HESI Health and Physical Assessment

When performing weight assessments for people within a community, which question would the nurse ask to determine a disease-related change in weight? "Does your diet include a strict calorie intake?" "Have you noticed any changes in the social aspects of eating?" "Are you taking medications such as diuretics or insulin?" "Have you noticed any unintentional weight loss in the past 6 months?"

"Have you noticed any unintentional weight loss in the past 6 months?" Rationale Unintentional or undesired weight loss during a certain period of time may indicate a weight change due to a disease, such as gastrointestinal problems. A strict calorie intake in a permitted limit is not related to any disease. Assessing the social aspects of a client's eating habits determines any lifestyle changes that may cause a weight change. Diuretics and insulin may cause weight loss or weight gain; this change is not disease-related.

During a skin assessment, the nurse notes, round and discrete lesions that are dark red in color and will not blanch. The lesions range from 1 to 3 mm in size. What is the first question the nurse should ask the client? • "Have you noticed any unusual bleeding?" "Have you fallen recently?" "How often do you drink alcohol?" "Have you been exposed to anyone with a rash lately?"

"Have you noticed any unusual bleeding? Rationale Petechiae are small, reddish-purple lesions that do not fade or blanch when pressure is applied and often indicate an increase in capillary fragility. Petechiae is a condition usually seen in clients with thrombocytopenia. Petechiae may indicate abnormal clotting factors. Most of the diseases that cause petechiae cause bleeding and microembolism formation.

When performing an assessment of the client's reproductive system, which finding in the past medical history indicates the client is at risk of cervical cancer? Vaginal discharge Ovarian dysfunction Human papilloma virus infection Hematuria and urinary incontinence

Human papilloma virus infection Rationale A human papilloma virus (HPV) infection increases the risk of cervical cancer. The presence of vaginal discharge may indicate a sexually transmitted infection. A history of ovarian dysfunction may increase the risk of ovarian cancer. The presence of hematuria and urinary incontinence may indicate urinary problems associated with gynecological disorders.

The nurse is assessing four infants. Currently, which infant has an abnormal weight? Infant. Age (Months). Weight at Birth. Current Weight 1. 4. 2.9. 6.1 2. 5. 3.3. 8.5 3. 12. 3.5. 10 4 11. 3.4. 10.3

Infant 2 Rationale The average birth weight of a newborn is 3.2 to 3.4 kg. An infant usually doubles his or her birth weight by 4 to 5 months of age. Infant 2's weight of 8.5 kg at 5 months is abnormal. Infant 1, weighing 6.1 kg, is of a normal weight. An infant has usually tripled his or her birth weight by around 1 year. Infants 3 and 4 are experiencing normal weight gain.

Upon entering an examination room for assessment of a confused client, which action would the nurse take? Perform an assessment quickly. Plan a focused physical assessment. Skip the examination until the client is reoriented. Leave the room to find the health care provider.

Plan a focused physical assessment. Rationale A focused assessment is the most common and efficient physical examination. The nurse would not rush through an assessment because of confusion. The nurse would not skip the assessment because of confusion. The nurse would never leave a confused client unattended.

Which question would the nurse ask the client when obtaining their health history? Select all that apply. One, some, or all responses may be correct. "Tell me about your food habits." "Do you use alcohol or tobacco?" "Have you sustained any personal loss recently?" "Have you ever experienced any allergic reactions?" "Does any family member have a long-term illness?"

"Tell me about your food habits." "Do you use alcohol or tobacco?" "Have you ever experienced any allergic reactions?" Rationale The health history of a client includes the client's food habits so that the nurse can obtain an assessment of the client's nutrition status. The nurse also assesses the client's habits and lifestyle patterns. Asking about the use of alcohol and tobacco helps determine the client's risk for diseases involving the liver or lungs. The health history includes descriptions of allergies and reactions to food, latex, drugs, or contact agents such as soap. While assessing the family history, the nurse assesses the client for stress-related problems by asking about recent personal losses. The family history provides information about family members to determine the risk for illnesses of a genetic or familial nature.

While preparing to teach a client about self-injection of insulin, which nurse's action would increase the effectiveness of the teaching session? Wait until a family member is also present. Assess the client's barriers to learning self-injection techniques. Begin with simple written instructions describing the technique. Wait until the client has accepted the new diagnosis of type 1 diabetes mellitus.

Assess the client's barriers to learning self-injection techniques Rationale Before a teaching plan can be developed, the factors that interfere with learning must be identified. Although family members can be helpful, client involvement in care is most important for promoting independence and self-esteem. Assessment comes before intervention; written instructions may not be the most appropriate teaching modality. The client may never accept the change but must learn to manage care; this may be an unrealistic expectation.

The client becomes confused and the nurse suspects the client is declining. Which assessment finding would indicate the client is not progressing as expected? Select all that apply. Asterixis Fetor hepaticus Negative Babinski sign Low-protein intake Decreased ammonia level Hyperreflexia Coherent Alcohol Anonymous attendance Esophageal varices development Consumption of potassium rich foods

Asterixis Fetor hepaticus Hyperreflexia Esophageal varices development Consumption of potassium rich foods Rationale: The assessment findings that indicate the client is not progressing as expected includes asterixis, fetor hepaticus, hyperreflexia, esophageal varices development, and consumption of potassium-rich foods. Asterixis is hand flapping, a sign of hepatic encephalopathy (a complication of cirrhosis. Fetor hepaticus is musty, sweet breath, characteristic of hepatic encephalopathy. Hyperreflexia occurs in Stage Ill of hepatic encephalopathy. Esophageal varices indicate the client is declining; esophageal varices can lead to bleeding and should not develop. Consumption of potassium rich foods indicates the client is declining because the client is taking spironolactone, a potassium-sparing diuretic; intake of potassium rich foods can lead to hyperkalemia and worsen his condition. All the other assessment findings indicate the client is improving. A negative Babinski sign is a neurological finding that indicates improvement; a positive Babinski sign can indicate hepatic encephalopathy. The client should have a low-protein intake; a high-protein intake can lead to hepatic encephalopathy. A decreased ammonia level indicates improvement; an elevated ammonia level can indicate hepatic encephalopathy. Coherent indicates the client is improving; mental confusion and inability to concentrate or think indicates hepatic encephalopathy. Attendance at Alcohol Anonymous indicates improvement; the client must abstain from alcohol.

At which site would the nurse obtain the temperature of a client admitted to a surgical unit in an unconscious state due to head trauma? Oral Axilla Temporal artery Tympanic membrane

Axilla Rationale The axilla would be the most appropriate site to obtain a temperature measurement in a client who is unconscious due to head trauma. The oral route is not accessible when the client is unconscious. Because the client is in a surgical unit, his or her head may be covered. Obtaining a temperature measurement through the temporal artery or tympanic membrane may not be possible.

The nurse is assessing four clients. Which client is at the highest medical risk of coronary heart disease and hypertension? client Height cm. Weight kg A. 180. 70 B. 185. 95 C. 152. 56 D. 145. 67

Client D Rationale A body mass index (BMI) higher than 30 is considered obesity and puts the client at a higher medical risk of coronary heart disease, some cancers, and hypertension. Client D (who is 145 cm tall and weighs 67 kg) has a BMI of 31.9, which indicates obesity. This can lead to coronary heart disease and hypertension. Client A has a BMI of 21.6, which indicates a normal weight. Client B has a BMI of 27.77, which indicates that the client is overweight but not obese. Client C, with a BMI of 24.24, is considered as having a normal weight.

While assessing a client, the nurse identifies the ratio of the anteroposterior diameter and transverse diameter of the chest as 1:1. Which finding supports this conclusion? Select all that apply. One, some, or all responses may be correct. Some correct answers were not selected Client has lordosis. Client is an older adult. Client has osteoporosis. Client has a history of smoking. Client has chronic lung disease.

Client is an older adult. Client has a history of smoking. Client has chronic lung disease. Rationale The 1:1 ratio of the anteroposterior diameter and transverse diameter of the chest indicates a barrel-shaped chest. This is a characteristic feature in an older adult who smokes and has chronic lung disease. In lordosis, there is an increase in lumbar curvature. Osteoporosis is a systemic skeletal condition in which there is a decreased bone mass and deterioration of bone tissue.

For which client would the nurse assess the carotid pulse? Select all that apply. One, some, or all responses may be correct. Some correct answers were not selected Client with cardiac arrest Client indicated for Allen test Client under physiological shock Client with impaired circulation to foot Client with impaired circulation to hand

Client with cardiac arrest Client under physiological shock Rationale Carotid pulse is indicated in clients with physiological shock or cardiac arrest when other sites are not palpable in the client. Assessment of the ulnar pulse is indicated in clients requiring an Allen test. Assessment of posterior tibial pulse and dorsalis pedis pulse is indicated in clients with impaired circulation to the feet. Assessment of the radial and ulnar pulse is indicated in clients with impaired circulation to the hands.

During an inspection of a client's mouth and pharynx, the nurse places a tongue blade on the back of the tongue which causes the client to gag. After removing the tongue blade, which action should the nurse take? Initiate aspiration precautions. Notify the healthcare provider. Document an intact gag reflex. Provide a warm salt water gargle.

Document an intact gag reflex. Rationale The placement of a tongue blade on the back of the tongue should stimulate a normal gag reflex, indicating that cranial nerves IX and X are intact. The nurse should document that the gag reflex is intact.

The nurse is conducting a family history as part of the assessment interview. Which action should the nurse take to ensure that sufficient information about the client's blood relatives is obtained? Document at least 3 generations of the client's family medical history if possible. Ask about any genetic conditions that may be present in the family. Instruct the client to develop a genogram to bring to the next visit. Request medical records of all the client's immediate family members.

Document at least 3 generations of the client's family medical history if possible. Rationale The family history assists the healthcare provider in determining the client's health risks. It is recommended that family medical history be traced back three generations if possible. These generations consists of the client's blood-relatives of any siblings, parents, and maternal and paternal grandparents.

While providing postoperative care for a client, who had surgery to repair a deviated septum, the nurse would monitor for which complication associated with this type of surgery? Occipital headache Periorbital crepitus Expectoration of blood Changes in vocalization

Expectoration of blood Rationale After a submucosal resection (SMR), hemorrhage from the area should be suspected if the client is swallowing frequently or expelling blood with saliva. A headache in the back of the head is not a complication of SMR. Crepitus is caused by leakage of air into tissue spaces; it is not an expected complication of SMR. The nerves and structures involved with speech are not within the operative area. However, the sound of the voice is altered temporarily by the presence of nasal packing and edema.

A client, admitted to the hospital with chest pain, reports shortness of breath, weakness, and vomiting. The nurse suspects acute coronary syndrome (ACS). At which site would the nurse check the client's pulse rate? Ulnar Radial Brachial Femoral

Femoral Rationale A client with chest pain, shortness of breath, weakness, and vomiting may be experiencing acute coronary syndrome (ACS). This can progress to cardiac arrest. In this client, the most appropriate place to check the pulse rate is the femoral site, because other pulses may not be reliably palpable. The ulnar site is used to assess the status of circulation to the hand and also used to perform the Allen test. The radial site is commonly used to assess the character of the pulse peripherally and to assess the status of the circulation to the hand. The brachial site is used to assess the status of the circulation to the client's lower arm or the blood pressure is being auscultated.

Upon entering the examination room of a client and their spouse, which action would the nurse take when the client is withdrawn and appears fearful of the spouse? Ask if there are concerns at home. Call the client later to ensure safety. Find a way to interview the client in private. Assume the client is nervous in medical settings.

Find a way to interview the client in private. Rationale Abuse is suspected when a client seems fearful of another person, and the nurse would find a way to interview the client in private. Asking about concerns at home should not be done in front of the spouse. Calling the client later does not address a possible immediate threat to the client's safety. The nurse would investigate the safety of the client, not assume nervousness.

Which term should the nurse use to document in the client's medical record for a high-pitched scratchy sound during auscultation of the heart? Murmur. Ejection click. Friction rub. Normal heart sound.

Friction rub. Rationale A high-pitched, scratchy, or grating sound heard during auscultation of the heart is called a pericardial friction rub, which is associated with inflammation of the pericardium, often seen during the following week in a client after a myocardial infarction. To best hear the pericardial friction rub, the nurse should have the client sitting upright and leaning forward while the client holds their breath and the nurse listens with the diaphragm of the stethoscope at the apex and left lower sternal border.

When preparing to assess a client with Clostridium difficile, which piece of personal protective equipment would the nurse put on before entering the client's room? Head covering Clear eye mask Full plastic gown N95 respiratory mask

Full plastic gown Rationale A client with Clostridium difficile should be on contact precautions to avoid the spread of the spores, so the nurse would wear a full plastic gown that is disposed of once the assessment is complete. A head covering, eye mask, and N95 respiratory mask are not necessary protective devices in the assessment of a client with Clostridium difficile.

Which condition would the nurse suspect upon finding a bluish coloration of the skin during an assessment? Anemia Liver disease Heart disease Autoimmune disease

Heart disease Rationale A bluish discoloration of the skin indicates cyanosis. This condition may be caused by increased amounts of deoxygenated hemoglobin, which may be due to heart disease or lung disease. In clients with anemia, the skin has a pallor due to a reduced amount of oxyhemoglobin. In clients with liver disease, the skin appears yellow or orange due to increased deposits of bilirubin. In autoimmune diseases, the skin will lose its pigmentation.

A client reports difficulty breathing and the nurse auscultates bilateral wheezing in the anterior upper lobes. Which potential rationale would explain this sound? Inflammation of the pleura Muscular spasms in the larger airways Sudden reinflation of groups of alveoli High velocity airflow through an obstructed airway

High velocity airflow through an obstructed airway Rationale Wheezing is a high-pitched sound that may be caused by a high velocity airflow through an obstructed or narrowed airway. Inflammation of the pleura may produce pleural friction rubs. Muscular spasms in larger airways or any new growth causing turbulence may produce rhonchi, which is a loud and low-pitched sound. Sudden reinflation of groups of alveoli may produce crackling sounds.

For which clinical indicator would the nurse question a prescription for gastric lavage? Decreased serum pH Increased serum oxygen level Increased serum bicarbonate levelDecreased serum osmotic pressure

Increased serum bicarbonate level Rationale Gastric lavage causes an excessive loss of gastric fluid, resulting in excessive loss of hydrochloric acid (HCI), which can lead to alkalosis; the HCl is not available to neutralize the sodium bicarbonate (NaHCO 3) secreted into the duodenum by the pancreas. The intestinal tract absorbs the excess bicarbonate, and alkalosis results. Gastric lavage will lead to alkalosis, which is associated with increased pH. Gastric lavage will not affect oxygen levels. Gastric lavage may lead to dehydration, which will increase osmotic pressure.

When assessing a client with a history of marijuana use, which long-term effect would the nurse associate with marijuana? Select all that apply. One, some, or all responses may be correct. Some correct answers were not selected Lung cancer Emphysema Heart disease Laryngeal disorder Stroke Chronic nasal irritation

Lung cancer Emphysema Heart disease Rationale Lung cancer, emphysema, and heart disease are outcomes potentially occurring due to marijuana use. Laryngeal disorders, stroke, and chronic nasal irritation are associated with the abuse of cocaine but are not associated with_mariiuana use

How should the nurse assess for lower extremity edema in a client who has been diagnosed with heart failure? Measure bilateral ankle circumference with a non-stretchable tape measure. Press skin over the tibia and report edema according to the grading scale. sk if the client feels the bilateral edema has changed and to what extent. Inspect the lower extremities together to compare the amount of swelling.

Measure bilateral ankle circumference with a non-stretchable tape measure. Rationale An accurate assessment of lower extremity edema is required when a client is treated for heart failure. Measuring ankle circumference is more accurate than other objective measures that can rely on individual interpretation, such as measuring pitting edema.

Which procedure should the nurse use to assess for a pulse deficit? Compare the brachial pulse and femoral pulse. Document the observed pulse rate and quality. Obtain the systolic blood pressure and subtract the apical pulse. Measure the apical pulse and compare it to the peripheral pulse.

Measure the apical pulse and compare it to the peripheral pulse. Rationale A pulse deficit is a palpable difference between the apical pulse at the point of maximal impulse and the radial pulse palpated at the wrist. The nurse should measure the apical pulse and compare it to the peripheral pulse to assess for a pulse deficit. If the pulse number is different from the apical pulse, then the radial pulse rate should be subtracted from the apical pulse and the remaining number is the number that should be recorded for the pulse deficit.

Which action would the nurse take when a client is receiving total parenteral nutrition (TPN)? Select all that apply.One, some, or all responses may be correct. Monitor for hydration Monitor weight daily Monitor vital signs every 4 hours Discard any solution after 24 hours Check the expiration date of the solution before administration

Monitor for hydration Monitor weight daily Monitor vital signs every 4 hours Discard any solution after 24 hours Check the expiration date of the solution before administration Rationale Monitoring hydration and weight to ensure the client is receiving the correct amount of nutrition and fluids is important for the nurse to perform. Vital signs would be monitored every 4 hours, as this may be an indicator of TPN complications. TPN would not be administered if it is expired, and any solution left after 24 hours would be discarded.

While assessing a client, the nurse identifies adventitious breath sounds. Upon further evaluation, the nurse finds loud, low-pitched, rumbling coarse sounds during inspiration. This sound is clearly heard while the client is coughing. Which condition would the nurse associate with these sounds? Inflammation of the pleura Reinflation of groups of alveoli Muscular spasms in the larger airways High-velocity airflow through an obstructed airway

Muscular spasms in the larger airways Rationale Adventitious breathing sounds (rhonchi) can bê heard when there are loud, low-pitched, rumbling, and coarse sounds during inspiration. These sounds can also be clearly heard while the client is coughing. Rhonchi may be caused by muscular spasms in the larger airways. Inflammation of the pleura may lead to a pleural friction rub sound. A crackling sound can be heard when there is a reinflation of groups of alveoli. In case of high-velocity airflow through an obstructed airway, wheezes or sibilant wheeze sounds may be heard.

While auscultating the heart, a health care provider notices S 3 heart sounds in four clients. Which client has the highest risk for heart failure? Child client Pregnant client Older adult client Young adult client

Older adult client Rationale The S 3 is the third heart sound heard after the normal "lub-dub." It is indicative of congestive heart failure in adults over 30 years old. In young, pregnant, and under 30-year-old clients, the third heart sound is often considered to be a normal parameter.

Which site would the nurse prefer to assess for determing the turgor of an older adult? Select all that apply. One, some, or all responses may be correct. Back of the neck Back of the hand Palm of the hand On the sternal area Back of the forearm

On the sternal area Back of the forearm Rationale Turgor indicates the elasticity of the skin. The ideal site to assess the skin for turgor in an older adult is back of the forearm or the sternal area. The back of the neck contains redundant skin and may not be reliable. The skin on the back of the hand is nonmally loose and thin; turgor assessed at that site may not be reliable. The palm of the hand is not an ideal site for the assessment of turgor.

The nurse administers an older adult clients medications via gastrostomy tube in the long-term care setting. Which finding would necessitate holding the feedings and medications and notifying the health care provider immediately? Select all that apply. One, some, or all responses may be correct. Some correct answers were not selected Absence of bowel sounds Presence of abdominal distension Residual capacity exceeding 300 mL Positive guaiac test of abdominal contents Seepage of feeding around tracheostomy

Presence of abdominal distension Positive guaiac test of abdominal contents Seepage of feeding around tracheostomy Rationale Monitoring toleration of medications and feeding is significant for the client with a gastrostomy tube. In older adults, abdominal distension may be caused by excess feeding administration rates, delayed gastric emptying, or decreased bowel motility. Bowel sounds are an indication of gastrointestinal activity. Absent bowel sounds could he caused by ileus or bowel ohstruction Pasitive auaiac fram ahdominal contents indicates bleeding Seepage of feeding solution around a tracheostomy tube may be caused by gastric reflux, placing the client at risk for aspiration. Residual capacity or gastric residual is usually assessed every 8 hours. A residual volume twice the infusion rate is considered abnormal and would be reported to the health care provider.

While assessing an older adult during a regular health checkup, the nurse finds signs of elder abuse. Which physical finding would confirm the nurse's suspicion? Select all that apply. One, some, or all responses may be correct. Presence of hyoid bone damage Presence of cognitive impairment Presence of burns from cigarettes Presence of bedsores Presence of unexplained bruises on the wrist(S)

Presence of burns from cigarettes Presence of bedsores Presence of unexplained bruises on the wrist(S) Rationale A physical finding of abuse in older adults can be the presence of burns from cigarettes. The physical presence of bedsores also indicates client abuse. Unexplained bruises on the wrists) may also be an indication of abuse in older adults. The presence of hyoid bone damage is an indication of intimate partner violence. The presence of cognitive impairment is a behavioral finding in older adult abuse.

A 50-vear-old client is diagnosed with chronic obstructive pulmonary disease (COPD). The clinical data on admission are as follows: a heart rate of 86 beats/min, a blood pressure of 142/82 mm Hg, a respiratory rate of 32 breaths/min, a tympanic temperature 98.2°F (36.8°C), oxygen saturation of 88%, and general discomfort with pain 2 out of 10. Which vital signs obtained by the nurse indicate an improvement in condition? Select the 3 findings that indicate client improvement. Radial pulse: 88 beats/min Temperature: 98.6°F (37°C) Respiratory rate: 14 breaths/min Blood pressure: 110/70 mm Hg Oxygen saturation: 92%Pain of 2 out of 10

Respiratory rate: 14 breaths/min Blood pressure: 110/70 mm Hg Oxygen saturation: 92% Rationale: The respiratory rate in older adults ranges from 12 to 20 breaths/min, and this range may be elevated in clients with chronic obstructive pulmonary disease (COPD). Thus, a rate decrease to 14 breaths/min indicates a positive outcome, as it is within normal range. COPD may also cause high blood pressure. Thus, a blood pressure of 110/70 mm Hg obtained during therapy indicates a positive outcome. The normal oxeen saturation rate should be 95% to 100%. An oxvren saturation increase from 88% to 92% indicates a positive outcome of the therav.

The nurse documents auscultation of coarse rhonchi in the anterior upper lung fields bilaterally that clears with coughing. Which condition would the nurse associate with these sounds? Parietal pleura rubbing against visceral pleura Random, sudden reinflation of groups of alveoliTurbulence due to muscular spasm and fluid or mucus in the larger airways High-velocity airflow through a severely narrowed or obstructed airway

Turbulence due to muscular spasm and fluid or mucus in the larger airways Rationale Loud, low pitched, rumbling coarse sounds heard over the trachea and bronchi are due to turbulence caused by muscular spasm when fluid or mucus is present in the larger airways. Pleural rub produces a sound of a dry or grating quality, best heard in the lower portion of the anterior lateral lung. Random and sudden reinflation of groups of alveoli produces crackling sounds predominantly heard in the left and right lung bases. High-velocity airflow through severely narrowed or obstructed airways results in a wheezing sound heard all over the lung.

While collecting a client's urine sample, which condition would the nurse suspect if the sample has a strong odor of ammonia? Malabsorption Bladder cancer Diabetic ketoacidosis Urinary tract infection

Unmary tract infection Rationale A strong ammonia odor in the urine can indicate that the client has a urinary tract infection, or possibly renal failure. Malabsorption can cause particularly foul-smelling stools in an infant. The ammonia odor does not indicate bladder cancer. Diabetic ketoacidosis usually causes a sweet/fruity odor on the breath.

When conducting an assessment of a client who does not speak English and an interpreter is unavailable, which action would the nurse not utilize? Using medical terminology Proceeding in an unhurried manner Speaking in a low and moderate voice Pantomiming words and simple actions while verbalizing them

Using medical terminology Rationale While assessing a client who does not understand English, nurses would follow certain guidelines when an interpreter is not available. Rather than using medical terminology, the nurse should use simple, more well-known words, like "pain" instead of "discomfort." The nurse's other actions are appropriate. Proceeding in an unhurried manner; speaking in a low, moderate voice; and pantomiming words and simple actions while verbalizing them promote effective communication,

The nurse performs the Weber and Rinne tests to assess which cranial nerve? VII VI. V. I

VIII Rationale The Weber and Rinne tuning fork tests are used to evaluate for hearing loss. These tests are performed to assess cranial nerve VIII, also known the acoustic or vestibulocochlear nerve.

While performing a physical assessment of a female client, the nurse positions the client in a left lateral recumbent position. Which body system would the nurse assess in this position? Select all that apply. One, some, or all responses may be correct. Some correct answers were not selected Heart Vagina Rectum Female genitalia Musculoskeletal system

Vagina Rectum Rationale Left prone recumbent position is indicated to examine vagina and rectum. Lithotomy is used to check female genitalia. Lateral recumbent position will aid in detecting murmurs of the heart. Prone position is indicated while assessing the musculoskeletal system.

An older client has just returned to the room following a surgical procedure. Which pain scale should the nurse use when assessing the client's pain level? Verbal descriptor scale. Wong-Baker scale. Numeric rating scale. Faces pain scale-revised.

Verbal descriptor scale. Rationale The descriptor scale uses words rather than numbers or pictures to describe pain. This method of reporting pain is less confusing and less abstract for older adults. The choices provided for rating the intensity of pain include the following: no pain, mild pain, moderate pain, and severe pain.

Which nurse's action would prevent aspiration when administering medications through a nasogastric tube? Place the client in the supine position Keep the head of the bed elevated 20 degrees Assess residual capacity and discarding the contents V Verify placement of the nasogastric tube

Verify placement of the nasogastric tube Rationale Actions to prevent aspiration in clients receiving medications via the nasogastric route include verifying placement of the nasogastric tube before instilling medications. The client would be placed in the high Fowler position when administering medications. It is important to check residual capacity before administering medications or feedings via a nasogastric tube; however, the gastric contents would be returned to prevent dangerous alterations in fluid and electrolyte values. Keeping the head of the bed elevated 20 degrees would not prevent aspiration. The head of the bed would be elevated 60 to 90 degrees for administration of medications or feeding.

While providing care for a client with heat stroke, the nurse measured and noted the temperature as 39°C. Which temperature would the nurse document in Fahrenheit?

102 Rationale Celsius is converted to Fahrenheit by multiplying the Celsius reading by 9/5 and adding the product to 32. In this case, the calculation is: (9/5)(39) + 32 = 102.2.

A client weighed 210 pounds (95.2 kg) on admission to the hospital. After 2 days of diuretic therapy, the client weighs 205.5 pounds (93.2 kg). Which numerical value reflects the liters of fluid excreted by the client? Record your answer using a whole number.

2 Rationale One liter of fluid weighs approximately 2.2 pounds (1 kg); therefore a 4.5-pound (2 kg) weight loss equals approximately 2 liters.

A client weighs 150 lb and is 5 feet 7 inches tall. Which numerical value reflects this client's body mass index (BMI)?

23.53 Rationale Body mass index (BMI) can be calculated by dividing the client's weight in kilograms by the height in meters squared. A client who weighs 150 lb (68 kg) and stands 5 feet 7 inches (1.7 m) tall will have a BMI of 23.53: 68/1.7 2 = 23.53.

Which client would experience impaired near vision? Select all that apply. One, some, or all responses may be correct. A client with myopia A client with presbyopia A client with hyperopia A client with retinopathy A client with macular degeneration

A client with presbyopia A client with hyperopia Rationale A loss of elasticity of the lens causes impaired near vision in presbyopia. Light rays focusing behind the retina are the cause of impaired near vision in clients with hyperopia. Myopia is caused by a refractive error where the light rays focus in front of the retina. Retinopathy is a noninflammatory change in the retinal blood vessels. Macular degeneration is a blurring of central vision caused by progressive degeneration of the central retina.

Which client would the nurse suspect as having an increased risk of hyperlipidemia? Select all that apply. One, some, or all responses may be correct. Client with corneal arcus Client with periorbital edema Client with decreased skin turgor Client with paleness of conjunctivae Client with yellow lipid lesions on eyelids

Client with corneal arcus Client with yellow lipid lesions on eyelids Rationale The presence of corneal arcus, which is the whitish opaque ring around the junction of the cornea and sclera, indicates that the client has hyperlipidemia. Yellow lipid lesions on the eyelids refer to xanthelasma, which indicates a client has hyperlipidemia. The presence of periorbital edema indicates the client may have kidney disease. Decreased skin turgor may be due to dehydration. Paleness of the conjunctivae indicates anemia.

Based upon the client's condition and assessment findings, the nurse decides additional assessments are needed. Drag from Word Choices to complete the sentence. The nurse plans to perform the following assessments: abdominal girth fluid wave iliopsoas muscle test E shifting dullness abdominal girth costovertebral angle tenderness linea nigra Sister Mary Joseph's nodule McBurney sign obturator test Murphy sign costovertebral angle tenderness fluid wave

shifting dullness abdominal girth fluid wave

While assessing a client's range of motion, the nurse explains adduction to the unlicensed assistive personnel (UAP). Which UAP statement indicates effective learning? "I will ask the client to move their arm toward their body." • "I will ask the client to bend their limb by decreasing the angle." "I will ask the client to move their hand so the ventral surface faces downward." "I will ask the client to move their head beyond its normal resting extended position."

" I will ask the client to move their arm toward their body." Rationale Adduction is moving the arm toward the body. Assessing the range of motion by bending the limb and decreasing the angle indicates flexion. Moving the hand by facing the ventral surtace downward indicates pronation. The moverent of the head beyond the normal resting extended position indicates hyperextension.

When assessing risk factors, which question would the nurse ask a client who has developed pneumonia? "Are you diabetic?" "Have you ever had pneeumonia?" "What do you use for contraception?""Do you have a history of intravenous [IV] drug abuse?"

"Are you diabetic?" Rationale Chronic diseases such as diabetes are a risk factor for developing infections such as pneumonia. Inquiring about the client's pneumonia history provides additonal information regarding the client's knowledge but does not let the nurse understand the client's risk factors. Contraception would be explored in sexual barrier devices for sexually transmitted infections. IV drug abuse would be explored to assess risk of exposure to blood-borne pathogens such as Hepatitis B.

After the nurse teaches a client, who is obese, measures to calculate the body mass index, which client statement indicates effective learning? Select all that apply. One, some, or all responses may be correct. "I should include sugared beverages in my diet." "I should lose at least half a pound to a pound each week." "My daily nutritional fat intake should be more than 30%." "I'll make sure to eat foods meeting my daily nutritional requirement." "I should stay away from unhealthy foods between meals and after dinner."

"I should lose at least half a pound to a pound each week." "I'II make sure to eat foods meeting my daily nutritional requirement." "I should stay away from unhealthy foods between meals and after dinner." Rationale A client's body mass index (BMI) height-weight range is appropriate when it is within 10% of the ideal body weight. To achieve this, the client should lose at least 0.5 to 1 lb (0.2-0.45 kg) per week. The client's daily nutritional intake should meet the minimal dietary reference index. Refraining from eating unhealthy foods between meals and after dinner will help the client achieve an appropriate BMI. The client should avoid sugared beverages to achieve the appropriate BMI. Another effective way to achieve this is a daily fat intake

A registered nurse teaches a new employee about precautions taken during a client's physical examination. Which employee's statement indicates effective learning? Select all that apply. One, some, or all responses may be correct. "I would examine the client in noise-free areas. "I would use latex gloves during the physical examination." "I would perform a physical examination in a cool room." "I would leave a combative client alone during a physical examination." "I would wear eye shields while examining a client with excessive drainage."

"I would examine the client in noise-free areas. "I would wear eye shields while examining a client with excessive drainage." Rationale Clients should be examined in noise-free areas to prevent interruptions. Wearing eye shields while examining a client with excessive drainage helps reduce contamination. Latex gloves should be used with caution because they may cause allergy in clients who are allergic to latex. A physical examination should be performed in a warm room to minimize discomfort. Combative clients should never be left alone during physical examinations.

After the nurse teaches a client about various measures to protect against food-borne illness, which client statement reflects ineffective learning? "I'll clean the inside of my refrigerator and microwave regularly!" "I'll wash my cooking utensils and cutting boards with tap water." "I'll wash my hands with warm, soapy water before touching or eating food." "I won't eat leftovers in my refrigerator after they've been there for 5 days."

"I'll wash my cooking utensils and cutting boards with tap water." Rationale Eating leftovers that have been kept in a refrigerator for more than 2 days may result in a food-borne illness caused by microbial growth in the food. Cleaning the inside of the refrigerator and microwave regularly will help prevent microbial growth. Cooking utensils and cutting boards should be washed with hot, soapy tap water as a means of preventing food-borne illness. Washing the hands with warm, soapy water before touching or eating food is one technique for preventing food-borne illness.

The nurse reviews the electronic health record and documents visit-related care in the nursing notes. Labs and diagnostic imaging reviewed. The nurse is performing a breast assessment. Which statement made by the client indicates a risk of breast cancer? Select all that apply. One, some, or all responses may be correct. "I had a late onset of menarche." "My frst child was born when I was 32." "I noticed a slight discharge from a nipple.""I perform breast self-examinations frequently." "I consume two to four glasses of alcohol a day." "My provider prescribed hormone replacement therapy (HRT)" "I am going to turn 60 years old next week." "My new diet is not helping me with my obesity very much."

"My frst child was born when I was 32." "I noticed a slight discharge from a nipple." "I consume two to four glasses of alcohol a day." "My provider prescribed hormone replacement therapy (HRT)" "My new diet is not helping me with my obesity very much." Rationale: Clients who gave birth to a first child after the age of 30 are at a risk of breast cancer. Discharge from the nipple may indicate an early symptom of breast cancer. Consuming two to four glasses of alcohol daily may also increase the risk of breast cancer.

During orientation, a registered nurse reviews content about the third heart sound (S 3) with recently employed nurses. Which participant's statement indicates ineffective learning? "S 3 is heard in clients with heart failure." "S 3 is normal in pregnant women." "S 3 is abnormal in adults over 31 years of age." "S 3 is normal in children and young adults."

"S 3 is normal in pregnant women." Rationale The third heart sound (S 3) can be heard when the heart attempts to fill an already distended ventricle. This sound may be common and normal in the last stages of pregnancy but not in all stages. This sound may be heard in heart failure clients. The S sound is abnormal in adults over the age of 31. This sound is normally heard in children and young adults.

Based on current research, when asked about spanking as a disciplinary technique, which response would the nurse utilize? "Effectiveness depends on the child's age." "Spanking is strongly suggestive of negative role behavior." "Spanking may be the only option when no other technique works." "Research studies have shown it to be an effective disciplinary technique."

"Spanking is strongly suggestive of negative role behavior." Rationale Research suggests that children who are spanked tend to use aggressive behavior. As they grow older, they learn their own behavior through their parents' behavior. Age is not significant in terms of the effectiveness of spanking. Research studies contradict the assertion that spanking is an effective disciplinary technique.

A client arrives at a health clinic reports, "I am here to have my tuberculin skin test read." The nurse notes a 7-mm indurated area at the injection site. Which nurse's statement describes this result? "The result indicates that you have active tuberculosis." "The result indicates you are infected with the tuberculosis organism." "The result indicates there are no tuberculin antibodies in your system." "The result indicates you have a secondary infection related to the tuberculin organism."

"The result indicates you are infected with the tuberculosis organism." Rationale An indurated area 5 mm or larger noted 48 to 72 hours after the tuberculin test indicates that the person is infected with the tuberculin organism. A positive tuberculin skin test accompanied by fever, coughing, weakness, and positive chest x-ray are manifestations of active tuberculosis. The other choices are incorrect.

client developed an allergic reaction during a physical assessment. Which nurses statement indicates a lack of understanding? "Type I immune response to latex has an immediate onset." "Type I immune reaction to latex leads to release of IgE antibodies." "Type IV immune reaction to latex occurs with first exposure." "Type IV immune response to latex occurs after 12 to 48 hours after exposure."

"Type IV immune reaction to latex occurs with first exposure." Rationale Both type I and type IV hypersensitive reactions require prior exposure to cause an immune response in a subsequent exposure. The most immediate immune response is a type I reaction, in which the body produces IgE antibodies against the allergen. A type IV immune response occurs 12 to 48 hours after the exposure to the allergen and is referred to as a delayed hypersensitivity response.

A client has a heart rate of 72 beats/min and stroke volume of 70 mL. Which numerical value reflects the client's cardiac output?

5040 The volume of blood pumped by the heart in 1 minute is the cardiac output. Cardiac output is the product of the heart rate and the stroke volume of the ventricle. Cardiac output in the client with a heart rate of 72 beats/min and stroke volume of 70 mL is 5040 mL/min: 72 × 70 = 5040.

Which client's body temperature indicates moderate hypothermia? Select all that apply. One, some, or all responses may be correct. Some correct answers were not selected 80°F (26.7°C) 84°F (28.9°C) 88°F (31.1°C) 92ºF (33.3°C) 96°F (35.6°C)

88°F (31.1°C) 92ºF (33.3°C) Rationale Moderate hypothermia is a body temperature between 86°F and 93.2°F (30°C-34°C). Clients with body temperatures between 88°F and 92°F (31.1°C-33.3°C) have moderate hypothermia. Mild hypothermia is a body temperature between 93.2°F and 96.8°F (34°C-36°C). Clients with body temperatures of 96°F (35.6°C) have mild hypothermia. Body temperature below 86°F (30°C) indicates severe hypothermia.

After assessing several clients, the nurse would determine which client will require parenteral nutrition? A client with brain neoplasm A client with anorexia nervosa A client with inflammatory bowel disease A client with severe malabsorption disorder

A client with severe malabsorption disorder Rationale A client with severe malabsorption disorder requires parenteral nutrition. Clients with a brain neoplasm, anorexia nervosa, or inflammatory bowel disease will require enteral nutrition.

The nurse is performing a head-to-toe assessment on a client. The nurse is assessing the client's pupillary light reflex by first darkening the room and asking the person to gaze into the distance. Then, the nurse advances a light toward one eye from the client's side. What would the nurse expect to see at this time? A consensual response in the opposite eye. No change in the eye on the opposite side of the face. Dilation of the eye on the opposite side of the face. Dilation of the eye on the same side of the face.

A consensual response in the opposite eye. Rationale To test the pupillary light reflex, the nurse should darken the room and ask the client to gaze into the distance to dilate the pupils. Then the nurse should advance a bright light into one pupil and note any response. Normally there will be constriction of the same-sided pupil (a direct light reflex) and simultaneous constriction of the other pupil (a consensual light reflex). The approximate pupil size that occurs when the light is shined into the eye should be estimated in millimeters using a gauge located on the penlight or in a healthcare record. The response to light and pupil size should also be documented.

While assessing a client who experienced an accident, the nurse found the client was unable to move her eyes laterally. Damage to which nerve led to this condition in the client? Optic nerve Facial nerve Abducens nerve Oculomotor nerve

Abducens nerve Rationale The abducens nerve is the VI cranial nerve, which helps in lateral movement of the eyeballs. Damage to this nerve limits lateral movement of the eyeball. Injury to the optic nerve causes changes in visual acuity. Injury to the facial nerve results in loss of facial expressions and loss of taste perception from the anterior third of the tongue. Injury to the oculomotor nerve limits the extraocular movements and pupillary responses.

As a part of a routine health assessment, the nurse assesses the kidneys as part of the abdominal assessment. Which assessment finding should the nurse conclude is normal when palpating the client's right kidney? Around smooth mass that slides between the fingers. The right kidney is palpated higher than the left kidney. The kidney slides forward and has movable nodules throughout. A vibration is felt slightly left of the abdominal midline.

Around smooth mass that slides between the fingers. Rationale Occasionally, when assessing the adult kidneys, the nurse may feel the lower pole of the right kidney as a round, smooth mass that slides between the fingers - or the nurse will feel nothing at all. Either condition is normal. The nurse should search for the right kidney by placing hands together in a "duck-bill" position at the client's right flank. The nurse should then press two hands together firmly and ask the client to take a deep breath. In most people, the nurse will feel no change.

A client reports sleeping until noon every day and taking frequent naps during the rest of the day. Initially, which action would the nurse take? Encourage the client to exercise during the day. Arrange a referral for a thorough medical evaluation. Explain that this behavior is an attempt to avoid facing daily responsibilities. Identify that the client is describing clinical findings associated with narcolepsy.

Arrange a referral for a thorough medical evaluation. Rationale This behavior is a sign of hypersomnia, and the client needs a medical assessment; it is commonly caused by central nervous system damage or certain kidney, liver, or metabolic disorders. Exercise is appropriate for a client experiencing insomnia, not hypersomnia. This behavior is a sign of hypersomnia, and medical causes should be ruled out before attributing it to a psychogenic cause. Narcolepsy consists of recurrent sudden waves of overwhelming sleepiness that occur during the day, even during activities such as eating or conversing.

The nurse reviews the electronic health record and documents visit-related care in the nursing progress notes. Labs drawn per provider orders. Which action would the nurse implement when a client is receiving total parenteral nutrition (TPN)? Select all that apply. One, some, or all responses may be correct. Assess hydration Ensure rapid delivery of each infusion Monitor weight daily Infuse using an electric pump Reassess vital signs every 4 hours Discard any solution after 24 hours Check the expiration date before administration Utilize peripheral IV for administration

Assess hydration Monitor weight daily Infuse using an electric pump Reassess vital signs every 4 hours Discard any solution after 24 hours Check the expiration date before administration

During a falls risk assessment, which action would the nurse take after learning the client experienced a recent fall? Apply restraint to prevent ambulating without assistance Discontinue all medications to remove the risk of polypharmacy Assess the circumstances of the fall, including feelings and setting Require family members to remain at the bedside to watch over the client

Assess the circumstances of the fall, including feelings and setting Rationale The circumstances of the fall, including feelings and setting, should be explored and documented to understand risk of falls for this client. Fall history alone does not warrant use of restraint. The nurse consults with the health care provider on polypharmacy but does not discontinue medications independently. The family is not required to remain at the bedside but is encouraged to understand fall risk.

While preparing to teach a client about self-injection of insulin, which nurse's action would increase the effectiveness of the teaching session? Wait until a family member is also present. V Assess the client's barriers to learning self-injection techniques. Begin with simple written instructions describing the technique. Wait until the client has accepted the new diagnosis of type 1 diabetes mellitus.

Assess the client's barriers to learning self-injection techniques. Rationale Before a teaching plan can be developed, the factors that interfere with learning must be identified. Although family members can be helpful, client involvement in care is most important for promoting independence and self-esteem. Assessment comes before intervention; written instructions may not be the most appropriate teaching modality. The client may never accept the change but must learn to manage care; this may be an unrealistic expectation.

While performing a physical assessment of a client, the nurse notices patchy areas with pigmentation loss on the skin, hands, and arms. With which probable cause would the nurse associate this finding? Anemia Pregnancy Lung disease Autoimmune disease

Autoimmune disease Rationale Patchy areas with loss of pigmentation on skin, hands, and arms are due to vitilige, which is caused by an autoimmune or congenital disease. Anemia results in pallor due to a reduced amount of oxyhemoglobin. A tan-brown color of the skin is noticed in pregnancy due to an increased amount of melanin. Lung disease or heart failure can cause cyanosis due to an increased amount of deoxygenated hemoglobin.

Which respiratory condition should the nurse document after measuring a respiratory rate of 8 breaths/minute? Tachypnea. Bradypnea. Hyperventilation. Hypoventilation.

Bradypnea. Rationale Bradypnea is a regular but slow rate of breathing indicated by a respiratory rate less than 10 breaths/minute. A client with a respiratory rate of 8 breaths/minute has Bradepnea.

During a health history interview, a male client reports that he smokes cigarettes and does not plan to quit. Which action is most important for the nurse to take? Document the client's statement verbatim. Calculate the client's pack year history. Express support for the client's right to choose. Ask about family history of lung cancer.

Calculate the client's pack year history. Rationale Calculation of cigarette pack year history provides useful screening data regarding the client's risk for health problems, which serves as the basis for the plan of care.

Upon assessing an older adult client with a diagnosis of dehydration, which finding would the nurse identify as an early sign of dehydration? Sunken eyes Dry, flaky skin Change in mental status Decreased bowel sounds

Change in mental status Rationale Older adults are sensitive to changes in fluid and electrolyte levels, especially sodium, potassium, and chloride, These changes will manifest as a change in mental status and confusion. It is difficult to assess dehydration in older adults based on sunken eyes, dry skin, and decreased bowel sounds because these can be prominent as general normal findings in the older adult client.

The nurse palpated the peripheral pulse of four different clients. Which client has an unacceptable heart rate? Client. Age. Heart beats/minute 1. 11 months 156 2. 4 years 105. 3. 2 years 148 4. 14 years 87

Client 3 Rationale The acceptable range of heartbeat for a toddler is between 90 and 140 beats per minute. Client 3, with a heartbeat of 148 beats per minute, has an abnormal heart rate. The normal range of heartbeat for an infant lies between 120 and 160 beats per minute. Preschoolers usually have a heartbeat ranging from 80 to 110 beats per minutes. A typical adolescent heart rate ranges from 60 to 90 beats per minute.

The chart provides the symptoms of four clients with different levels of impaired vision. Which client would the nurse suspect as having macular degeneration? Client A Impaired near vision Client B Loss of central vision Client C Cross appearance of eyes Client D Inability to see distant objects

Client B Rationale Client B's loss of central vision is caused by macular degeneration. Impaired near vision in client A is due to presbyopia or hyperopia. Strabismus is a congenital condition in which both eyes do not focus on an object simultaneously; this results in the cross appearance of eyes, as seen in client C. Client D's inability to see distant objects is caused by myopia.

Which information, obtained during a client's health history, would the nurse classify as biographical information? Select all that apply. One, some, or all responses may be correct. Symptoms Client's age Family structure Type of insurance Occupation status

Client's age Type of insurance 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.

In which sequential order would the nurse perform the assessment of a lesion? Observing for any exudate, odor, amount, and consistency Collecting information about its color, size, shape, type, grouping, and distribution Measuring each lesion for height, width, and depth Measuring the size of the lesion in centimeters by using a small, clear, flexible ruler

Collecting information about its color, size, shape, type, grouping, and distribution Observing for any exudate, odor, amount, and consistency Measuring the size of the lesion in centimeters by using a small, clear, flexible ruler Measuring each lesion for height, width, and depth Rationale The first step in assessing the lesion is to collect standard information about the lesion. This information includes the color, location, texture, size, shape, type, grouping (clustered or linear), and distribution (localized or generalized). The next step is to observe for any exudate, odor, amount, and consistency. After this step, the size of the lesion is measured in centimeters by using a small, clear, flexible ruler. Finally, each lesion is measured for height, width, and depth.

For the client with a closed chest tube drainage system connected to suction, which assessment finding requires additional evaluation by the nurse? A column of water 20 cm high in the suction control chamber 75 mL of bright red blood in the drainage collection chamber An intact occlusive dressing at the insertion site Constant bubbling in the water-seal chamber

Constant bubbling in the water-seal chamber Rationale Constant bubbling in the water-seal chamber is indicative of an air leak. The nurse would assess the entire length of the system from the container to the client's chest wall tube insertion site to find the source of the air leak. If the source of the air leak is not found in the system and bubbling continues, the leak is most likely within the client's chest or at the insertion site. This could cause the lung to collapse because of a buildup of air pressure within the pleural cavity, and the health care provider should be notified. In this type of surgical procedure, 75 mL of blood in the chest tube collection chamber is an expected finding in the early postoperative period. A column of water 20 cm high in the suction control chamber and an intact occlusive dressing at the chest tube insertion site are also expected assessment findings.

The nurse is assessing a healthy young adult during an annual physical examination. Which assessment technique should the nurse implement when palpating the abdominal aorta? Deep palpation above and to the left of the umbilicus. Palpation of the abdomen as the client completes a deep breath. With the client standing, compress the abdomen as the nurse stands behind the client. With the palm of one hand, compress the abdomen 2 fingerbreaths below xiphoid process.

Deep palpation above and to the left of the umbilicus. Rationale Deep palpation above and to the left of the umbilicus is effective in sensing the pulsation of the aorta.

The nurse palpates a weak pedal pulse in the client's right foot. Which assessment findings should the nurse document that are consistent with diminished peripheral circulation? (Select all that apply.) Diminished hair on legs. Bruising on extremities. Skin cool to touch. Capillary refill less than 3 seconds. Darkened skin on extremities.

Diminished hair on legs. Skin cool to touch. Rationale Diminished hair on the legs and skin that is cool to touch are expectant signs of decreased arterial blood flow.

When the nurse completes a thorough assessment to identify the reason for a client's anxiety, which critical thinking attitude is involved in this situation? Discipline Confidence Responsibility Thinking independently

Discipline Rationale The nurse shows discipline in collecting a thorough assessment to identify the source of the client's anxiety. Confidence involves completing a task or goal such as performing a procedure or making a diagnostic decision. Responsibility is applicable when performing a nursing skill by following standard care practices. Thinking independently involves reading the nursing literature, talking with other nurses, and sharing ideas about nursing interventions.

While performing a head-to-toe assessment, the nurse assesses the client's pupillary accommodation. During the second portion of the test, the nurse notes that the client's pupils constrict and there is a convergence of the axes of the eyes. What action should the nurse implement next? Document a normal finding. Request a referral to an opthamologist. Repeat the test after having the client rest for 5 minutes. Ask the client, "Have you noticed that you cannot see things close up?"

Document a normal finding. Rationale When testing for pupillary accommodation, the nurse asks the client to focus on a distant object and then shift the gaze to a penlight tip near the nose. Focusing on a distant object causes both pupils to dilate; shifting the gaze to a near object (a finger or a penlight tip), which is held about 7 to 8 cm (3 inches) from the client's nose, should result in bilateral pupillary constriction with both eyes focused on the object simultaneously.

To assess the status of circulation to the foot, which site would the nurse monitor for a pulse? Select all that apply. One, some, or all responses may be correct. Some correct answers were not selected Carotid artery Femoral artery Popliteal artery Dorsalis pedis artery Posterior tibial artery

Dorsalis pedis artery Posterior tibial artery Rationale The dorsalis pedis pulse and posterior tibial pulse are sites of assessments of circulation to the foot. The carotid pulse, located along the medial edge of the sternocleidomastoid muscle in the neck, is an easily accessible site to assess physiologic shock or cardiac arrest. The femoral artery pulse and popliteal artery pulses are helpful in assessing the circulation to the lower leg.

A client has been diagnosed with bilateral lower lobe atelectasis. Which percussion sound should the nurse expect to hear when percussing over the client's lower lobes? Dull, thud-like. Hyperresonant, booming. Tympanic, drum like. Flat, extremely dull.

Dull, thud-like. Rationale An atelectatic or consolidated lung will produce a dullness or thud-like sound when percussed during an assessment.

During an assessment, which finding prompts the nurse to don a protective gown? Open sore Abrasions of the skin Excessive wound drainage Productive, moist coughing

Excessive wound drainage Rationale Excessive wound drainage may require more protection than gloves, so a protective gown should be donned by the nurse. An open sore and abrasions to the skin should be approached with gloved hands. A moist, productive cough should prompt the nurse to provide a mask to the client.

During a survey, tne community nurse meets a cilent wno never visitea a gynecologist arter the birth of a second child. The client reports the client's mother or sister never had annual gynecologic examinations. Which factor appears to be influencing the client's health practice? Spiritual belief Family practices Emotional factors Cultural background

Family practices Rationale Family practices influence the client's perception of the seriousness of diseases. The client does not feel the need to seek preventive care measures because no family member practices preventive care. The client is apparently not being influenced by spiritual beliefs in this instance. An individual's spiritual beliefs and religious practices may restrict the use of certain forms of medical treatment. Emotional factors such as stress, depression, or fear may influence an individual's health practice; however, this client does not show signs of being affected by emotional factors. The client is said to be influenced by cultural background if they follow certain beliefs about the causes of illness and uses customary practices to restore health.

The nurse reviews the electronic health record and documents care in the nursing progress notes. Labs drawn and imaging completed per provider orders. The nurse expects a client with an elevated temperature to exhibit which indicators of pyrexia? Select all that apply. One, some, or all responses may be correct. •Dyspnea Increased appetite Flushed face Precordial pain Increased pulse rate Increased blood pressure General lethargy Chills

Flushed face Increased pulse rate General lethargy Chills

When the defining characteristics of a client's assessment data apply to more than one diagnosis, which action would the nurse take? Select all that apply. One, some, or all responses may be correct. Reassess the client. Reject all diagnoses. Gather more information. Identify related factors. Review all defining characteristics.

Gather more information. Identify related factors. Review all defining characteristics. Rationale The nurse must gather more information to clarify interpretations of assessment data. The correct interpretation of information allows the nurse to select the proper diagnosis that applies to the client. A related factor is a condition or etiology that gives a context for the defining characteristics. The nurse would identify related factors to individualize a nursing diagnosis for the client. The nurse would review all of the defining characteristics, eliminate irrelevant ones, and confirm the relevant ones. The nurse must interpret the data to form data clusters only after reassessing and validating them. At this stage, the nurse would have only validated assessment data in the database. The nurse need not reject all of the diagnoses. The nurse would review all of the defining characteristics to support or eliminate the irrelevant ones.

A client has come to the clinic for a routine health assessment. What is the best assessment question for the nurse to ask a client after observing tophi on the client's ear cartilage? Have you had sudden and severe pain in the toes or feet? Do you have a family history of osteoporosis? Have you ever had pain along the side of your leg? Do you have a history of rheumatoid arthritis or bursitis?

Have you had sudden and severe pain in the toes or feet? Rationale Tophi (plural form of tophus) are deposits of uric acid crystals found in the skin, cartilage, and or on the surface of joints. Tophi are seen in the advanced stages of gout, a condition in which uric acid crystals have deposited into the joints, particularly, the toes. Gout will often present clinically as sudden and severe pain in the toes or lower extremities. The nurse should ask about a history of sudden and severe pain in the toes or lower extremities after observing tophi on the ear cartilage.

Which condition would the nurse suspect when an older adult is unable to see nearby objects? Select all that apply. One, some, or all responses may be correct. Cataract Glaucoma Hyperopia Presbyopia Macular degeneration

Hyperopia Presbyopia Rationale In hyperopia, the client has farsightedness. In this condition, the client is unable to see near objects. Presbyopia is an impaired near vision that may occur with aging. The nurse can suspect either of the conditions. In cataracts, there is an increased opacity of the lens that blocks light rays from entering the eye, leading to impaired vision. Glaucoma is a condition in which there is intracular structural damage resulting from elevated intracular pressure. Macular degeneration is caused by blurred central vision that often occurs suddenly. This is caused by a progressive degeneration of the center of the retina.

Which type of breathing pattern would a client experiencing hypercarbia exhibit ? Eupnea Tachypnea Hypoventilation Kussmaul respiration

Hypoventilation Rationale Hypercarbia may occur during hypoventilation. The respiratory rate is abnormally low and the depth of ventilation is depressed in hypoventilation. In eupnea, the normal rate and depth of respiration are interrupted while singing. The rate of breathing is regular, but abnormally rapid in tachypnea. Respirations are abnormally deep, regular, and the rate is increased in Kussmaul respiration.

The nurse is assessing a client who reports having shoulder pain. Which sign is the best indicator of a rotator cuff tear? Inability to adduct the arm from the body. Inability to slowly lower the arm when abducted. Inability to externally rotate the arm. Inability to internally rotate the arm.

Inability to slowly lower the arm when abducted. Rationale Rotator cuff damage can be assessed with the Drop Arm test, in which the affected arm is passively abducted at 90 degrees and the client is unable to keep the arm elevated or slowly and smoothly lower the arm from this position without moving the shoulder forward to have the other muscles compensate for the torn rotator cuff muscle.

When teaching a health awareness class, which situation would the nurse teach as being the highest risk factor for the development of a deep vein thrombosis (DVT)? Pregnancy Inactivity Aerobic exercise Tight clothing

Inactivity Rationale A DVT, or thrombus, may form as a result of venous stasis. It may lodge in a vein and can cause venous occlusion. Inactivity is a major cause of venous stasis leading to DVT. Pregnancy and tight clothing are also risk factors for DVT secondary to inactivity. Aerobic exercise is not a risk factor for DVT.

When measuring a client's blood pressure during a physical examination, which error will result in false high diastolic reading? Inflating the cuff too slowly Wrapping the cuff too loosely Applying the stethoscope too firmly Repeating the assessment too quickly

Inflating the cuff too slowly Rationale Inflating or deflating the cuff too slowly will yield false high diastolic readings. Wrapping the cuff too loosely will result in false high systolic and diastolic values. Applying the stethoscope too firmly will result in false low diastolic readings. Repeating the assessment too quickly will result in false high systolic readings.

A client is being assessed upon admission to the medical-surgical unit. The nurse is preparing to complete a head-to-toe assessment and will begin at the head of the client. Which technique should the nurse use to begin the assessment? Inspect the hair and skin. Palpate the temperature of the skin. Percuss for tenderness. Auscultate the temporal arteries.

Inspect the hair and skin. Rationale The usual order for a physical assessment is inspection, palpation, percussion, and auscultation. When beginning a physical assessment, the nurse should perform an inspection, which is a general survey of the individual as a whole and of each body system.

fecal occult blood test (FOBT)

It helps to diagnose and monitor various conditions, such as gastrointestinal bleeding or colon cancer.

An assessment of an 89-year-old client yeilds a history of severe congenital spinal deformity. Which condition would describe the nurse's finding? Lordosis Kyphosis Presbycusis Osteoporosis

Kyphosis Rationale Kyphosis is an increase in the curvature of the thoracic spine and may result from a congenital abnormality. Lordosis, also known as swayback, is an increased lumbar curvature and may not be a congenital abnormality. Presbycusis is the loss of acuity for high-frequency tones and is not related to the spine. Osteoporosis is a condition in which the bones become brittle and fragile from the loss of tissue and bone mass.

The nurse examines the skin of an older adult client. Which skin variation is considered a normal finding for a client in this age group? • Dryness. Lentigines. • Bruising. * Tenting

Lentigines. Rationale Lentigines or commonly referred to as liver spots are irregularly shaped dark spots on the skin caused by aging and extensive sun exposure. This skin variation is a normal finding in an older adult client.

During cardiac auscultation, the nurse hears a split in the second heart sound when listening to the second left intercostal space of a male client. To assess this sound more fully, what action should the nurse implement? Inch the stethoscope down the left side of the client's sternum. Ask the client to cough and then listen at the site again. Instruct client to hold his breath so the sound is clearer. Listen to the sound while observing the clients respirations.

Listen to the sound while observing the clients respirations. Rationale A split S2 is heard only in the pulmonic valve area (second left interspace). Listening while observing respirations allows the examiner to determine the type of S2 split that is occurring. Other actions are not useful in auscultating a split S2.

A client in the second trimester of pregnancy arrives at the clinic for a general health checkup, including a pelvic examination. For which position would the nurse prepare the client? Left lateral recumbent position Supine position Lithotomy position Dorsal recumbent position

Lithotomy position Rationale Lithotomy position provides maximum exposure to the female genitalia and easy examination of the region; this position is recommended for examining clients who are pregnant. Left lateral recumbent position is indicated for rectal and vaginal examinations. Supine position is recommended for examining anterior thorax, lungs, breasts, axilla, heart abdomen, extremities, and pulse. Dorsal recumbent position is mainly indicated to examine the abdomen because it promotes abdominal relaxation.

The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard bowel sounds in the right upper quadrant. Which action should the nurse take next? Auscultate over the other 3 abdominal quadrants. Count the number of bowel sounds per minute. Note the character and frequency of bowel sounds. Count to determine how many bowel sounds occur in one minute.

Note the character and frequency of bowel sounds. Rationale Bowel sounds originate from the air and fluid movement through the stomach and intestines. A wide range of normal sounds can occur depending on when the last meal was ingested. The nurse should assess for hyperactive or hypoactive bowel sounds during auscultation, noting the character and frequency. It is not necessary to count the number of bowel sounds per minute and to listen to all four quadrants. It is necessary to listen for bowel sounds for a minimum of 5 minutes before declaring bowel sounds absent.

Which technique should the nurse use to assess a client for scoliosis? • Watch gait while the client ambulates down the hallway. Observe spine while the client is erect and bent forward. Palpate neck while the client rotates head from side to side. • Assess for presence of pain when the client twists the torso.

Observe spine while the client is erect and bent forward. Rationale Scoliosis is a lateral curvature of the spine seen upon inspection of the spine while the client stands erect and then bends forward.

Which nurses action is important for establishing good communication with the client who has impaired hearing? Speaking at a normal volume Reducing environmental noise Obtaining the client's attention before speaking Rephrasing rather than repeating if misunderstood

Obtaining the client's attention before speaking Rationale The first step that the nurse would take for starting communication with a client with impaired hearing is getting the client's attention before speaking. The nurse would never shout and would always speak in a normal volume. The nurse would reduce the environmental noise before starting a conversation to avoid disturbances. The nurse would always rephrase the sentences rather than repeating if misunderstood because it can cause confusion.

When assessing a client who had a thyroidectomy yesterday, which cue would the nurse associate with an initial sign of hypocalcemia? Headache Pallor Paresthesias Blurred vision

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 vision are not signs of hypocalcemia.

Which method would the nurse use to assess a client suspected of having a distended bladder? Inspect and palpate the epigastric region. Auscultate and percuss the inguinal areas. Percuss and palpate the hypogastric region. Bilaterally percuss and palpate the lumbar areas.

Percuss and palpate the hypogastric region. Rationale To detect a distended bladder, percussion and palpation should be performed over the hypogastric region of the abdomen. Percussion of a distended bladder would produce a dull sound and feel firm on palpation. Inspecting and palpating in the epigastric region, auscultating and percussing in the inguinal areas, or percussing and palpating bilaterally in the lumbar areas are all inaccurate procedures to assess for a distended bladder.

Following abdominal auscultation of a client who is admitted for signs of splenomegaly, which additional assessment should the nurse use to verify splenomegaly? Rebound tenderness. Percussion. Deep palpation. Inspection.

Percussion Rationale When splenomegaly is suspected, percussion of the spleen produces a dull sound and is a safe method of verifying enlargement.

While providing care for a client who is postoperative, the nurse observed a pulse deficit during physical assessment. Which pulses would the nurse use to assess the pulse deficit? Radial and apical pulse Apical and carotid pulse Radial and brachial pulse Apical and temporal pulse

Radial and apical pulse Rationale Pulse deficit may be associated with an abnormal rhythm. Pulse deficit is the difference between the radial and apical pulse. The carotid pulse is measured when a client's condition worsens suddenly. The brachial pulse is used to measure blood pressure. The temporal pulse is used to assess the pulse in children.

A registered nurse is teaching a nursing student about the proper techniques of an abdominal assessment. Which order of assessment indicates effective learning? "I will note the position of the umbilicus." "I will inspect the surface motion of the abdomen." "I will assess for bowel motility by auscultation." "I will palpate to assess for any abdominal tenderness."

Rationale An abdominal assessment involves three steps: inspection, auscultation, and palpation. The first step is to examine the surface motion of the abdomen to check for any masses or bulging. The second step is to note the position of the umbilicus and check for any underlying masses. The third step is to assess the bowel sounds by auscultation to check bowel motility. The fourth step is to palpate the abdomen for any tenderness.

In which sequential order would the nurse assess the visual level of a client? Direct the dient to stand or sit 60 cm away from eye level. Ask the dient to dose his or her left or right eye gently and look directly at the nurses opposite eye. Move a finger equidistant between the nurse and the dient outside the field of vision. Ask the dient to report when he or she is able to see the finger. Close the oppesite eye to superimpose the field of vision.

Rationale The first step while assessing the visual level of the client is to direct the client to stand or sit 60 cm away at eye level. Next, the nurse would ask the client to gently close or cover one eye and look at the nurse's eye directly opposite. Then, the nurse would also close his or her right eye to superimpose the field of vision. After this, the nurse would move a finger equidistant between the nurse and the client outside the field of vision. Finally, the nurse would ask the client to report when he or she is able to see the finger.

A Muslim male client refuses to let the female nurse listen to his breath sounds during the examination. How should the nurse respond? Explain how the nursing skill will be performed before proceeding. Examine client with an additional healthcare provider for support. Request a male nurse or healthcare provider to perform the exam. Avoid any skills that involve touching the client during the exam.

Request a male nurse or healthcare provider to perform the exam. Rationale Modesty is an important value in the Muslim community, and Muslims are reluctant to expose any part of their body to healthcare members. Muslim clients are accustomed to examination by "same-sex" healthcare providers.

While providing care for a client with heat stroke, the nurse measured and noted the temperature as 109°F. Convert this temperature into Celsius and record the number using one decimal place.

Temperature in degrees Fahrenheit (°F) = (Temperature in degrees Celsius (°C) * 9/5) + 32 Temperature in degrees Celsius (°C) = (Temperature in degrees Fahrenheit (°F) - 32) * 5/9

A client is admitted to the hospital with severe diarrhea, abdominal cramps, and vomiting for 5 days. Upon further assessment, the primary health care provider finds the symptoms occurred after the client ate eggs, salad dressings, and sandwich fillings. Which food-borne disease would the provider suspect in this client? Listeriosis Shigellosis Salmonellosis Staphylococcus

Salmonellosis Rationale A client with salmonellosis will experience severe diarrhea, abdominal cramps, and vomiting; these symptoms last as long as 5 days after the intake of contaminated food. This disorder may be caused by Salmonella typhi or Salmonella paratyphi. The causative organism is usually present in such foods as eggs, salad dressings, and sandwich fillings. A client with listeriosis will experience severe diarrhea, fever, headache, pneumonia, meningitis, and endocarditis 3 to 21 days after infection. The symptoms of shigellosis range from cramps and diarrhea to a fatal dysentery that lasts for 3 to 14 days. Pain, vomiting, diarrhea, perspiration, headache, fever, and prostration lasting for 1 or 2 days are the symptoms of a Staphylococcus infection.

Which posture and location relative to the client would the nurse assume when performing a Romberg test? Sitting next to the client Standing behind the client Standing in front of the client Standing to the side of the client

Standing to the side of the client Rationale The nurse would be standing to the side of the client when performing a Romberg test because the client is most likely to sway side to side. Sitting does not safely position the nurse to support an unbalanced client. Standing behind or in front of the client is not optimal for safety because the client is most likely to sway side to side.

A client with a history of cardiac dysrhythmias is admitted to the hospital due to a fluid volume deficit caused by a pulmonary infection. Which physiologic change would the nurse expect with this client? Select the 3 findings that the nurse would expect. Respiratory rate of 12 breaths/minute Blood pressure of 135/80 mm Hg Oxygen saturation of 100% Temporal temperature of 101.2°F (38.4°C) Radial pulse rate of 72 and irregular Pain of 6 of 10 with coughing

Temporal temperature of 101.2°F (38.4°C) Radial pulse rate of 72 and irregular Pain of 6 of 10 with coughing Rationale: The normal temperature range is 96.8°F (36°C) to 100.4°F (38°C); temperature is often elevated with any type of infection. Cardiac dysrhythmias are associated with a pulse deficit in which the radial pulse would be irregular; reassessment would not be required. Pleural pain associated with cough is expected with a pulmonary infection. In pulmonary infections, the respiratory rate would more likely be elevated than at the low end of normal. In fluid volume deficit, the blood pressure may be decreased. If oxygen saturation was changed with this client, it would be decreased, whereas 100% is at the high end of normal. A respiratory rate of 12 breaths/minute, a blood pressure of 135/80 mm Hg, and an oxygen saturation of 100% would not be considered physiologic changes expected with this client.

Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. The client is experiencing Liver / Ascites/ oliguria as evidenced by tea-colored urine/albumin 2.6 g/dL/ hemorrhoids/ Purple bruising and. bulging flanks/ white blood cell count of 4000/mm, /decrease in urine output,

The client is experiencing ascites as evidenced by albumin 2.6 g/dL and bulging flanks. Rationale: The client is experiencing ascites as evidenced by albumin 2.6 g/dL and bulging flanks. Ascites is collection of fluid in the peritoneal cavity from the cirrhosis. Serum albumin is reduced because of the plasma proteins in the ascites, allowing the intravascular fluid to move into the interstitial tissues. When the client is in bed the fluid collects in the flanks because of gravity, producing bulging flanks. Even though the client is experiencing jaundice, client findings would include increased bilirubin, yellowing of skin, and tea-colored urine. Only tea-colored urine is listed. Tea-colored urine is not associated with ascites. Portal hypertension is increased pressure in the portal vein, producing prominent abdominal veins, hemorrhoids, esophageal varices, and spider angiomas. Only spider angiomas are listed. Spider angiomas are not associated with ascites. The client does not have liver cancer but does have cirrhosis of the liver from alcohol drinking. Although the client has tea-colored urine, oliguria is a decrease in urine output, producing less than 500 mL/24 hours. A white blood cell count of 4000/mm? is not associated with ascites, jaundice, portal hypertension, liver cancer, or oliguria. Tea-colored urine is associated with jaundice because of the excess bile/bilirubin in the urine. Increased ammonia (98 mg/dL) is indicative of cirrhosis and encephalopathy, not ascites.

A client who does not understand English requires an interpreter. Which action by the nurse may exacerbate health disparities? The nurse expects the interpreter to act as the client's advocate. The nurse expects the interpreter to have a health care background. The nurse maintains steady eye contact with the client. The nurse talks only to the interpreter about the client.

The nurse talks only to the interpreter about the client. Rationale The nurse would follow certain strategies while working with an interpreter for a client who does not understand English. The nurse would talk to the client about the client's condition and care and not to the interpreter, The interpreter may act as a client advocate and represent the client's needs to the nurse. The nurse would use a trained medical interpreter who has a health care background. The nurse would maintain eye contact with the client and obtain feedback to be certain that the client understands.

A 16-year-old client has a blood pressure reading of 119/75 mm Hg. Which numerical value is the approximate pulse pressure?

The top number minus the bottom number is the pulse pressure.

The nurse performs a respiratory assessment and auscultates high-pitched, creaking, and accentuated breath sounds on expiration. Which term describes the findings? Rhonchi Wheezes Pleural friction rub Bronchovesicular

Wheezes Rationale Wheezes are one of the most common breath sounds assessed and auscultated in clients with asthma and chronic obstructive pulmonary disease (COPD). Wheezes are produced as air flows through narrowed passageways. Rhonchi are coarse, rattling sounds similar to snoring and are usually caused by secretions in the bronchial airways. A pleural friction rub is an abrasive sound made by two acutely inflamed serous surfaces rubbing together during the respiratory cycle. Bronchovesicular sounds are intermediate between bronchial (upper) and vesicular (lower) breath sounds; they are normal when heard between the first and second intercostal spaces anteriorly and posteriorly between scapulae.