HESI FUNDAMENTALS 2

Which intellectual factor would the nurse consider as a dimension when gathering data for a client's health history? A. Attention span B. Primary language C. Coping mechanisms D. Activity and coordination

A. Attention span Rationale: Attention span is an intellectual dimension used to gather data for a health history. The social dimension for gathering the health history includes primary language. A coping mechanism is considered to be a social subdimension used to gather a client's health history data. Physical and developmental subdimensions would include activities and coordination.

Which stage of Piaget's theory of cognitive development would the nurse observe in a preschooler? A. Sensorimotor B. Preoperational C. Formal operations D. Concrete operations

B. Preoperational Rationale: The second stage of Piaget's theory of cognitive development is the preoperational stage. It is observed from 2 to 7 years. During this stage, the child may learn to think with the use of symbols and mental images. The first stage is the sensorimotor stage, observed from birth to 2 years. During this stage, the child learns about themselves and their environment through motor and reflex actions. The fourth stage is formal operations, characterized by a prevalence of egocentric thought. The concrete operations stage is stage 3, which signifies that the child is able to perform mental operations.

Which physical assessment of the skin indicates that a client is addicted to a phencyclidine? A. Burns B. Vasculitis C. Diaphoresis D. Red and dry skin

D. Red and dry skin Rationale: Red and dry skin is associated with phencyclidine abuse. A client with alcohol abuse will have burns on the skin. Vasculitis is associated with cocaine abuse. Diaphoresis is associated with chronic abuse of sedative hypnotics.

Which physical change would the nurse observe in a client with malnutrition? Select all that apply. A. Hypotension B. Dry, dull hair C. Abdominal edema D. Delayed wound healing E. Depletion of muscle mass

A. Hypotension B. Dry, dull hair C. Abdominal edema (seen with protein malnutriton) D. Delayed wound healing E. Depletion of muscle mass

The nurse is assessing a client after surgery. Which assessment finding would the nurse obtain from the primary source? A. X-ray reports B. Severity of pain C. Results of blood work D. Family caregiver interview

B. Severity of pain Rationale: The primary source of information during an assessment is the client. The nurse gathers information about the client's pain from the primary source, the client. Medical records such as x-ray reports and results of blood work are secondary sources of information. The client's family caregiver is a secondary source of information.

Which would be a normal blood pressure of a 12-year-old client? A. 95/65 mm Hg B. 105/65 mm Hg C. 110/65 mm Hg D. 119/75 mm Hg

C. 110/65 mm Hg A 12-year-old client typically has a blood pressure of 110/65. A 1-year-old client would typically have a blood pressure of 95/65 mm Hg. A 6-year-old client would typically have a blood pressure of 105/65 mm Hg. A 14- to 17-year-old client has a typical blood pressure of 119/75 mm Hg.

Which physical skin finding indicates opioid abuse? A. Diaphoresis B. Red, dry skin C. Needle marks D. Spider angiomas

C. Needle marks Rationale: Needle marks of the skin indicate opioid abuse. Diaphoresis indicates sedative hypnotic abuse. Red, dry skin indicates phencyclidine abuse. Spider angiomas indicate alcohol abuse.

Which are extrinsic factors responsible for falls in older adults? Select all that apply. A. Impaired vision B. Cognitive impairment C. Environmental hazards D. Inappropriate footwear E. Improper use of assistive devices

C. Environmental hazards D. Inappropriate footwear E. Improper use of assistive devices Rationale: Environmental hazards, inappropriate footwear, and improper use of assistive devices are extrinsic factors that are responsible for falls in older adults. Impaired vision and cognitive impairment are intrinsic factors that are responsible for falls in older adults.

Which critical thinking skill demonstrates maturity in the nurse? A. Eagerness to acquire knowledge B. Being tolerant of different views C. Trust in own reasoning processes D. Ability to reflect on own judgements

D. Ability to reflect on own judgements Rationale: Maturity is the ability of a critical thinker to reflect on his or her own judgments. A critical thinker realizes that multiple solutions are acceptable. Inquisitiveness is the eagerness to acquire knowledge. A critical thinker is considered open-minded if he or she respects the right of others to have different opinions and is tolerant of different views. The critical thinker possesses self-confidence and trusts in his or her own reasoning process.

Which integumentary finding is related to skin texture? A. Elasticity B. Vascularity C. Fluid buildup D. Surface character

D. Surface character Rationale: Assessing for texture refers to evaluating the character of the surface of the skin. Assessing for elasticity refers to determining the turgor of the skin. Assessing for vascularity refers to determining skin circulation. Fluid buildup in the tissues indicates edema.

Which fine-motor skills may be observed in an 8 to 10 month-old infant? Select all that apply. A. Using pincer grasp well B. Picking up small objects C. Showing hand preference D. Crawling on the hands and knees E. Pulling oneself to standing or sitting

A. Using pincer grasp well B. Picking up small objects C. Showing hand preference Rationale: The fine motor skills evident in 8- to 10-month-old infants include the accurate use of the pincer grasp and picking up small objects. At this stage, infants may also demonstrate a hand preference. Crawling on the hands and knees and pulling oneself to a standing or sitting position are considered gross motor skills.

Which food would the nurse recommend to a client when instructing to increase potassium intake? A. Onion B. Celery C. Orange D. Cheese E. Oatmeal

C. Orange Rationale: Oranges and other citrus fruits contain potassium. Onions, celery, cheese, and oatmeal do not contain potassium in any significant amounts.

Which piece of equipment must the nurse ensure remains sterile during care of the client? A. Bedpan B. Stethoscope C. Suction catheter D. Blood pressure cuff

C. Suction catheter Rationale: Suction catheters that enter the respiratory tract are to remain sterile to prevent transmission of infection directly to the respiratory tract. Bedpans, stethoscopes, and blood pressure cuffs are to be clean, but not sterile, for effective and safe care.

Which is the regulator of extracellular osmolarity? A. Sodium B. Potassium C. Chloride D. Calcium

A. Sodium Rationale: Sodium is the most abundant extracellular fluid cation and regulates serum (extracellular) osmolarity, as well as nerve impulse transmission and acid-base balance. Potassium is the major intracellular osmolarity regulator, and it also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. Chloride is a major extracellular fluid anion and follows sodium. Calcium is an extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction.

The nurse assessed a client's pulse rate and recorded the score as 3+. Which describes the strength of the pulse? A. Strong B. Bounding C. Expected D. Diminished

A. Strong Rationale: A pulse strength of 3+ is considered full or strong. A bound pulse is 4+. A pulse strength is considered normal and expected when it is 2+. The pulse strength is diminished or barely palpable when the score is 1+.

When assessing a patient for malnutrition, the nurse would monitor for an increase in liver enzymes and a decrease in which water-soluble vitamin? Select all that apply. A. Biotin C. Niacin C. Folic Acid D. Riboflavin E. Vitamin C

A. Biotin C. Niacin C. Folic Acid D. Riboflavin E. Vitamin C Rationale: Water-soluble vitamins include biotin, niacin, folic acid, riboflavin, vitamin C, thiamine, pyridoxine, cyanocobalamin, and pantothenic acid. These along with fat-soluble vitamins are decreased during malnutrition along with elevated liver enzymes.

How can the nurse evaluate the effectiveness of communication with a client? A. Client feedback B. Medical assessments C. Health care team conferences D. Client's physiological responses

A. Client feedback Rationale: Feedback permits the client to ask questions and express feelings and allows the nurse to verify client understanding. Medical assessments do not always include nurse-client relationships. Team conferences are subject to all members' evaluations of a client's status. Nurse-client communication should be evaluated by the client's verbal and behavioral responses.

A student nurse is assessing the blood pressure of a client with the client's arm unsupported. Which is the expected error in the obtained reading. A. False high reading B. False low diastolic reading C. False high systolic reading D. False high diastolic reading

A. False high reading Rationale: If the client's arm is unsupported, or if the arm is below the heart level, the resulting outcome is a false high reading. Application of the stethoscope too firmly against antecubital fossa will result in a false low diastolic reading. Repeated assessments of blood pressure too often result in a false high systolic reading. Deflating the cuff too slowly results in a false high diastolic reading.

A client is discussing with the nurse concerns about their unhealthy family relationships. During the nurse-client interaction the client begins to talk also about a job problem. The nurse's response is, "Let's go back to what we were just talking about." Which therapeutic communication technique did the nurse use? A. Focusing B. Restating C. Exploring D. Accepting

A. Focusing Rationale: Focusing is a technique that directs a client back to the original topic of discussion. Restating the main idea of what the client has said encourages the client to continue speaking or clarifies what has been said. Exploring permits the nurse the delve deeper into the subject when the client tends to stay on a superficial level. Accepting is a technique used to understand and demonstrate regard for what the client stated.

Which of these is an ethical issue related to the long-term care setting? Select all that apply. A. Guardianship B. Power of attorney C. Advance directives D. Responsible party designation E. Do-not-resuscitate (DNR) orders F. Adherence to a patient's bill of rights

A. Guardianship B. Power of attorney C. Advance directives D. Responsible party designation E. Do-not-resuscitate (DNR) orders F. Adherence to a patient's bill of rights Rationale: Resident rights are a universal priority in all long-term care settings. Guardianship, power of attorney, advance directives, responsible party designation, do-not-resuscitate orders, and adherence to a patient's bill of rights are all ethical issues related to the long-term care setting.

An older adult with a history of diabetes reports giddiness, excessive thirst, and nausea. During an assessment, the nurse notices the client's body temperature as 105 F (40.6 C), orally. Which condition would the nurse suspect in the client? A. Heat stroke B. Heat exhaustion C. Accidental hypothermia D. Malignant hyperthermia

A. Heat stroke Rationale: Older adults are more at risk of heat stroke. Symptoms of heat stroke include giddiness, excessive thirst, nausea, and increased body temperature. Heat exhaustion is indicated by a fluid volume deficit. Heat exhaustion occurs when profuse diaphoresis results in excess water and electrolyte loss. Accidental hypothermia usually develops gradually and goes unnoticed for several hours. When the skin temperature drops below 95 F (35 C), the client suffers from controlled shivering, memory loss, depression, and poor judgment. Malignant hyperthermia is an adverse effect of inhalation anesthesia indicated by a sudden rise in body temperature in intraoperative or postoperative clients.

Which goals of care are associated with the family health system model? Select all that apply. A. Improving family health or well-being B. Preparing for family transitions later in life C. Providing assistance in family management of illness conditions D. Promoting positive family behaviors to achieve essential tasks E. Achieving health outcomes related to the family's areas of concern

A. Improving family health or well-being C. Providing assistance in family management of illness conditions E. Achieving health outcomes related to the family's areas of concern Rationale: When working with families, the goals of care are to improve family health or well-being, assist the family in managing the illness conditions, and achieve health outcomes related to the family's area of concern. In the developmental stage, the nurse would help the family prepare for later transitions and promote positive family behavior to achieve essential tasks.

Which disease process places a client at increased risk for infection? Select all that apply. A. Leukemia B. Lymphoma C. Emphysema D. Schizophrenia E. Osteoarthritis

A. Leukemia B. Lymphoma C. Emphysema Rationale: Disease processes that increase the client's risk for infection include leukemia, lymphoma, and emphysema, which lead to a diminished immune system. Schizophrenia and osteoarthritis do not impair a person's immune system.

Which risk factor increases a client's risk for infection in the community? Select all that apply. A. Lifestyle B. Occupation C. Chronic diseases D. Frequent traveling E. Diagnostic procedures

A. Lifestyle B. Occupation D. Frequent traveling Rationale: Adults are at risk for infection in the community via lifestyle choices such as high-risk behaviors that can lead to human immunodeficiency virus (HIV) and sexually transmitted infections. Occupational hazards include those who work in the mining or health care industries. Frequent travelers can be exposed to infections from other parts of the country or world. Chronic diseases such as pneumonia, skin breakdown, and diagnostic procedures happen in the health care setting.

The nurse notices cyanosis in a client with heart disease. Which site would the nurse assess to confirm cyanosis? A. Lips B. Sclera C. Conjunctiva D. Mucus membrane

A. Lips Rationale: The lips and nail beds are the best sites to assess for cyanosis. The sclera and mucous membrane are assessed in jaundice. The conjunctiva is assessed for the presence of pallor.

What is the inflammation of the skin at the base of the nail called? A. Paronychia B. Koilonychia C. Beau lines D. Splinter hemorrhage

A. Paronychia Rationale: Paronychia is the inflammation of skin at the base of the nail. Concavely curved nails are called koilonychias. Transverse depressions in nails indicating a temporary disturbance of nail growth are called Beau lines. Red or brown linear streaks in the nail bed are caused by minor trauma to nails, subacute endocarditis, or trichinosis and are called splinter hemorrhages.

A client with internal bleeding is in the intensive care unit (ICU) for observation. At the change of shift an alarm sounds, indicating a decrease in blood pressure. Which is the correct nursing action? A. Perform an assessment of the client before resuming the change-of-shift report B. Continue the change-of-shift report and include the decrease in blood pressure. C. Lower the diastolic pressure limits on the monitor during the change-of-shift report D. Turn off the alarm temporarily and alert the oncoming nurse to the decrease in blood pressure.

A. Perform an assessment of the client before resuming the change-of-shift report Rationale: The cause of the alarm should be investigated, and appropriate intervention instituted. After the client's needs are met, then other tasks can be performed. An alarm should never be ignored; the client's status takes priority over the change-of-shift report. The diastolic pressure limit has been prescribed by the primary health care provider and should not be changed for the convenience of the nurse. Alarms always should remain on; the alarm indicates that the client's blood pressure has decreased and immediate assessment is required.

The nurse is caring for a client who had a hip replacement 2 days prior. Which nursing intervention would the nurse perform next? A. Provide perineal care B. Turn and position the client C. Give a complete bed bath D. Document the bowel movement

A. Provide perineal care Rationale: Providing perineal care helps preserve skin integrity for the client who is incapable of providing self-care. Turning and positioning a client who has decreased physical mobility after hip surgery is important in preventing skin breakdown, but it is not an immediate client need. Giving a complete bed bath is not necessary after each bowel movement because only the perineal area is typically soiled. Documenting the bowel movement should be done only after meeting immediate needs of the client.

Which are physiologic symptoms asses in a client with sleep deprivation? Select all that apply. A. Ptosis and blurred vison B. Agitation and hyperactivity C. Confusion and disorientation D. Increased sensitivity to pain E. Decreased auditory alertness

A. Ptosis and blurred vison E. Decreased auditory alertness Rationale: Ptosis may result from a loss of elasticity of the eyelids, which is a physiologic symptom of sleep deprivation. Decreased auditory alertness and blurred vison are also physiologic symptoms of sleep deprivation. Agitation, hyperactivity, confusion, disorientation, and increased sensitivity to pain are psychologic symptoms of sleep deprivation.

The nurse assesses for hypocalcemia in a postoperative client. Which is one of the initial signs that might be present? A. Headache B. Pallor C. Paresthesias D. Blurred vison

C. Paresthesias Rationale: Normally, calcium ions block the movement of sodium into cells. When calcium is low, this allows sodium to move freely into cells, creating increased excitability of the nervous system. Initial symptoms are paresthesias. This can lead to tetany if untreated. Headache, pallor, and blurred visons are not signs of hypocalcemia.

Which intervention reflects the nurse's approach of "family as a context"? A. Trying meet the client's comfort B. Evaluating the client family's coping skills C. Determining the client family's energy level D. Trying to meet the client family's nutritional needs

A. Trying meet the client's comfort Rationale: In the "family as context" approach, the focus is on the client. The nursing care aims at meeting the client's comfort, hygiene, and nutritional needs. The "family as a client" approach focuses on the family's needs as a whole to determine their coping skills. This approach also includes assessment of the family's energy level to determine if the family would be able to meet the client's needs. In addition, the approach "family as a client" involves assessment of the family's nutritional needs.

Which pulse site is used for the Allen test? A. Ulnar B. Popliteal C. Brachial D. Femoral

A. Ulnar Rationale: The radial site is used for the Allen test. The popliteal pulse is used to assess status of circulation to lower leg. The status of the circulation in the lower arm and blood pressure are assessed using the brachial pulse. The femoral pulse is used to assess the character of the pulse during physiological shock or cardiac arrest when other pulses are not palpable.

To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse would change the administration set how often? A. Every 4 to 8 hours B. Every 12 to 24 hours C. Every 24 to 48 hours D. Every 72 to 96 hours

D. Every 72 to 96 hours Rationale: Best practice guidelines recommend replacing administration sets no more frequently than 72 to 96 hours after initiation of use in clients not receiving blood, blood products, or fat emulsions. This evidence-based practice is safe and cost effective. Changing the administration set every 4 to 48 hours is not a cost-effective practice.

The new nurse is approached by a surveyor from the department of health. The surveyor asks the nurse about the best way to prevent the spread of infection. Which answer by the nurse is correct? A. "Let me get my preceptor." B. "Wash your hands before and after any client care." C. "Clean all instruments and work surfaces with an approved disinfectant." D. "Ensure proper disposal of all items contaminated with blood of body fluids."

B. "Wash your hands before and after any client care." Rationale: The best means to prevent the spread of infection is to break the chain of infection. This is most easily accomplished by the simple act of hand washing before and after all client contact. "Let me get my preceptor" and "Clean all instruments and work surfaces with an approved disinfectant" may be correct, but they are not the best responses for this situation. It is not necessary that all items contaminated with blood or body fluids be disposed.

Which description of family-centered care is correct? A. The nursing care is focused on the client as an individual. B. A collaborative plan of care is developed to achieve optimal health C. The health care provider is the expert in developing a plan of care. D. The nursing care is based solely on standards of practice

B. A collaborative plan of care is developed to achieve optimal health Rationale: Family-centered care is commonly used to describe optimal health care as experienced by families. The term is frequently accompanied by terms such as "partnership," "collaboration," and families as "experts" to describe the process of care delivery. Family care addresses the family versus one individual. The health care provider collaborates with the family to develop a plan of care. Evidence-based standards of practice are incorporated into a collaborative family-centered care plan. Standards are not the only guidelines considered in a family-centered plan of care.

Which intervention improves client satisfaction? A. Recording the vital signs and leaving the room B. Adjusting the bed and asking if the client is comfortable C. Leaving the door of the room open while attending to the client D. Telling the client that the primary health care provider will visit soon

B. Adjusting the bed and asking if the client is comfortable Rationale: The nurse expresses concern and commitment by adjusting the bed and asking if the client is comfortable. This intervention shows the nurse's willingness to enter into a nurse-client relationship and promotes greater client satisfaction. The client may feel that the nurse is just performing a set of assigned tasks by recording the vital signs and leaving the room. This intervention does not build client satisfaction. The nurse would close the door after entering the room to ensure privacy while providing care. The nurse does not provide effective client satisfaction by informing the client about the primary health care provider's imminent visit.

A client with a diagnosis of malabsorption syndrome exhibits a symptom of spastic muscle spasms. Which electrolyte is responsible for this symptom? A. Sodium B. Calcium C. Potassium D. Phosphorous

B. Calcium Rationale: The muscle contraction-relaxation cycle requires an adequate serum calcium/phosphorous ratio; the reduction of the ionized serum calcium level associated with malabsorption syndrome causes tetany (spastic muscle spasms). Sodium is the major extracellular cation. The major route of sodium excretion is the kidneys, under the control of aldosterone. Although it plays a part in neuromuscular transmission, potassium is not related to the development of tetany. Potassium is the major intracellular cation. Potassium is part of the sodium-potassium pump and helps balance the response of nerves to stimulation. Potassium is not related to the development of tetany. Although phosphorous is closely related to calcium, because they exist in a specific ratio, phosphorous is not related to the development of tetany.

The advanced practice registered nurse (APRN) is caring for a pregnant woman ready to deliver. Which type of APRN would care for this client? A. Clinical nurse specialist (CNS) B. Certified nurse midwife (CNM) C. Certified nurse practitioner (CNP) D. Certified registered nurse anesthetist (CRNA)

B. Certified nurse midwife (CNM) Rationale: The CNM is qualified and has the skills to care for a pregnant woman. The CNS is an advanced practice registered nurse (APRN) who is an expert clinician in a specialized area of practice. The CNP is an APRN who provides health care to a group of clients, usually in an outpatient, ambulatory care, or community-based setting. The CRNA is an APRN with an advanced education in the nurse anesthesia accredited program.

After reviewing a client's reports, the primary health care provider suggests palliative care for the client. Which conditions would qualify the client for this type of care? A. Peptic ulcer B. Chronic renal failure C. Cognitive impairment D. Congestive heart failure E. Chronic obstructive lung disease

B. Chronic renal failure D. Congestive heart failure E. Chronic obstructive lung disease Rationale: Palliative care aims to minimize client suffering and reduce the undesirable effects resulting from an incurable disease or condition. Disease conditions such as severe chronic renal failure, congestive heart failure, and chronic obstructive lung disease cannot be cured completely with medications, but palliative care may reduce client suffering form the beginning of therapy to the end stages. Conditions such as peptic ulcer and cognitive impairment can be completely reversed by medications; therefore these clients do not require palliative care.

The nurse is gathering a client's health history. Which information would the nurse classify as biographical information? Select all that apply. A. Symptoms B. Client's age C. Family structure D. Type of insurance E. Occupation status

B. Client's age D. Type of insurance E. Occupation status Rationale: Biographical information is factual demographic data about the client usually obtained by the admitting office staff. The client's age, types of insurance, and occupation status are considered biographical information. If the client presents with an illness, the nurse gathers details about the symptoms of the illness, which is descriptive information, not biographical information. The nurse obtains information about family structure while assessing the family history of the client. It is not biographical information.

Which parts of the body assessed by the nurse would confirm a diagnosis of frostbite? Select all that apply. A. Axilla B. Fingers C. Ear lobes D. Forehead E. Upper thorax

B. Fingers C. Ear lobes Rationale: Areas particularly susceptible to frostbite are the fingers, toes, and earlobes. These parts of the body should be assessed to determine frostbite. The axilla is generally used to assess the body temperature; this site is used to diagnose a fever. The forehead and upper thorax are assessed to detect diaphoresis.

The nurse is caring for a client who is having diarrhea. Which client data would the nurse closely monitor to prevent an adverse outcome? A. Skin condition B. Fluid and electrolyte balance C. Food intake D. Fluid intake and output

B. Fluid and electrolyte balance Rationale: Monitoring fluid and electrolyte balance is the most important nursing intervention because excess loss of fluid through the multiple loose bowel movements associated with diarrhea lead to alteration in fluid and electrolyte imbalance. Although skin may become excoriated with diarrhea, this is not a life-threatening condition and is not the nursing priority. Even though absorption of nutrients is decreased with diarrhea malnutrition, it is not a life-threatening condition and is not the priority nursing intervention. Fluid intake and output provides information about fluid balance only, without taking into consideration the loss of electrolytes that accompanies diarrhea and is not the best choice.

Which action relates with the relevance strategy of the motivational learning model proposed by Keller? A. Extrinsic and intrinsic reinforcements for any learning effort B. Linking the person's needs, interests, and motives for learning C. Arousing and sustaining a person's curiosity and interest in learning D. Having positive hope for successful achievements as a result of learning

B. Linking the person's needs, interests, and motives for learning Rationale: Keller proposed a motivational learning model that includes four factors: attention, relevance, confidence, and satisfaction (ARCS). Relevance strategies involves linking the person's needs, interests, and motives for learning. The attention strategies include arousing and sustaining one's curiosity and interest. Confidence strategies include helping people develop a positive expectation for goal achievement. Satisfaction strategies provide extrinsic and intrinsic reinforcement for efforts.

The nurse pulls up on the client's skin and releases it to determine whether the skin returns immediately to its original position. Which is the nurse assessing for? A. Pain tolerance B. Skin turgor C. Ecchymosis formation D. Tissue mass

B. Skin turgor Rationale: Skin turgor is assessed by gently pinching the skin and releasing it while observing the degree of elasticity. If the skin pinch remains elevated or is slow to return to its original position, this may be an indication of dehydration or deficient fluid volume. This assessment technique is not appropriate for assessing pain tolerance, checking for ecchymosis formation, or measuring tissue mass.

In which situation would the nurse consider family members as the primary source of information? A. The client is an older adult B. The client is an infant or child C. The client is brought in as an emergency D. The client is critically ill and disoriented E. The client visits the outpatient department

B. The client is an infant or child C. The client is brought in as an emergency D. The client is critically ill and disoriented Rationale: The nurse interviews the parents who care for the infant or child. Thus the parents become the primary source of information. A client who is brought to the emergency department may not be in a position to explain the circumstances that led to the visit. In this case the family or significant others who accompany the client become the primary source of information. The family becomes the primary source of information when the client is critically ill, disoriented, and unable to answer questions. Generally, the client is the primary source of information. The older adult who is conscious, alert, and able to answer the nurse's questions is the primary source of information. The client who visits the outpatient department is capable of providing accurate answers to the nurse's questions. This client is the primary source of information during assessment.

The nurse is providing restraint education to a group of nursing students. Which reason to use restraints is incorrect to teach? A. To prevent a confused client from pulling out an intravenous (IV) line B. To prevent an adult client from getting up at night when there is insufficient staffing on the unit C. To maintain immobilization of a client's leg to prevent dislodging a skin graft D. To keep an older adult client from falling out of bed after a surgical procedure

B. To prevent an adult client from getting up at night when there is insufficient staffing on the unit Rationale: Restraints are not used for staff convenience. An older adult client who is unable to sleep should be assessed for physiological reasons for this and for safety needs before consideration of any restraint device. Various forms of restraint devices are indicated for client protection from injury and to maintain essential medical therapies, such as pulling out an IV, dislodging a skin graft, or preventing falls.

Which documentation is most informative for an assessment of drainage on a surgical dressing? A. "Moderate amount of drainage." B. "No change in drainage since yesterday." C. "A 10 mm-diameter area of drainage at 1900 hours." D. "Drainage is doubled in size since last dressing change."

C. "A 10 mm-diameter area of drainage at 1900 hours." Rationale: A 10 mm-diameter area of drainage at 1900 hours is objective data and gives specific details regarding the assessment and a time frame. By providing size, it establishes parameters to compare with previous assessments and to further evaluate the drainage. "Moderate amount of drainage," "No change in drainage since yesterday," and "Drainage is doubled in size since last dressing change" are not specific, objective, or measurable.

A home health nurse checks the client's vital signs and obtains a blood sample for an international normalized ratio (INR). After these tasks are completed, the client asks the nurse to straighten the blankets on the bed. Which response by the nurse is correct? A. "I would, but my back hurts today." B. "Okay. It will be my good deed for the day." C. "Of course. I want to do whatever I can for you." D. "I would like to, but it is not in my job description."

C. "Of course. I want to do whatever I can for you." Rationale: Helping the client meet physical needs is within the role of the nurse; arranging blankets on the client's bed is an appropriate intervention. The nurse's comfort needs should not take precedence over the client's needs; the nurse would not assume responsibility for the role of care provider if incapable of providing care. This act is not a good deed but fulfills the expected role of the nurse; this response sounds grudgingly compliant. Straightening the blankets is within the nurse's job description.

A client is diagnosed with acquired immunodeficiency syndrome (AIDS). When examining the client's oral cavity, the nurse assesses white patchy plaques on the mucosa. The nurse recognizes that this finding most likely represents which opportunistic infection? A. Cytomegalovirus B. Histoplasmosis C. Candida albicans D. Human papillomavirus

C. Candida albicans Rationale: White patchy plaques on the oral mucosa would most likely be a result of C. albicans, a yeast-like fungal infection. This condition is also known as "thrush." Cytomegalovirus may cause a serious viral infection in persons with HIV, resulting in retinal, gastrointestinal, and pulmonary manifestations. Histoplasmosis is an infection caused by an inhalation of spores of the fungus Histoplasma capsulatum and is characterized by fever, malaise, cough, and lymphadenopathy. Human papillomavirus typically manifests as warts on the hands and feet, as well as mucous membrane lesions of the oral, anal, and genital cavities. It may be transmitted without the presence of warts through body fluids, with some forms associated with cancerous and precancerous conditions.

A client who underwent a physical examination reports itching after 2 days. Which condition would the nurse expect? A. Eczema B. Hypersensitivity C. Contact dermatitis D. Anaphylactic shock

C. Contact dermatitis Rationale: A client who is allergic to latex may experience an allergy after a physical examination with latex gloves. Itching is one of the clinical signs of a latex allergy. Contact dermatitis is a delayed immune response that occurs 12 to 48 hours after exposure. Eczema is a skin condition that can be worsened with excessive drying. Hypersensitivity is an immediate allergic reaction that occurs due to chemicals that are used to make gloves. Anaphylactic shock is also an immediate allergic reaction that occurs due to natural rubber latex.

Which intrinsic factor is associated with the fall of an older adult? A. Wet floors B. Poor lighting C. Lack of exercise D. Inappropriate footwear

C. Lack of exercise Rationale: Intrinsic risk factors associated with the fall of an older adult may include a lack of exercise or deconditioning. Wet floors, poor lighting, and inappropriate footwear are extrinsic risk factors.

Which behavioral characteristic, according to temperament theory, is demonstrated by a slow-to-warm up child? A. Highly active B. Irritable and irregular in habits C. Negative reaction to new stimuli D. A positive mild-to-moderately intense mood

C. Negative reaction to new stimuli Rationale: A slow-to-warm up child may react negatively with mild intensity to any new stimuli or a change. A difficult child is highly active as well as irritable and irregular in habits. An easy child usually has a positive mild-to-moderately intense mood.

Which definition is involved in the caring process called knowing, according to Swanson's theory of caring? A. Being emotionally present for the other B. Sustaining faith in the other's capacity to get through an event C. Striving to understand an event as it has beaning in the life of the other D. Facilitating the other's passage through life transitions and unfamiliar events

C. Striving to understand an event as it has beaning in the life of the other Rationale: In Swanson's theory of the caring process, knowing involves striving to understand an event as it has meaning in the life of another. The definition of being emotionally present for the other is related to the caring process called being with. The definition of sustaining faith in the other's capacity to get through an event or transition is related to the caring process called maintaining belief. The definition of facilitating the other's passage through life transitions and unfamiliar events is related to the caring process called enabling.

Which psychosocial health concern involves accepting descriptive statements stated by a confused older client? A. Reminiscence B. Reality orientation C. Validation therapy D. Therapeutic communication

C. Validation therapy Rationale: Validation therapy is the psychosocial concern involved in accepting the descriptive statements made by a confused older client. Reminiscence is recalling the past. Reality orientation involves helping a confused older client agree with the nurse's statements. Therapeutic communications enables the nurse to perceive and respect the older client's uniqueness and health care expectations.

A client with a head injury underwent a physical examination. The nurse observes that the client's temperature assessments do not correspond with the client's condition. Which part of the client's brain would the nurse suspect is injured? A. Pons B. Medulla C. Thalamus D. Hypothalamus

D. Hypothalamus Rationale: The hypothalamus controls the body temperature. Damage to the hypothalamus may cause abnormalities in the body temperature values during a physical assessment. The pons is responsible for maintaining the level of consciousness. The medulla controls heart rate and breathing. The thalamus performs motor and sensory functions.

Which positioning would be avoided while assessing a client with a history of asthma? A. Sitting B. Supine C. Dorsal recumbent D. Lateral recumbent

D. Lateral recumbent Rationale: The lateral recumbent position is used to assess heart function. A client with asthma or other respiratory problems may not tolerate the lateral recumbent position. The sitting position is used to assess the heart, thorax, and lungs; this position should be avoided in physically weakened clients. The supine position is used to assess the heart, abdomen, extremities, and pulses. The dorsal recumbent position is used for an abdominal assessment and to assess the head, neck, and lungs.

The nurse is assessing a client's nails and finds a slight convex curve at the angle from the skin to nail base of about 160 degrees. Which condition would the nurse suspect? A. Clubbing B. Paronychia C. Koilonychia D. Normal finding

D. Normal finding Rationale: The client's nail, which has a slight convex curve at the angle from the skin to nail base of about 160 degrees, is normal. In clubbing, there is a change in the angle between the nail and the nail base larger than 180 degrees. Paronychia is the inflammation of the skin at the base of the nail. Koilonychia is the concave curves on the nail.

Which statement is true for attachment of the newborn? A. Attachment occurs over the first 28 days. B. Attachment begins in the first week of birth. C. Attachment is the overlapping of soft skull bones. D. Attachment is the interaction between parent and child

D. Attachment is the interaction between parent and child Rationale: Attachment is the interaction between the parent and the child. The nurse promotes the parents' and newborn's need for physical contact by encouraging breast-feeding. Attachment is a process that evolves over the first 24 months. The newborn is awake and alert for the first half-hour after birth, during which parent-child interaction begins. Molding is the overlapping of the soft skull bones commonly seen in newborns who had vaginal births. Molding allows the fetal head to adjust to the various diameters of the maternal pelvis during birth.

Which physical assessment technique involves listening to the sounds of the body? A. Palpation B. Inspection C. Percussion D. Auscultation

D. Auscultation Rationale: Auscultation involves listening to the sounds of the body. Palpation involves using the sense of touch to assess and collect data. An inspection involves the nurse carefully looking to collect data. Percussion involves tapping the skin with the fingertips to vibrate underlying tissues and organs.

The nurse is reviewing a client's plan of care. Which is the determining factor in the revision of the plan? A. Time available for care B. Validity of the problem C. Method for providing care D. Effectiveness of the interventions

D. Effectiveness of the interventions Rationale: When the implementation of a plan of care does not produce the desired outcome effectively, the plan should be changed. Time is not relevant in the revision of a plan of care. Client response to care is the determining factor, not the validity of the health problem. Various methods may have the same outcome; their effectiveness is most important.

The nurse at a community heath care center focuses on providing primary preventative care. Which is the focus of primary preventative care? A. Rehabilitating the client B. Treating early stages of disease C. Preventing complications from illness D. Promoting health in healthy individuals

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

The nurse is assessing a client who is undergoing chemotherapy. The nurse notes that the client is using a scarf to cover the head. The nurse asks the client about coping with the altered body image. Which functional pattern would the assessment include? A. Value-belief pattern B. Role-relationship pattern C. Cognitive-perceptual pattern D. Self-perception-self-tolerance pattern

D. Self-perception-self-tolerance pattern Rationale: The nurse is applying Gordon's self-perception-self-tolerance pattern to assess the client. This functional pattern describes the client's self-worth, emotional patterns, and body image. The value-belief pattern describes patterns of values, beliefs, spiritual practices, and goals that guide the client's choices or decisions. The role-relationship pattern describes patterns of role engagements and relationships. The cognitive-perceptual pattern describes sensory-perceptual patterns, language adequacy, memory, and decision-making ability.

Why would the nurse establish "moderately hard" client-centered goals? Select all that apply. A. To decrease the cost of treatment during therapy B. To decrease the number of follow-up visits by the client C. To achieve the goal in a shorter period of time with less effort D. To prevent the client from quitting before the goal is achieved E. To prevent the client from losing motivation toward achieving the goal

D. To prevent the client from quitting before the goal is achieved E. To prevent the client from losing motivation toward achieving the goal Rationale: Health care providers generally design moderately hard client-centered goals because, if they goals are too hard to achieve, the client may give up before completely achieving the,. However, if the goals are too simple, it may create a feeling that the goal is of no benefit or is not worth pursing. Designing moderately hard client-centered goals will not decrease the cost of treatment. Moderately hard client-centered goals will not necessarily be completed in a shorter period of time with less effort. Establishing moderately hard client-centered goals will not necessarily reduce the number of follow-up visits required.