nurse best explain the rationale for this subjective assessment?

Having bad sunburns when you're a child puts you at risk for skin cancer later in life.

The nurse is assessing a 69-year-old woman's risks for lung disease. The woman states, ìIt shouldn't be a problem for me. My husband smokes quite heavily but I've been a lifelong nonsmoker.î The nurse should recognize the need to teach the client about what topic?

Health risks of secondhand smoke

The nurse analyzes the data obtained from a client's nutritional assessment and develops a health promotion diagnosis related to nutrition for a client. Which of the following would be the best example?

Health-seeking behaviors related to desire and request to alter amount of food intake

When talking to a client before starting the physical exam, the nurse notes that the client consistently tilts her head to one side. Which of the following should the nurse examine first?

Hearing acuity

During the health interview, a client tells the nurse that he ìcan't breathe all that wellî at night when he is lying down and that this significantly disrupts his sleep. The nurse should assess this client further for which of the following health problems?

Heart failure

When evaluating nutrition in an adult female client, which laboratory value would most concern the nurse?

Hemoglobin A1c of 9%

A client tells the nurse that the intravenous line must be placed in his right hand. Based on the nurse's understanding of the major religions, the nurse identifies this request as reflecting which of the following?

Hinduism

During a client's spiritual assessment, the client explains that the ultimate purpose of her existence is to achieve a state that she describes as nirvana. The nurse should recognize that this client ascribes to what religion?

Hinduism

During a health screening event, the nurse is assessing a client's risk factors for lung cancer. When addressing the most significant risk factor for lung cancer, the nurse should question the client about which of the following?

History of tobacco use

The nurse is conducting the health interview of an adult client who has sought care because of a wicked cough leading to dyspnea. When trying to differentiate between pathologic lung changes and an infection as the etiology of the client's cough and resultant dyspnea, what interview question should the nurse ask?

How long have you been experiencing your cough?

A client has a history of emphysema. During the respiratory assessment, the nurse percusses the client's chest, expecting to find which of the following?

Hyperresonance

A nurse is working with a client who has a history of headaches. When preparing to assess the client's temporomandibular joint (TMJ), the nurse should provide what instruction?

I'm going to put my fingers in front of your ears and ask you to open your mouth wide.

A client has sought care because of the development of pruritic lesions between her toes, which the nurse suspects are attributable to a fungal etiology. How can the nurse best corroborate this suspicion?

Illuminate the area using a Wood's light.

A nurse is relying heavily on gestures and simplified language during the assessment of a client from another culture who speaks minimal English. During the lengthy assessment, the nurse asks the client if she is okay by making a circle with his thumb and forefinger. The nurse should be aware of which of the following?

In some cultures, this gesture is offensive.

A nurse is performing an otoscopic exam of a client's right tympanic membrane. At which location would the nurse document seeing the cone of light if it were in the appropriate place?

In the 5 o'clock position

A client's history reveals that he has been taking oral steroid therapy for several years for the treatment of an autoimmune disorder. During assessment, the nurse would expect the client's skin to have what characteristic?

Increased thinness

A nurse is caring for a patient whose diagnosis of cystic fibrosis results in the production of large amounts of sticky mucus. The client has a history of repeated hospital admissions for complications of his disease and receives daily treatments to mobilize the secretions. When planning the care of this client, what nursing diagnosis is most plausible?

Ineffective Airway Clearance related to respiratory secretions

The nurse has completed a focused ear and hearing assessment and gathered the following data: the client speaks very softly, denies hearing loss, and has never had and cannot afford additional hearing tests; the client fails the whisper test. Which nursing diagnosis would be most appropriate?

Ineffective health maintenance related to denial of hearing problem and inadequate resources for additional testing

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?

Inner ear problem

The nurse is performing an ear assessment of an adult client. Which of the following actions constitutes the correct procedure for using an otoscope when examining the client's ears?

Inserting the speculum down and forward into the ear canal

A client presents to an ambulatory clinic with purulent, bloody drainage of the ear. Which of the following should the nurse assess first?

Inspect the client's external ear canal.

During an integumentary assessment, the nurse notes that the client's fingernails are very thin and concave. The nurse knows the client needs medical follow-up for further assessment to rule out which condition?

Iron deficiency anemia

A nurse assesses a client's spirituality and religious practices. During the assessment, the nurse notes that the client is very quiet and rarely asks any questions of the health care workers. The nurse recognizes that this behavior may be associated with which religion?

Islam

While interviewing a hospitalized client, he states, "The holy days of Ramadan are coming soon. I am not to have any food or drink from sunrise to sunset during this time." Further assessment reveals that the client's request is associated with which religion?

Islam

A client asks why cerumen is important, stating, ìIt just clogs up the ears anyway.î How should the nurse best describe the purpose of cerumen?

It helps to keep the ear drum soft and functioning well.

A nurse educator is leading a group of nurses in exercises aimed at improving cultural competence. Which of the following would the educator use to best describe an aspect of the term culture?

It is shared through norms for behaviors, values, and beliefs.

A client is receiving an intradermal injection to evaluate general immunity during a nutritional assessment. Which of the following conclusions is suggested if the client has no reaction?

It may be immunosuppression resulting from undernourishment.

A nurse is working with a client who has received a terminal diagnosis. To help the nurse identify the client's possible coping responses, which of the following would be most important for the nurse to understand about spirituality?

It varies in different situations.

An obese teenage boy from a culture that values increased body mass has been referred to the clinic. The nurse is assessing him for malnutrition based on his electronic health record and current health complaints. His mother questions the nurse's rationale, stating, Anyone can see he's not malnourished. Just look at the size of him! How should the nurse best respond?

It's actually very possible for a person to be overweight but have inadequate nutrition.

blood transfusion are not allowed by

Jehovah witnesses

A nurse educator is reviewing the unit's resources about religious groups and their views about blood and blood products, organ donation, and autopsy. A member of which group is most likely to refuse a blood transfusion?

Jehovah's Witnesses

The nurse is caring for the family of a client who has just died. The family requests that the client's arms not be crossed and that any of the clothing and dressings containing blood be left and be prepared for burial with the client. The nurse understands this family's request as indicative of what religious beliefs?

Judaism

A nurse is planning a spiritual assessment of a client who is experiencing intractable losses in function as a result of disease. Which of the following principles should inform the nurse's assessment?

Knowledge of the most common spiritual practices in the community is a priority.

The nurse is preparing to auscultate the client's thorax. Which of the following actions is the priority during this component of assessment?

Listen at each site for at least one complete respiratory cycle.

A nurse is conducting a focused head and neck assessment of a client. When preparing to assess the client's thyroid gland, the nurse should be aware of which of the following principles?

Many clients have an additional (third) thyroid lobe.

The nurse is assessing the face of a client with a diagnosis of Parkinson's disease. Which of the following would the nurse most likely assess?

Masklike expression

What 14 bones makes of the face?

Maxilla Zygomatic Inferior conchae Nasal Lacrimal Palatine Vomer Mandible (jaw)

The nurse needs to obtain the height of a client who is unable to stand. Which of the following would the nurse do?

Measure from client's arm span using one of his arms outstretched.

A nurse is assessing a client's skeletal muscle mass in the context of a comprehensive nutritional assessment. Which measurement would yield the most valid and reliable data?

Mid-arm circumference

The nurse is preparing to lead a health promotion activity among a group of clients from different cultures. The nurse would expect that which client would require the least amount of personal space?

Middle Easterner

A nurse is planning care that is grounded in the fact that clients are holistic beings. Which of the following lists of components constitute the view of clients as holistic beings?

Mind, body, spirit

A nurse is providing a client with instructions on how to perform self-examination of the skin. The nurse would encourage the client to perform this examination at which frequency?

Monthly

Which of the following findings should the nurse document after assessing the thyroid gland of an older adult without abnormalities?

Nodularity

The nurse assesses chest expansion in a 30-year-old man and finds it to be 8 cm. The nurse should document this as which of the following?

Normal expansion

While inspecting the client's tympanic membrane, the nurse notes a pearly gray and shiny appearance. The nurse would interpret this finding as which of the following?

Normal tympanic membrane

After teaching a group of students about spirituality and religion, the instructor determines that the students need additional teaching when a student states which of the following?

Nursing has only recently begun to incorporate spirituality into client care.

A nurse has collected extensive data relating to a client's spirituality. Which type of data would the nurse need to validate the information obtained during this assessment?

Objective data

A nurse is admitting a client to a long-term care facility. In order to elicit reliable and valid data during the spiritual assessment, the nurse understands that the focus must be on which of the following?

Objectivity when performing the assessment

A nurse has identified the goal of becoming more culturally sensitive and competent. What is the primary rationale for cultural sensitivity in health care settings?

Obtain accurate assessment data.

The nurse is preparing to palpate a client's temporal artery. The nurse would place the hands at which location?

On each side between the top of the ear and the eye

The nurse is preparing to perform the Rinne test on a client. The nurse should place the tuning fork at which location first?

On the client's mastoid process

The nurse is performing an assessment of a client admitted to the emergency department in status asthmaticus. The nurse should carefully inspect which part of the body in an effort to differentiate central cyanosis from peripheral cyanosis?

Oral mucosa

A nurse palpates a client's ear and finds that the tragus is exquisitely tender. The nurse should suspect which of the following health problems?

Otitis externa

The nurse's assessment of an older adult client's ears and hearing suggests the possible presence of conductive hearing loss. Which of the following is the most likely etiology of this abnormal assessment finding?

Otitis media

During a health history, a client reports complaints of headaches. Which of the following would lead the nurse to suspect that the client is experiencing cluster headaches?

Pain radiating from eye to temporal region

A 15-year-old boy shows the school nurse a ìbumpî on his neck. The nurse observes a raised, erythematous, solid, 0.3-cm by 0.2-cm mass. The nurse would document the presence of which of the following?

Papule

A "mask-like" face marks

Parkinson disease

A nursing educator is evaluating a colleague's examination of a client's thyroid gland. The educator would determine that the nurse needs additional instruction when the nurse demonstrates which technique?

Percussion

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?

Perform a random blood sugar test.

In which health condition would the nurse most likely expect to assess a capillary refill time that is longer than 2 seconds?

Peripheral vascular disease

subjective vertigo

Person feels like he or she spins

The nurse is reviewing a client's spirituality using the SPIRIT Spiritual Assessment Tool. Which of the following would the nurse assess when addressing the letter "P"?

Personal spirituality

While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse should recognize the presence of which of the following?

Petechiae

A client is diagnosed with pulmonary edema, and the nurse is performing a rapid assessment prior to treatment. The nurse would be most concerned about which of the following assessment findings related to the client's sputum?

Pink and frothy

The nurse is preparing to auscultate a client's lungs after completing thoracic inspection, palpation, and percussion. How should the nurse best prepare for this assessment technique?

Place the diaphragm on the client's posterior chest wall.

A nurse is assessing an Asian client and observes several reddened and bruised areas on the skin. Further assessment reveals that the client was using cupping to treat back pain. The nurse understands this as which of the following?

Placing heated glass jars on the skin that are allowed to cool

A nurse is conducting a focused ear and hearing assessment of an adult client who has a history of mild hearing loss. When performing the whisper test, what instruction should the nurse begin with?

Please cover your ear that has the weakest hearing.

While assessing the health of a client's respiratory system, the nurse is palpating for fremitus. What instruction should the nurse provide to the client during this component of assessment?

Please say the number 'ninety-nine' for me.

A nurse is modifying an Asian client's diet to accommodate the concept of hot and cold. The nurse demonstrates an understanding of this concept when identifying which of the following as a cold condition?

Pneumonia

A 66-year-old client states that he has increasing difficulty hearing high-pitched sounds. The patient's statement most likely suggests that he has what diagnosis?

Presbycusis

The nurse is assessing a client who has been admitted with signs and symptoms that are consistent with malnutrition. Which of the following physiological phenomena would the nurse recognize as an early indicator of malnutrition?

Protein stores are lower than normal

Assessment of an adult female client's face reveals a moon shape, increased hair distribution, and a reddened tone to the client's cheeks. What collaborative problem is most clearly suggested to the nurse by these assessment data?

RC: Cushing's syndrome

The results of a client's Rinne test suggest that bone conduction and air conduction are both reduced. Which of the following would be most appropriate?

Refer the client for further evaluation.

The emergency department nurse notes a clear, watery discharge from the client's ear following a bicycle accident. Which of the following actions should the nurse do next?

Refer the client immediately for further evaluation.

A 2-year-old girl has been brought to the ambulatory clinic by her mother who states, ìShe's put a pea in her ear, and I think she did it 2 days ago because that was the last time we ate them.î The nurse's otoscopic examination confirms the presence of this foreign body in the girl's middle ear. How should the nurse best respond to this assessment finding?

Refer the girl to her primary care provider for prompt removal of the pea.

A nurse is providing care at an inner-city shelter, and a man who frequents the shelter presents with a significant frontal growth that is located midline at the base of his neck. The nurse should recognize the need for what referral?

Referral for further assessment of thyroid function

A nurse is completing an admission assessment of an adult client, during which the client states, "I've never been a religious man, but I'm definitely spiritual." How should the nurse best understand an aspect of the relationship between spirituality and religion?

Religion consists of the spiritually focused rituals and practices of a group.

The nurse's assessment of a hospital client's spirituality reveals that the client will accept very few of the standard treatments for her health problems. How should the nurse follow up this assessment finding?

Report the finding to the appropriate supervisors.

The nurse is interviewing a female Hispanic client who is scheduled for a cardiovascular education program. The client states, ìI can't eat and I don't sleep because my daughter left to return to Mexico. I am sad and nervous. I need rest.î The nurse suspects that she is suffering from susto. Which action by the nurse would be best?

Reschedule the education program.

The nurse is assessing the various lobes of the client's lungs. To gather accurate data, the nurse must assess which lobe anteriorly?

Right middle lobe

Assessment of a client reveals a history of insulin-dependent diabetes mellitus, weight loss, polyuria, poor skin turgor, nausea, loss of appetite, and a blood glucose level measured by finger stick of 348 mg/dL. Which of the following nursing diagnoses would be the nurse's priority?

Risk for imbalanced fluid volume related to inadequate oral intake and frequent urination

The nurse is assessing a fair-skinned, Caucasian woman with red hair and freckled skin. During health promotion, the nurse should focus education on which of the following topics?

Risks of sun exposure

When considering the various cultural aspects associated with death rituals, which of the following should guide a nurse's practice?

Rituals for burial and bereavement are likely to reflect original cultural practices.

An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what?

Sebum production

The nurse chooses to use a formal assessment technique when doing a client's spiritual assessment. Which of the following techniques would be most appropriate?

Self-response assessment instrument

A nurse is reviewing the laboratory test results of an adult client who has numerous chronic health challenges. Which assessment result would alert the nurse to potential malnutrition?

Serum albumin of 2.6 g/dL

What to note while palpating the lymph nodes?

Size and shape Delimitation Mobility Consistency Tenderness and location

The nurse is assessing a 79-year-old client's posterior thorax during a focused respiratory assessment. The nurse should attribute what assessment finding to age- related changes?

Slight kyphosis

The nurse is assessing the apices of the client's lungs. The nurse should locate them at which position?

Slightly above the clavicle

Which factor, if present in a client's lifestyle and health practices assessment, would alert the nurse to the need for performing a more thorough head and neck assessment?

Smokeless tobacco use

When assessing whispered pectoriloquy, the nurse should instruct a client to do which of the following?

Softly repeat the words one-two-three.

A nurse is preparing to begin work in a diverse, urban community with members of numerous different religious traditions. The nurse should identify which statement as best reflective of Buddhism?

Some holy days include fasting from dawn to dusk.

An adult client has been diagnosed with bronchitis. Which of the following would the nurse most likely hear on auscultation?

Sonorous wheezes

The school nurse assesses unequal shoulder and scapula height in an adolescent. Which of the following should the nurse assess next?

Spinal column

A client describes herself as "dumbfounded" that she has been diagnosed with cancer, stating, "I had such a clear vision from God that I was negative for cancer. Now I have no idea what I can trust." This client's statement is suggestive of what nursing diagnosis?

Spiritual distress

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?

Stage II

Whisper test

Stand 2 feet behind the client, move your head 1 foot away from 1 ear and whisper 3 random letters/numbers. Repeat a different set on other ear.

How to palpate the thyroid

Stand behind the client and ask the client to lower the chin to the chest and turn the neck slightly to the right. This will relax the client's neck muscles. Then place your thumbs on the nape of the client's neck with your other fingers on either side of the trachea below the cricoid cartilage. Use your left fingers to push the trachea to the right. Then use your right fingers to feel deeply in front of the sternomastoid muscle. Ask the client to swallow as you palpate the right side of the gland. Reverse the technique to palpate the left lobe of the thyroid.

A nurse states, Hispanic people have no clue about primary prevention of illness. The nurse is demonstrating which of the following?

Stereotyping

When preparing to assess a client's thoracic cage, the nurse should locate which landmark when determining where to begin the assessment of the ribs and intercostal spaces?

Sternal angle

A nurse is palpating the position of the client's trachea. At which anatomic site would the nurse first position a finger for palpation?

Sternal notch

The nurse can best palpate the superficial cervical nodes, the deep cervical chain, and the supraclavicular nodes by first locating which muscle?

Sternomastoid

A nurse should conduct an assessment of a client's Risk for Complications after gathering data related to the client's spirituality. When planning the client's care, the nurse should be aware that complications are primarily due to the effect of spirituality on what phenomenon?

Stress

The nurse's assessment reveals that a client is in a low percentile for midarm muscle circumference (MAMC) and a high percentile for triceps skin fold (TSF) thickness. Which of the following would be appropriate?

Teaching the client muscle-building exercises

A nurse has completed an assessment of a client's lymph nodes. Which of the following data would the nurse document as an abnormal finding?

Tender

When assessing the client's ear, which finding should the nurse identify as indicating a need for further assessment and possible treatment?

Tender tragus

The nurse is collecting data from a client about his nutrition. Which of the following would the nurse document as objective data?

Tenting of client's skin observed upon skin pinch.

The nurse is completing a comprehensive nutritional assessment and has assessed and documented the client's triceps skin fold thickness (TSF) using calipers. This assessment finding allows the nurse to determine which of the following?

The amount of the client's subcutaneous fat stores

A nurse's colleague states, "I think Mrs. Nguyen in room 412 is a Buddhist, so she'll definitely be a vegetarian." The nurse should understand what principle of religion and spirituality when planning clients' care?

The beliefs of members of a particular religion are not necessarily homogeneous.

The nurse is completing a client's ear assessment. What assessment finding would indicate the need to perform Weber's test?

The client has unilateral hearing loss.

A nurse is assessing an older adult client's risk for pressure ulcers using the Braden Scale for Predicting Pressure Sore Risk. Which aspect of the client's current health status would be reflected in her score on this scale?

The client is consistently incontinent of urine.

A clinic nurse is conducting a comprehensive assessment of a 70-year-old male client of Native American ethnicity. The nurse observes that the client rarely makes eye contact and holds his head low during the assessment. How should the nurse best interpret this practice?

The client may be showing the nurse respect.

The nurse's assessment of an 81-year-old client's hearing has corroborated her recent history of hearing loss. The nurse questions the client about her use of hearing aids, to which the client responds, ìI've got enough frustration in my life without having to fiddle with those.î The nurse should suspect which of the following?

The client may have had a negative experience with hearing aids in the past.

A client has sustained a brain stem injury and is being treated in the intensive care unit. Which of the following would the nurse need to consider when assessing this client's respiratory status?

The client will have a loss of involuntary respiratory control.

A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale?

The client's ability to change position

The nurse is providing care for a client with a history of chronic heart failure. The client is in bed with the head of her bed at 45 degrees, and the nurse is assessing the client's neck veins. What assessment finding would be most consistent with a nursing diagnosis of fluid volume excess related to chronic heart failure?

The client's jugular veins are clearly visible and firm to palpation.

The nurse is assessing a client's spiritual history using the SPIRIT acronym. The nurse should begin the assessment by identifying what aspect of spirituality?

The client's sources of hope

Cultural diversity

The co-existence of a difference in behavior, traditions, and customs—in short, a diversity of cultures, often resulting from cross-border population flows; "pluralism"

A nurse is preparing for an assessment by reviewing a new client's electronic health record, which documents the presence of macules on the client's left flank and mid-back regions. The nurse should recognize what characteristic of these skin lesions?

The lesions will not be palpable.

A hospital nurse is performing a nutritional assessment of a 39-year-old obese client who has been recently diagnosed with type 2 diabetes. The nurse has completed the collection of subjective data and is preparing to proceed with objective data collection. Which principle should guide the nurse's subsequent actions?

The nurse should be aware that the client may find assessment embarrassing.

A nurse recognizes the need to perform a spiritual assessment of a newly admitted hospital client, but the circumstances surrounding the client's diagnosis and family dynamics make this challenging. What variable is likely to have the greatest impact on enhancing the quality of data from the nurse's spiritual assessment?

The quality of rapport between the nurse and the client

The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs?

The right lung has three lobes, while the left lung has two lobes.

A nurse is preparing a teaching session for a group of new parents about ear infections and measures to prevent them. The nurse is planning to address the reasons why children are more susceptible to these infections than adults. Which of the following would the nurse describe?

The size and shape of children's eustachian tubes makes them vulnerable.

Culture

The totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, lifeways, and all other products of human work and thought characteristic of a population or people that guide their worldview and decision making

A nurse is providing care for a client who has decreased mobility secondary to a recent stroke. Which of the following assessment findings would be indicative of a stage I pressure ulcer?

There is a nonblanching reddened area on the client's coccyx region.

During a Weber test, the client reports lateralization of sound to the good ear. How should the nurse interpret this assessment finding?

There is a sensorineural hearing impairment.

A nurse is working with a 22-year-old woman of Asian ethnicity who has been diagnosed with bipolar disorder. When planning culturally appropriate care, the nurse should consider which of the following?

There may be shame associated with having a psychiatric disorder.

During the health history, a client describes recent episodes of intermittent facial pain lasting several minutes. The nurse should recognize that this complaint is suggestive of what health problem?

Trigeminal neuralgia

The nurse is conducting an assessment of an adult client who describes herself as being in good health. Inspection of the client's nail beds reveals the presence of a bluish tone. The nurse should recognize that this finding is most likely attributable to what phenomenon?

Vasoconstriction

A group of students is reviewing the vertical reference lines of the thorax. They demonstrate understanding when they identify which line as a reference line for the posterior thorax?

Vertebral line

An older adult client reports that he is experiencing severe trunk pain and is concerned that he might have shingles. Which type of lesion would the nurse most likely assess?

Vesicle

The nurse assesses a client and palpates a temporal artery that is hard, thick, and tender with absent pulsations. The nurse would gather additional information related to which aspect of health?

Vision

Cracked lips & Red beefy tongue

Vit B12 deficiency

Night Blindness

Vitamin A deficiency

Paresthesia

Vitamin B deficiency

Petichiae & Ecchymosis

Vitamin C and K deficiency

Bone pain & Bowlegs

Vitamin D and Ca Deficiency

A nurse will be working in a clinic in South Asia for several weeks, where the majority of residents have darkly pigmented skin. The nurse should expect a higher-than-average incidence of what integumentary health problem?

Vitiligo

The nurse is assessing a dark-skinned client whose forearms are hands have distinct regions of depigmentation. The nurse should document the presence of what health problem?

Vitiligo

A nurse health promotion teaching is focusing on hygiene and the prevention of illness. When instructing clients how to clean their ears, what action should the nurse recommend?

Washing with a warm, moist washcloth

A client who works in a manufacturing plant is attending a teaching session on plant safety. Which of the following would be an important risk prevention measure to teach regarding hearing?

Wearing ear protection when in the work environment

When obtaining the nutritional health history from a female client, which of the nurse's questions would best elicit information about the client's knowledge of her own health status?

What are your height and usual weight?

A client has sought care at the clinic, telling the nurse, ìThis ringing in my ears has gone on for weeks, and it's driving me crazy.î The patient denies exposure to excessive noise levels. The nurse recognizes the likely presence of tinnitus and should follow up with which of the following questions?

What medications are you currently taking?

A nurse is implementing appropriate infection control precautions while performing a client's skin assessment. During which of the following components of the assessment should the nurse wear gloves?

When palpating lesions on the client's skin

marasmus

`A disease of severe protein-calorie malnutrition during early infancy, in which growth stops, body tissues waste away, and the infant eventually dies.

exophthalmos

abnormal protrusion of the eyeball

microcephaly

abnormally small head

spiritual assessment

active and ongoing conversation, assesses spiritual needs of the client through spiritual assessment

presbycusis

age related hearing loss

The external ear is composed of

auricle and external auditory canal

Jehovah's Witnesses refuse

blood transfusions due to beliefs, body cannot be sustained by another's blood, accepting transfusions will bar recipient from eternal salvation

a "sunken" face with depressed eyes and hollow cheeks is typical of

cachexia (emaciation or wasting)

atelectasis

collapsed lung

What are the 5 constructs of cultural competence?

cultural awareness cultural skill cultural knowledge cultural encounters cultural desire

Inability to hear high frequency sounds in older adults is related to

degeneration of hair cells

Religion may lead to

depression or anxiety over not meeting group expectations, and certain spiritual practices may delay needed medical care

otorrhea

discharge from the ear

Swelling, enlarged masses—or nodules— on the neck may indicate an

enlarged thyroid gland, inflammation of lymph nodes, or a tumor

goiter

enlargement of the thyroid gland

Purulent, bloody drainage suggests an infection of the

external ear

The ear consists of three distinct parts

external ear middle ear inner ear

A conductive hearing loss would be related to a dysfunction of the

external or middle ear

Possible negative impacts of religion/spirituality

failure to seek timely medical care withholding standardized medical care based on religious dogma

objective vertigo

feels like the room is spinning

Acculturation

gives up traits of his/her culture of origin as result of context with another culture

Worldview

he way individuals or groups of people look at the universe to form basic assumptions and values about their lives and the world around them; includes cosmology, relationships with nature, moral and ethical reasoning, social relationships, magicoreligious beliefs, and aesthetics

The risk of hypothyroidism increases with

head and neck irradiation

tuning fork and crude hearing tests give basic idea whether the client has

hearing loss, what type, and whether there is a problem with equilibrium

Rinne test

hearing test using a tuning fork; checks for differences in bone conduction and air conduction

Weber test

hearing test using a tuning fork; distinguishes between conductive and sensorineural hearing loss

Presbycusis often begins with a loss of ________-frequency sounds (a woman's voice) followed later by the loss of ________-frequency sounds.

high; low

Exophthalmos is seen in

hyperthyroidism

Sudden trouble seeing or visual disturbances in one or both eyes or sudden trouble walking, dizziness, or loss of balance or coordination may be a sign of an

impending stroke

A sensorineural loss would be related to dysfunction of the

inner ear

Stage 1 Pressure Ulcer

intact skin with nonblanchable redness

Cultural imposition

intrusive application of the majority group's cultural view upon individuals

spoon nails

iron deficiency

ears and _______ develop around the 5th to 8th week of pregnancy

kidneys

The trachea may be pulled to the affected side in cases of

large atelectasis, fibrosis or pleural adhesions

values

learned beliefs that are perceived to be appropriate or inappropriate

fissure

linear crack in the skin may extend to the dermis and may be painful

Normally air conduction is heard

longer

erosion

loss of superficial epidermis that does not extend to the dermis

What 3 bones of the middle ear transmit sound waves?

malleus, incus, stapes

Neck landmarks deviate from midline or are obscured because of

masses or abnormal growths

tenderness over the mastoid process suggests

mastoiditis

A stiff neck is often a late symptom seen in

meningitis

spiritual practices have the potential to encourage greater...

mental and physical health

80 to 90% IBW

mild malnutrition

70 to 80% IBW

moderate malnutrition

What is the sensory organ of hearing?

organ of corti

tenderness to auricle or tragus is associated with

otitis externa or postauricular cyst

tenderness behind the ear suggests

otitis media

A sudden decrease in ability to hear in one ear may be associated with

otitis media or cerumen impaction

Purulent drainage associated with pain and a popping sensation is characteristic of

otitis media with perforation of the tympanic membrane

Stereotyping

oversimplified conception, opinion, or belief about some aspect of individual/ group.

otalgia

pain in the ear

Stage 2 Pressure Ulcer

partial thickness skin loss of dermis, shallow ulcer

Normal tympanic membrane

pearly gray, shiny, translucent (not transparent), slightly concave, intact, small flutter or moves with swallowing

Subculture

people with culture that differentiates from larger culture of which they are part

hematocrit

percentage of blood volume occupied by red blood cells

pleural adhesions

pleural membranes stick together or to the wall of the chest and produce pain on movement or breathing

death rituals

practices depend on customs

Christian scientists frequently rely on

prayer alone to heal illnesses, rarely seek mainstream medical care, and have higher rates of mortality than the general population

Kawshiorkor

protein deficiency listless, swollen belly

Muscle wasting

protein, carbohydrate, and fat deficiency

Abnormal ear shape may be complemented with

renal disease

Low set ears or > 10 degree angle suggests

retardation or congenital syndromes

Red Conjunctiva

riboflavin deficiency

religion

rituals, practices, and experiences shared within group, involve a search for the sacred

A tightened-hard face with thinning facial skin is seen in

scleroderma

spirituality

search for life meaning/purpose, seeks to understand life's ultimate questions in relation to the sacred

less than 70% IBW

severe malnutrition

Trigeminal neuralgia (tic douloureux) is manifested by

sharp, shooting, piercing facial pains that last from seconds to minutes

CN XI

shrugging of the shoulders by the trapezius muscles and turning the head against resistance by the sternomastoid muscles

acromegaly

skull and facial bones are larger and thicker

HOPE

sources of Hope Organized religion Personal spirituality and practices Effects on medical care and end-of-life issues

A sudden, severe headache with no known cause may be a sign of impending

stroke

Otitis externa is often referred to as

swimmer's ear

Skin Turgor Test

tests for adequate hydration especially in elderly pinch a small fold of skin, observing elasticity

Cultural relativism

the belief that the behaviors and practices of people should be judged only from the context of their cultural system

Assimilation

the gradual adoption and incorporation of characteristics of the prevailing culture

fibrosis

the thickening and scarring of connective tissue, usually as a result of injury.

Weber test: If sound lateralizes to 1 ear

then there is conductive and sensorineural loss

Darwin tubercle

thickening along the upper ridge of the helix

Radiation therapy has been linked to the development of

thyroid cancer

What is the largest endocrine gland in the body?

thyroid gland

The client with a goiter may also have a

tight feeling in the throat, a hoarse voice, cough, hoarseness, difficulty swallowing, difficulty breathing

Eighty-five percent of head and neck cancers are linked to

tobacco use

sensorineural hearing

transmission of sound waves in the inner ear

conductive hearing

transmission of sound waves through the external and middle ear

transferrin

transport protein for iron

The trachea is pushed to the unaffected side in cases of a

tumor, enlarged thyroid lobe, pneumothorax, or with an aortic aneurysm

What separates the external ear from the middle ear?

tympanic membrane

Ethnocentrism

universal tendency of humans to think their ways of thinking, acting, and believing are the only right, proper, and natural ways.

Delimitation

whether they are discrete or confluent

You should only auscultate the thyroid if

you find an enlarged thyroid gland during inspection or palpation

A client expresses frustration that the nurse is assessing his spirituality, stating, "I thought I was here to have my tumor removed, not to figure out what I believe or don't believe about God." How should the nurse best justify the need for a spiritual assessment?

"Spirituality actually has a significant effect on your overall health."

When taking the Daily Spiritual Experiences Scale, a client says the word "God" in the scale is bothersome. Which response by the nurse would be most helpful in encouraging a client to complete the scale?

"Substitute whatever word you prefer that would represent the divine or holy."

A nurse is completing a comprehensive assessment of a client who has been referred to the clinic. Which of the following would be most appropriate for the nurse to ask when beginning to assess the client's spirituality?

"What gives you hope or peace?"

A nurse recognizes the need to assess a client's spirituality after the client has been admitted from the emergency department to the medical unit. How should the nurse best initiate this assessment?

"Would you describe yourself as being a religious or spiritual type of person?"

Romberg test

-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed -expected finding: client should be able to stand with minimal swaying for at least 20 seconds

A nurse weighs a client today and finds that the client's weight has increased 2.2 lbs from the previous day. The nurse interprets this finding as suggesting a fluid gain of which amount?

1.0 liters

During an initial prenatal visit, the nurse is performing a nutritional assessment of a woman who has just learned that she is pregnant for the first time. The nurse has determined that the client has an average stature and is 5 feet, 3 inches tall. What is this client's ideal body weight?

115 lbs.

Tricep skin fold thickness men

13.5 mm

normal pre albumin levels

15 - 30 mg/dL

tricep skin fold thickness women

16.5 mm

normal transferrin levels

200 - 400 mg/dL

mid-arm muscle circumference women

23.2 cm

mid-arm muscle circumfrence men

23.5 cm

An adult client weighs 175 pounds and is 5 feet 6 inches tall. The nurse determines that the client's body mass index is which of the following?

28

normal serum albumin level

3.5-5.5 g/dL

Non diabetic HgbA1c

4 - 6%

Total protein levels

6-8 g/dL

A nurse in the intensive care unit is calculating an acutely ill client's 24-hour fluid balance. The nurse should include insensible fluid losses of what volume when performing this assessment?

800 to 1000 mL

Optimal diabetic control HgbA1c

<7 %

A nurse is assessing an African-American client who has a longstanding diagnosis of hypertension. The nurse should be aware that the client may experience a greater-than- average effect of what medication?

A diuretic

Enculturation

A natural conscious/unconscious conditioning process of learning accepted cultural norms, values, and roles in society and achieving competence in one's culture through socialization.

A community health nurse is planning a health promotion campaign that will focus on cancer prevention. Which educational intervention should the nurse select in order to most influence participants' risks of head and neck cancers?

A smoking cessation program

Ethnicity

A socially, culturally, and politically constructed group that holds in common a set of characteristics not shared by others with whom members of the group come into contact

A client's recent weight loss and diarrhea has been attributed to hyperthyroidism. When auscultating the client's thyroid gland, what assessment finding is most consistent with this diagnosis?

A sound of turbulent blood flow in the thyroid

The nurse's assessment reveals that a male client can neither turn his head against resistance nor shrug his shoulders. The nurse should document a potential deficit in the functioning of which cranial nerve?

Accessory (XI)

A nurse is palpating the head and neck of a newly referred client. Which of the following would the nurse suspect if assessment reveals that the client's skull and facial bones are larger and thicker than normal?

Acromegaly

Assessment of a client's nails reveals the presence of Beau's lines. The nurse interprets this finding as suggestive of which of the following?

Acute illness

Otoscopic examination of a 69-year-old client's tympanic membrane reveals that it is red, bulging, and distorted. The nurse also notes a diminished light reflex. To what should the nurse most likely attribute this assessment finding?

Acute otitis media

When reviewing cultural differences that relate to the incidence and prevalence of disease among various cultural groups, the nurse would expect to see the highest prevalence of asthma in which group?

African Americans

The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiological process?

Air passing through constricted passageways

The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an ìitching rash.î Which question would be most important for the nurse to ask?

Are you allergic to foods, medications, or other substances?

An older adult client has presented to the emergency department with signs and symptoms of dehydration. When assessing the client for risk factors that may have contributed to this condition, what question should the nurse prioritize?

Are you currently taking any diuretic medications?

A 55-year-old client is being evaluated for a suspected hearing impairment. Which of the nurse's health interview questions is most likely to yield relevant data?

Are you having difficulty hearing high-frequency sounds?

A nurse is validating assessment findings with a client, and the client proceeds to describe some of the psychological and spiritual components that she believes underlie her disease process. This understanding of the cause of illness is most closely associated with which of the following?

Asian cultures

The nurse is assessing a client's respiratory rate and rhythm during the beginning of a shift. The nurse knows that a normal breathing rate is between approximately 10 and 20 breaths per minute, but the client's rate is 29 breaths per minute. How should the nurse respond to this assessment finding?

Ask the client if she has recently exerted herself.

While using an otoscope to assess the ears of an 8-year-old boy, the nurse observes white spots on the boy's tympanic membrane. The nurse also observes that no redness is present. Which action would be most appropriate?

Ask the mother whether the child has had numerous ear infections.

A client has sought care because he is concerned that a mole on his scalp may be evidence of skin cancer. During assessment using the mnemonic ABCDE, which finding would the nurse identify as being most suggestive of melanoma?

Asymmetric, irregular borders

The nurse is assessing the head and neck of a 51-year-old male client. Following inspection and palpation of the client's thyroid gland, the nurse determines that the gland is enlarged. What is the next action that the nurse should perform?

Auscultate the client's thyroid.

ASKED mnemonic to examine cultural competence

Awareness Skill Knowledge Encounters Desire

Assessment of a client's nails reveals brownish-black discoloration and crumbling of the nail plate. The nurse should suspect which of the following etiologies?

Bacterial infection

A nurse is preparing to palpate a client's submental lymph nodes. At what anatomic location should the nurse position his or her hands?

Behind the tip of the client's mandible

ethnocentrism

Belief in the superiority of one's nation or ethnic group.

Drooping, weakness, or paralysis on one side of the face may also result from a neurologic condition known as

Bell Palsy

A group of students is reviewing information about general assessment indicators of nutritional status. The students demonstrate a need for additional review when they identify which of the following as an indicator of adequate nutritional status?

Brittle hair

While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. The nurse would document which of the following?

Bronchial breath sounds