Health Assessment

Focus on therapeutic conversation for a client who voices feelings about abuse

(*get them safety, let person know your concerned, ask them if they are or ever have been being abused

A 45-year-old client states that he used to drink a cocktail nightly after work and also had a drink with his meal. Now he has two drinks before dinner and two or three more drinks during his meal. As the client continues to describe his alcohol intake, the nurse discovers that he also has added a couple of drinks at night to help him sleep. Which is the most accurate assessment of his alcohol consumption? 1. Tolerance 2. Addiction 3. Adjustment 4. Heavy social drinking

1

A client being seen in the emergency department immediately after being sexually assaulted appears calm and controlled. The nurse analyzes this behavior as indicating which defense mechanism? 1. Denial 2. Projection 3. Rationalization 4. Intellectualization

1

A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse should tell the client that which is the first step in this 12-step program? 1. Admitting to having a problem 2. Substituting other activities for gambling 3. Stating that the gambling will be stopped 4. Discontinuing relationships with people who gamble

1

A nurse provides dietary instructions to a client at risk for hypokalemia about which foods are high in potassium and should be included in the daily diet. The nurse should tell the client that which fruit is highest in potassium? 1. Kiwi 2. Apples 3. Peaches 4. Pineapple

1

The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior? 1. Reflecting a cultural value 2. An acceptance of the treatment 3. Client agreement to the required procedures 4. Client understanding of the preoperative procedures

1

The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions? 1. Information regarding shelters 2. Instructions regarding calling the police 3. Instructions regarding self-defense classes 4. Explaining the importance of leaving the violent situation

1

The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement? 1. "I no longer feel that I deserve the beatings my husband inflicts on me." 2. "My attendance at the meetings has helped me to see that I provoke my husband's violence." 3. "I enjoy attending the meetings because they get me out of the house and away from my husband." 4. "I can tolerate my husband's destructive behaviors now that I know they are common with alcoholics."

1

The nurse educator is providing in-service education to the nursing staff regarding transcultural nursing care; a staff member asks the nurse educator to describe the concept of acculturation. The nurse educator should make which most appropriate response? 1. "It is a process of learning a different culture to adapt to a new or changing environment." 2. "It is a subjective perspective of the person's heritage and a sense of belonging to a group." 3. "It is a group of individuals in a society who are culturally distinct and have a unique identity." 4. "It is a group that shares some of the characteristics of the larger population group of which it is a part."

1

The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. The nurse should implement which best action? 1. Continue with the instructions, verifying client understanding. 2. Walk around the client so that the nurse constantly faces the client. 3. Give the client a dietary booklet and return later to continue with the instructions. 4. Tell the client about the importance of the instructions for the maintenance of health care.

1

A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply. 1. Broth 2. Coffee 3. Gelatin 4. Pudding 5. Vegetable juice 6. Pureed vegetables

1 2 3

Which clients has a high risk of obesity and diabetes mellitus? Select all that apply. 1. A 40-year-old Latino American man 2. A 45-year-old Native American man 3. A 23-year-old Asian American woman 4. A 35-year-old Hispanic American man 5. A 40-year-old African American woman

1 2 4 5

The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings does the nurse expect to note? Select all that apply. 1. Dental decay 2. Moist oily skin 3. Loss of tooth enamel 4. Electrolyte imbalances 5. Body weight well below ideal range

1 3 4

Which are the most likely characteristics of an alcohol abuser? Select all that apply. 1. Male 2. Single 3. Suicidal at least once 4. Abusing drugs as well as alcohol 5. Employed in a minimal wage job 6. Been through detoxification at least twice

1 3 4

Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. 1. Monitor vital signs. 2. Maintain NPO status. 3. Provide a safe environment. 4. Address hallucinations therapeutically. 5. Provide stimulation in the environment. 6. Provide reality orientation as appropriate.

1 3 4 6

The nurse instructs a client who is at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines that the client understands the food sources of potassium if the client states that which food items are lowest in potassium, providing less than 200 mg per serving? Select all that apply. 1. Grapes 2. Carrots 3. Spinach 4. Asparagus 5. Avocadoes 6. Applesauce

1 4 6

What weeks of pregnancy does the fetus movement begin to be felt by the client?

18-20 weeks

The health care provider has prescribed medication therapy for a client with an alcohol abuse problem to assist in the maintenance of sobriety. The nurse reviews the client's record and expects to note that which medication has been prescribed? 1. Clonidine (Catapres) 2. Disulfiram (Antabuse) 3. Pyridoxine hydrochloride (vitamin B6) 4. Chlordiazepoxide hydrochloride (Librium)

2

The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care? 1. Ask the client why he started taking illegal drugs. 2. Ask the client about the amount of drug use and its effect. 3. Ask the client how long he thought that he could take drugs without someone finding out. 4. Not ask any questions for fear that the client is in denial and will throw the nurse out of the home.

2

The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet? 1. Vitamin A 2. Vitamin B12 3. Vitamin C 4. Vitamin E

2

The nurse is providing a health promotion session to a group of teenagers and is discussing the abuse of barbiturates. The nurse should provide which information to the teenagers? 1. Commonly results in a rush of energy 2. Is the cause of many drug overdose deaths 3. Results in only psychological dependency 4. Brings about an increase in blood pressure (BP)

2

When assessing a client's possible physical dependency on alcohol, the nurse should ask which priority question? 1. "Are you drinking more than you did 5 years ago?" 2. "How do you feel when you haven't had a drink all day?" 3. "Does your drinking ever cause you problems with your family?" 4. "Do you ever feel that you really need a drink to calm your nerves?"

2

When communicating with a client who speaks a different language, which best practice should the nurse implement? 1. Speak loudly and slowly. 2. Arrange for an interpreter to translate. 3. Speak to the client and family together. 4. Stand close to the client and speak loudly.

2

The nurse caring for an Orthodox Jewish client plans a diet that adheres to the practices of the client's faith. The nurse recognizes that which principles are consistent with dietary kosher laws? Select all that apply. 1. Meat and milk can be eaten together. 2. Eating fish with scales and fins is allowed. 3. Unleavened bread is eaten during Passover week. 4. Meat from animals who are vegetable eaters is allowed. 5. Meat is allowed if the food animal is ritually slaughtered.

2 3 4 5

A nurse is working with a client who shows signs of benzodiazepine withdrawal. The nurse should suspect that the client has suddenly discontinued taking which prescribed medication? 1. Sertraline (Zoloft) 2. Fluoxetine (Prozac) 3. Diazepam (Valium) 4. Haloperidol (Haldol)

3

A nurse should monitor a client with a history of opioid abuse for which signs and symptoms associated with opioid withdrawal? 1. Tachycardia, mild hypertension and fever, sweating, nausea, vomiting, and marked tremor 2. Increased appetite, irritability, anxiety, restlessness, anxiety, and altered concentration 3. Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, craving, diarrhea, and mydriasis 4. Depression, high drug craving, fatigue with altered sleep (insomnia or hypersomnia), hypertension, agitation, and paranoia

3

A nurse should monitor the client with a history of heroin addiction for which signs/symptoms of heroin withdrawal? 1. Constipation, insomnia, and hallucinations 2. Staggering gait, slurred speech, and violent outbursts 3. Nausea, vomiting, diarrhea, muscle aches, and diaphoresis 4. Decreased heart rate and blood pressure and dry nose, mouth, and skin

3

An Asian American client is experiencing a fever. The nurse recognizes that the client is likely to self-treat the disorder, using which method? 1. Prayer 2. Magnetic therapy 3. Foods considered to be yin 4. Foods considered to be yang

3

An adolescent has been prescribed an amphetamine to help manage a diagnosis of attention deficient hyperactivity disorder. To best minimize the risk of abuse and/or overdose, the nurse expects that the medication will be administered via which method? 1. Sublingual tablets 2. Rectal suppository 3. Intradermal patch 4. Weekly intramuscular injections

3

The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food item on the list? 1. Oranges 2. Broccoli 3. Cream cheese 4. Broiled haddock

3

The nurse is providing care to a Puerto Rican-American client who is terminally ill. Numerous family members are present most of the time, and many of the family members are very emotional. What is themost appropriate nursing action for this client? 1. Restrict the number of family members visiting at one time. 2. Inform the family that emotional outbursts are to be avoided. 3. Make the necessary arrangements so family members can visit. 4. Contact the health care provider to speak to the family regarding their behaviors.

3

What action should the nurse consider when counseling a client of the Amish tradition? 1. Speak only to the husband. 2. Use complex medical terminology. 3. Avoid using scientific or medical jargon. 4. Stand close to the client and speak loudly.

3

A 37-year-old client who is recovering from benzodiazepine dependence says, "I think I've walked under a black cloud. I've lost so many people. First, my brother dies of the big C; then my husband leaves me for a 20-year-old bimbo. I wish I had a Xanax right now." Which statement by the nurse would be therapeutic? 1. "The big C—it must have been a terrible loss for you when your brother died." 2. "Did you ever stop to think that your spouse might have gotten fed up with your using Xanax so much?" 3. "It sounds as if you feel that all of this has just happened to you. I wonder what part you played in events?" 4. "Can you tell me what you think the Xanax can do for you? Are there other things you used to do that might help you just as well?"

4

A nurse should interpret that which comment by a client whose husband uses violence against her is consistent with the presence of low self-esteem commonly found with battered wife syndrome? 1. "I'm lucky to be married to a man who really loves me the way that he does." 2. "I told him that this is his last chance. If it happens again, I'm leaving for good." 3. "I stay because there's enough in it for me. I don't have to work full time this way." 4. "Things would be fine at home if I just could do better. He has a lot of pressures on him at work."

4

A nursing student is discussing cultural diversity issues in a clinical conference when the nursing instructor asks the student to describe ethnocentrism. Which statement, if made by the student, would indicate a lack of understanding of the concept of ethnocentrism? 1. "It is a tendency to view one's own ways as best." 2. "It is acting in a superior manner toward other cultures." 3. "It is believing that one's own way is the only acceptable way." 4. "It is imposing one's beliefs on individuals from another culture."

4

The nurse educator asks a student to list the five categories of complementary and alternative medicine (CAM), developed by the National Center for Complementary and Alternative Medicine. Which statement, if made by the nursing student, would indicate an understanding of the five categories of CAM? 1. Herbology, hydrotherapy, acupuncture, nutrition, and chiropractic care 2. Mind-body medicine, traditional Chinese medicine, homeopathy, naturopathy, and healing touch 3. Biologically based practices, body-based practices, magnetic therapy, massage therapy, and aromatherapy 4. Whole medical systems, mind-body medicine, biologically based practices, manipulative and body-based practices, and energy medicine

4

The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? 1. Hypotension, ataxia, hunger 2. Stupor, lethargy, muscular rigidity 3. Hypotension, coarse hand tremors, lethargy 4. Hypertension, changes in level of consciousness, hallucinations

4

The nurse is preparing a plan of care for a client who is a Jehovah's Witness. The client has been told that surgery is necessary. The nurse considers the client's religious preferences in developing the plan of care and should document which information? 1. The client believes the soul lives on after death. 2. Medication administration is not allowed. 3. Surgery is prohibited in this religious group. 4. The administration of blood and blood products is not allowed.

4

The role of the nurse regarding complementary and alternative medicine should include which action? 1. Advising the client about "good" versus "bad" therapies 2. Recommending herbal remedies that the client should use 3. Discouraging the client from using any alternative therapies 4. Educating the client about therapies that he or she is using or is interested in using

4

Thiamine supplementation and other nutritional vitamin support measures are prescribed for clients who have been using alcohol to prevent or decrease the risk of which complication? 1. Cirrhosis 2. Delirium tremens 3. Esophageal varices 4. Wernicke-Korsakoff syndrome

4

A nurse is performing an assessement on a client who is at 38 weeks' gestation and notes that the fetal heart rate is 174 beats/min. On the basis of this finding, the appropriate nursing action is to: A) Notify the physician. B) Check the mother's heart rate. C) Document the finding. D) Tell the client that the fetal heart rate is normal.

A

A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse understands that the client should be able to find out at 12 weeks' gestation because by the end of the twelfth week: A) The sex of the fetus can be determained by the appearance of the external genitalia. B) The sex of the fetus can be determined because the testes are descended int o the scrotal sac. C) The sex of the fetus can be determined because the external genitalia begins to differentiate. D) The sex of the fetus can be determined because the internal differences in males and females become apparent.

A

A nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student responds correctly by stating that which of the following are functions of amniotic fluid? Select all that apply. A) Allows for fetal movement. B) Is a measure of kidney function. C) Surrounds, cushions, and protects the fetus. D) Maintains the body temperature of the fetus. E) Prevents large particles such as bacteria from passing to the fetus. F) Provides an exchange of nutrients and waste products between the mother and the fetus.

A B C D

How does the healthcare provider determine the presence of ballottement in a pregnant woman??

An obsolete method of diagnosing pregnancy: with the tip of the forefinger in the vagina, a sharp tap is made against the lower segment of the uterus;the fetus, if present, is tossed upward and (if the finger is retained in place)will be felt to strike against the wall of the uterus as it falls back.

A nurse explains some of the purposes of the placenta to a client during a prenatal visit. The nurse determines that the client understands some of these purposes when the client states that the placenta: A) Cushions and protects the baby. B) Is the way the baby gets food and oxygen. C) Maintains the temperature of the baby. D) Prevents all antibodies and viruses from passing to the baby.

B

A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse would document the GTPAL for this client as A) G=3, T=2, P=0, A=0, L=1 B) G=2, T=1, P=0, A=0, L=1 C) G=1, T=1, P=1, A=0, L=1 D) G=2, T=0, P=0, A=0, L=1

B

A nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and expects the finding to be which of the following? A. 22cm B. 30cm C. 36cm D. 40cm

B

A pregnant client is seen in a health care clinic for a regular prenatal visit. the client tells the nurse that she is experiencing irregular contractions, and the nurse determines that she is experiencing Braxton Hicks contractions. Based on this finding which nursing actions is appropriate? A) Contact the physician. B) Inform the client that these contractions are common and may occur throughout the pregnancy. C) Instruct the client to maintain bedrest for the remainder of the pregnancy. D) Call the maternity unit and inform them that the client will be admitted in a prelabor condition.

B

The nurse is conduction a prenatal class on the female reproductive system. When a client in the class asks why the fertilized egg stays in the fallopian tube for 3 days, the nurse responds that the reason for this is that it: A) Promotes the fertilized ovum's chances of survival. B) Promotes the fertilized ovum's normal implantation in the top portion of the uterus. C) Promotes the fertilized ovum's exposure to estrogen and progesterone. D) Promotes the fertilized ovum's exposure to luteinizing hormone and follicle-stimulating hormone.

B

A nurse should explain which of the following to a pregnant client found to have a gyencoid pelvis? A) That her type of pelvis has a narrow pubic arch. B) That her type of pelvis is a wide pelvis, but has a short diameter. C) That her type of pelvis is the most favorable for labor and birth. D) That she will need a cesarean section because this type of pelvis is not favorable for a normal labor and vaginal delivery.

C