HESI- Health Assessment 2022

The nurse is collecting data from a client. Which symptom described by the client is characteristic of an early symptom of benign prostatic hyperplasia? A.Nocturia B.Scrotal edema C.Occasional constipation D.Decreased force in the stream of urine

Correct Answers: D Rationale:Decreased force in the stream of urine is an early symptom of benign prostatic hyperplasia. The stream later becomes weak and dribbling. The client then may develop hematuria, frequency, urgency, urge incontinence, and nocturia. If untreated, complete obstruction and urinary retention can occur. Constipation or scrotal edema is not associated with benign prostatic hyperplasia.

The nurse is performing an assessment on a client with a diagnosis of anemia that developed as a result of blood loss after a traumatic injury. The nurse would expect to find which sign or symptom in the client as a result of the anemia? A.Bradycardia B.Muscle cramps C.Increased respiratory rate D.Shortness of breath with activity

Correct Answers: D Rationale:The client with anemia is likely to experience shortness of breath and complain of fatigue because of the decreased ability of the blood to carry oxygen to the tissues to meet metabolic demands. The client is likely to have tachycardia, not bradycardia, as a result of efforts by the body to compensate for the effects of anemia. Muscle cramps are an unrelated finding. Increased respiratory rate is not an associated finding.

The nurse is performing an assessment on a client with dementia. Which piece of data gathered during the assessment indicates a manifestation associated with dementia? A.Use of confabulation B.Improvement in sleeping C.Absence of sundown syndrome D.Presence of personal hygienic care

Correct Answers:A Rationale:The clinical picture of dementia ranges from mild cognitive deficits to severe, life-threatening alterations in neurological functioning. For the client to use confabulation or the fabrication of events or experiences to fill in memory gaps is not unusual. Often, lack of inhibitions on the part of the client may constitute the first indication of something being "wrong" to the client's significant others (e.g., the client may undress in front of others, or the formerly well-mannered client may exhibit slovenly table manners). As the dementia progresses, the client will have difficulty sleeping and episodes of wandering or sundowning. Often, a lack of hygiene care may be noted in a client with dementia.

A confrontation test is prescribed for a client seen in the eye and ear clinic. How would the nurse perform this test? Arrange the actions in the order that they would be performed. All options must be used. 1.Asks the client to cover one eye 2.Examiner covers eye opposite to the eye covered by the client. 3.Asks the client to report when object is first noted 4.Stands 2 to 3 ft (60 to 90 cm) in front of client and faces the client5.The examiner brings in an object gradually from periphery

Correct Answer: 4,2,1,5,3 (I think it should be 4,1,2,5,3 based on rationale) Rationale:The confrontation test is a gross measure of peripheral vision. It compares the person's peripheral vision with the examiner's, whose vision is assumed to be normal. If the client does not see the object at the same time as the nurse, peripheral field loss is expected. The client needs to be referred to an eye care specialist. The procedure is conducted in the following order: stand 2 to 3 ft (60 to 90 cm) in front of the client and face the client; client covers one eye on request; nurse covers the eye opposite the one covered by the client; an object is gradually brought inward from the periphery; and the client reports when the object is first noted.

After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse would expect to note which finding? A. Waves of loud gurgles auscultated in all four quadrants. B. Low-pitched swishing auscultated in one or two quadrants. C. Relatively high-pitched clicks or gurgles auscultated in one or two quadrants. D. Very high pitched, loud rushes auscultated in especially in one or two quadrants.

Correct Answer: A Rationale:Although frequency and intensity of bowel sounds vary, depending on the phase of digestion, normal bowel sounds are relatively high-pitched clicks or gurgles. Loud gurgles (borborygmi) indicate hyperperistalsis and are commonly associated with nausea and vomiting. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. Bruits are not normal sounds. Bowel sounds are very high-pitched and loud (hyperresonance) when the intestines are under tension, such as in intestinal obstruction. Therefore, options 2, 3, and 4 are incorrect.

The nurse is testing a client for astereognosis. The nurse would ask the client to close the eyes and perform which action? A.Identify three numbers or letters traced in the client's palm. B.Identify an object in the client's hand. C.State whether one or two pinpricks are felt when the skin is pricked bilaterally in the same place. D.Identify the smallest distance between two detectable pinpricks, made with two pins held at various lengths.

Correct Answer: B Rationale:Astereognosis is the inability to discern the form or configuration of common objects using the sense of touch. Graphesthesia is the inability to recognize the form of written symbols. The remaining options test for extinction phenomena and two-point stimulation, respectively.

A chest x-ray report states that the client has a left apical pneumothorax. The nurse caring for the client monitors the status of breath sounds in that area by placing the stethoscope at which location? A.Near the lateral 12th rib B.Just under the left clavicle C.In the fifth intercostal space D.Posteriorly under the left scapula

Correct Answer: B Rationale:The apex of the lung is the rounded, uppermost part of the lung. The nurse would place the stethoscope just under the left clavicle. The other options are incorrect locations.

The nurse is assessing a client who presents with right upper quadrant pain, which of the following organs would the nurse palpate for based on the client's complaint.When assessing a client with a complaint of right upper quadrant pain liver during an assessment, the nurse would palpate which abdominal quadrant? A.Gallbladder B.Liver C.Pancreas D.Apex of the stomach

Correct Answer: B Rationale:The liver is located in the right upper quadrant of the abdomen; therefore, since the assessment requests palpation the gallbladder, pancreas and apex of the stomach are easily palpated due to their position behind the liver or other organs.

The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique would the nurse implement to test the motor function of this nerve? A.Ask the client to puff out the cheeks. B.Separate the client's jaw by pushing down on the chin. C.Place a small amount of sugar on the client's tongue and ask them to identify the taste. D.Ask the client to rotate the head forcibly against resistance applied to the side of his or her chin.

Correct Answer: B Rationale:The motor function (muscles of mastication) of cranial nerve V (trigeminal nerve) is assessed by palpating the temporal and masseter muscles as the person clenches the teeth. The muscles would feel equally strong on both sides. The nurse would try to separate the client's jaws by pushing down on the chin; normally, the jaws cannot be separated. Asking the client to puff out the cheeks tests the facial nerve. Placing an object on the client's tongue tests sense of taste and the sensory function of the facial nerve. Checking for equal strength by asking the person to rotate the head forcibly against resistance applied to the side of the client's chin assesses cranial nerve XI, the spinal accessory nerve.

The nurse is caring for a client with a new diagnosis of hypothyroidism. Which clinical manifestations might the nurse expect to note on examination of this client? Select all that apply. A.Irritability B.Periorbital edema C.Coarse, brittle hair D.Slow or slurred speech E.Abdominal distention F.Soft, silky, thinning hair

Correct Answer: B, C, D,E Rationale:The manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormones. The client may exhibit skin manifestations, such as coarse, brittle hair; thick, brittle nails; coarse, scaly skin; delayed wound healing; periorbital edema; and face puffiness. Neuromuscular manifestations include lethargy, slow or slurred speech, and impaired memory. Gastrointestinal manifestations include complaints of constipation, weight gain, and abdominal distention. Irritability and soft, silky, thinning hair on the scalp are manifestations of hyperthyroidism.

The nurse is monitoring a client for signs of hypocalcemia after thyroidectomy. Which sign or symptom, if noted in the client, would most likely indicate the presence of hypocalcemia? A. Bradycardia B. Flaccid paralysis C. Tingling around the mouth D. Absence of Chvostek's sign

Correct Answer: C Rationale:After thyroidectomy the nurse assesses the client for signs of hypocalcemia and tetany. Early signs inclfingertips, muscle twitching or spasms, palpitations or aude tingling around the mouth and in the rrhythmias, and Chvostek's and Trousseau's signs. Bradycardia, flaccid paralysis, and absence of Chvostek's sign are not signs of hypocalcemia.

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds would the nurse expect to hear when performing a respiratory assessment on this client? A.Stridor B.Crackles C.Wheezes D.Diminished

Correct Answer: C Rationale:Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency. Crackles are produced by air passing over retained airway secretions or fluid, or the sudden opening of collapsed airways. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring.

The nurse is performing a neurological assessment on a client and elicits a positive Romberg's sign. The nurse makes this determination based on which observation? A. An involuntary rhythmic, rapid twitching of the eyeballs. B. A dorsiflexion of the ankle and great toe with fanning of the other toes. C. A significant sway when the client stands erect with feet together, arms at the side and the eyes closed. D. A lack of sense of position when the client is unable to return extended fingers to a point of reference.

Correct Answer: C Rationale:In Romberg's test, the client is asked to stand with the feet together and the arms at the sides, and to close the eyes and hold the position; normally the client can maintain posture and balance. A positive Romberg's sign is a vestibular neurological sign that is found when a client exhibits a loss of balance when closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function. A lack of normal sense of position coupled with an inability to return extended fingers to a point of reference is a finding that indicates a problem with coordination. A positive gaze nystagmus evaluation results in an involuntary rhythmic, rapid twitching of the eyeballs. A positive Babinski's test results in dorsiflexion of the ankle and great toe with fanning of the other toes; if this occurs in anyone older than 2 years, it indicates the presence of central nervous system disease.

A client with pneumonia is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to use in obtaining the client's health history? A.Focus only on the physical assessment. B.Obtain all history information from the family members. C.Plan short sessions with the client to obtain data. D.Use the primary healthcare provider's medical history.

Correct Answer: C Rationale:The best source of information is the client. Option 1 is incorrect; the physical examination is not part of the health history. Option 2 is incorrect because it refers to all information. Option 4 is incorrect because the primary health care provider's medical history provides data that are different from the nurse's assessment. All efforts need to be made to obtain as much information as possible from the client, using short sessions and closed-ended questions.

A nursing student is performing a respiratory assessment on an adult client and is assessing for tactile fremitus. Which action by the nursing student indicates a need for further teaching? A.Palpating over the lung apices in the supraclavicular area B.Asking the client to repeat the word ninety-nine during palpation C.Palpating over the breast tissue to assess and compare vibrations from one side to the other D.Comparing vibrations from one side to the other as the client repeats the word ninety-nine

Correct Answer: C Rationale:When assessing for tactile fremitus, the nurse would begin palpating over the lung apices in the supraclavicular area. The nurse would compare vibrations from one side to the other as the client repeats the word ninety-nine.

The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which action to obtain the assessment data? A. Turn the flashlight on directly in front of the eye and watch for a response. B. Check pupil size, and then ask the client to alternate looking at the flashlight and the examiners finger. C. Instruct the client to look straight ahead, and then shine the flashlight from the temporal area to the eye. D. Ask the client to follow the flashlight through the six cardinal positions of gaze

Correct Answer: D Rationale:The nurse asks the client to follow the flashlight through the six cardinal positions of gaze to assess for eye movement related to cranial nerves III, IV, and VI. Options 1 and 3 relate to pupillary response to light. Also, shining the light directly into the client's eye without asking the client to focus on a distant object is not an appropriate technique. Option 4 assesses accommodation of the eye.

The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a ventricular rate of 150 beats/min. The nurse should next assess the client for which finding? No options for answers.

Correct Answer: Hypotension Rationale:The client with uncontrolled atrial fibrillation with a ventricular rate greater than 100 beats/min is at risk for low cardiac output due to loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.

The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? A.The client rigidly extends the arms with pronated forearms and plantar flexion of the feet. B.The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. C.The client passively flexes his hip and knee in response to neck flexion and reports pain in the vertebral column. D.The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.

Correct Answer:C Rationale:Brudzinski's sign is tested with the client in the supine position. The nurse flexes the client's head (gently moves the head to the chest), and there would be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed if the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Kernig's sign also tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended. Decorticate posturing is abnormal flexion and is noted when the client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated. Decerebrate posturing is abnormal extension and occurs when the arms are fully extended, forearms pronated, wrists and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed.

A client sustains a burn injury to the entire right and left arms, the right leg, and the anterior thorax. According to the rule of nines, the nurse would assess that this injury constitutes which body percentage? Fill in the blank.__________________%

Correct Answers: 54% Rationale:According to the rule of nines, the right arm is equal to 9% and the left arm is equal to 9%. The right leg is equal to 18% and the left leg is equal to 18%. The anterior thorax is equal to 18% and the posterior thorax is equal to 18%. The head is equal to 9% and the perineum is equal to 1%. If the anterior thorax, the right leg, and the right and left arms were burned, according to the rule of nines, the total area involved would be 54%.

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data would alert the nurse to this occurrence? A.Inability to pass flatus B.Loss of anal sphincter control C.Severe, constant pain with rapid onset D.Firm, nontender mass palpable at the lower right costal margin

Correct Answers: A Rationale: An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually manifests as a more constant generalized discomfort. Option 4 is the description of the physical finding of liver enlargement. The liver may be enlarged in cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, an enlarged liver is not a sign of paralytic ileus or intestinal obstruction.

The nurse is performing an assessment on a client with a diagnosis of Bell's palsy. The nurse would expect to observe which finding in the client? A.Facial drooping B.Periorbital edema C.Ptosis of the eyelid D.Twitching on the affected side of the face

Correct Answers: A Rationale: Bell's palsy is a one-sided facial paralysis caused by the compression of the facial nerve (cranial nerve VII). Assessment findings include facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and speech or chewing difficulty. The remaining options are not associated findings in Bell's palsy.

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? A.Return of distal pulses B.Brisk bleeding from the site C.Decreasing edema formation D.Formation of granulation tissue

Correct Answers: A Rationale: Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. The escharotomy releases the tourniquet-like compression around the arm. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and elevation control the bleeding, but occasionally an artery is damaged and may require ligation. Escharotomy does not affect the formation of edema. Formation of granulation tissue is not the intent of an escharotomy.

The nurse is assessing an electrocardiogram (ECG) rhythm strip for a client. The PP and RR intervals are regular. The PR interval is 0.14 second, and the QRS complexes measure 0.08 second. The overall heart rate is 58 beats/min. The nurse would report the cardiac rhythm to be which rhythm? A.Sinus bradycardia B.Sick sinus syndrome C.Normal sinus rhythm D.First-degree heart block

Correct Answers: A Rationale: Normal sinus rhythm is defined as a regular rhythm with an overall rate of 60 to 100 beats/min. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second, respectively. Since the HR is less than 60 but all sinus measurements are met the rhythm is a sinus bradycardia.

The nurse in the postanesthesia care unit is monitoring a client for signs of bleeding after a rhinoplasty. Which observation indicates to the nurse that bleeding may be occurring? A.Frequent swallowing B.Client complaints of discomfort C.Ecchymosis around the client's eyes D.Blood on the external nasal dressing

Correct Answers: A Rationale: The client needs to be assessed for frequent swallowing, which may be the only sign of bleeding. Bleeding may not always be externally visible after rhinoplasty because blood may run down the back of the client's throat. The surgical procedure and the packing may be uncomfortable, so discomfort is expected and analgesics would be prescribed. The area around the client's eyes is expected to be edematous and ecchymotic, and ice compresses are applied. Some blood on the external nasal dressing is expected.

The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? A.Listening to lung sounds B.Palpating for organomegaly C.Assessing for jugular vein distention D.Assessing for peripheral and sacral edema

Correct Answers: A Rationale: The client with heart failure may present with different symptoms, depending on whether the right or the left side of the heart is failing. Peripheral and sacral edema, jugular vein distention, and organomegaly all are manifestations of problems with right-sided heart function. Lung sounds constitute an accurate indicator of left-sided heart function.

A client with diabetes mellitus who takes insulin is seen in the health care clinic. The client tells the clinic nurse that after the insulin injection, the insulin seems to leak through the skin. The nurse would appropriately determine the problem by asking the client which question? A."Are you rotating the injection site?" B."Are you aspirating before you inject the insulin?" C."Are you using a 1-inch needle to give the injection?" D."Are you placing an air bubble in the syringe before injection?"

Correct Answers: A Rationale: The client would be instructed that insulin injection sites need to be rotated within one anatomical area before moving on to another area. This rotation process promotes uniform absorption of insulin and reduces the chances of irritation. The remaining options are not associated with the condition (skin leakage of insulin) presented in the question.

The nurse is preparing to perform a Weber test on a client. The nurse would obtain which item needed to perform this test? A. A Tuning Fork B. Stethoscope C. Tongue Blade D. Reflex Hammer

Correct Answers: A Rationale:A tuning fork is needed to perform the Weber test, during which the nurse places the vibrating tuning fork at the midline of the client's forehead or above the upper lip over the teeth. Normally the sound is heard equally in both ears by bone conduction. If the client has a sensorineural hearing loss in one ear, the sound is heard in the other ear. If the client has a conductive hearing loss in one ear, the sound is heard in that ear. The items identified in the remaining options are not needed to perform the Weber test.

A client with a history of panic disorder comes to the emergency department and states to the nurse, "Please help me. I think I'm having a heart attack." What is the priority nursing action? A.Assess the client's vital signs. B.Identify the client's activity during the pain. C.Assess for signs related to a panic disorder. D.Determine the client's use of relaxation techniques.

Correct Answers: A Rationale:Clients with panic disorders experience acute physical symptoms, such as chest pain and palpitations. The priority is to assess the client's physical condition to rule out a physiological disorder. Therefore, options 2, 3, and 4 are not the priority

The nurse is performing a neurological assessment on a client and is assessing the function of cranial nerves III, IV, and VI. Assessment of which aspect of function will yield the best information about these cranial nerves? A.Eye Movements B.Response to verbal Stimuli C.Pupil Response to light and accommodation D.Tongue Movement and Taste

Correct Answers: A Rationale:Eye movements are under the control of cranial nerves III, IV, and VI

A client arrives in the hospital emergency department with a closed head injury to the right side of the head caused by an assault with a baseball bat. The nurse assesses the client neurologically, looking primarily for motor response deficits that involve which area? A.The left side of the body B.The right side of the body C.Both sides of the body equally D.Cranial nerves only, such as speech and pupillary response

Correct Answers: A Rationale:Motor responses such as weakness and decreased movement will be seen on the side of the body that is opposite an area of head injury. Contralateral deficits result from compression of the cortex of the brain or the pyramidal tracts. Depending on the severity of the injury, the client may have a variety of neurological deficits.

Which client is at greatest risk for committing suicide? A.A client with metastatic cancer B.A client with a newly diagnosed cardiac disorder C.A client who just had an argument with the fiancé D.A newly divorced client who states has custody of the children

Correct Answers: A Rationale:The person at greatest risk for suicide is the client with terminal illness. Other high-risk groups include adolescents, drug abusers, persons who have experienced recent losses, those who have few or no social supports, and those with a history of suicide attempts and a suicide plan.

The nurse is performing an assessment on a client suspected of having herpes zoster. The nurse would expect to note which types of lesions on inspection of the client's skin? A. Clustered skin vesicles B. A generalized body rash C. Small blue-white spots with a red base D. A fiery-red edematous rash on the cheeks

Correct Answers: A Rationale:The primary lesion of herpes zoster is a vesicle. The classic presentation is grouped vesicles on an erythematous base along a dermatome. Because they follow nerve pathways, the lesions do not cross the body's midline. Options 2, 3, and 4 are incorrect descriptions

The nurse is monitoring a client with Graves' disease for signs of thyrotoxic crisis (thyroid storm). Which signs or symptoms, if noted in the client, will alert the nurse to the presence of this crisis? A.Fever and tachycardia B.Pallor and tachycardia C.Agitation and bradycardia D.Restlessness and bradycardia

Correct Answers: A Rationale:Thyrotoxic crisis (thyroid storm) is an acute, potentially life-threatening state of extreme thyroid activity that represents a breakdown in the body's tolerance to a chronic excess of thyroid hormones. The clinical manifestations include fever with temperatures greater than 100° F (37.8° C), severe tachycardia, flushing and sweating, and marked agitation and restlessness. Delirium and coma can occur.

THE NURSE IS ASSESSING A CLIENT'S LEGS FOR THE PRESENCE OF EDEMA. THE NURSE NOTES THAT THE CLIENT HAS MILD PITTING WITH SLIGHT INDENTATION AND NO PERCEPTIBLE SWELLING OF THE LEG. HOW WOULD THE NURSE DEFINE AND DOCUMENT THIS FINDING? A. 1+ EDEMA B. 2+ EDEMA C. 3+ EDEMA D. 4+EDEMA

Correct Answers: A Rationale:Edema is accumulation of fluid in the intercellular spaces and is not normally present. To check for edema, the nurse would imprint the thumbs firmly against the ankle malleolus or the tibia. Normally, the skin surface stays smooth. If the pressure leaves a dent in the skin, pitting edema is present. Its presence is graded on the following 4-point scale: 1+, mild pitting, slight indentation, no perceptible swelling of the leg; 2+, moderate pitting, indentation subsides rapidly; 3+, deep pitting, indentation remains for a short time, leg looks swollen; 4+, very deep pitting, indentation lasts a long time, leg is very swollen.

The nurse is preparing to perform an assessment on a child being admitted to the hospital with a diagnosis of sickle cell crisis, vaso-occlusive crisis. Which findings would the nurse expect to note on assessment of the child? Select all that apply. A.Pallor B.Fever C.Joint Swelling D.Blurred Vision E.Abdominal Pain

Correct Answers: A,B,C,E Rationale:Sickle cell crises are acute exacerbations of the disease. Vaso-occlusive crisis is caused by stasis of blood with clumping of cells in the microcirculation, ischemia, and infarction. Manifestations include pallor; fever; painful swelling of hands, feet, and joints; and abdominal pain. Blurred vision is not a manifestation of vaso-occlusive crisis

The nurse assesses the sternotomy incision of a client on the third day after cardiac surgery. The incision shows some slight puffiness along the edges and is non-reddened, with no apparent drainage. The client's temperature is 99° F (37.2° C) orally. The white blood cell count is 7500 mm3 (7.5 × 109/L). How would the nurse interpret these findings? A. Incision is slightly edematous but shows no active signs of infection. B. Incision shows early signs of infection, although the temperature is nearly normal. C. Incision shows no sign of infection, although the white blood cell count is elevated. D. Incision shows early signs of infection, supported by an elevated white blood cell count.

Correct Answers: A Rationale:Sternotomy incision sites are assessed for signs and symptoms of infection, such as redness, swelling, induration, and drainage. An elevated temperature and white blood cell count 3 to 4 days postoperatively usually indicate infection. Therefore, the option indicating that there is slight edema and no active signs of infection is correct.

The nurse is caring for a client diagnosed with type 1 diabetes mellitus experiencing the Somogyi effect. Which blood glucose results and treatment would the nurse expect? A. 0300 blood glucose 68 mg/dL (3.8 mmol/L) and 0700 blood glucose 200 mg/dL (11.1 mmol/L). B. 0300 blood glucose 190 mg/dL (10.6 mmol/L) and 0700 blood glucose 240 mg/dL (13.3 mmol/L). C. 0300 blood glucose 190 mg/dL (10.6 mmol/L) and 0700 blood glucose 60 mg/dL (12.8 mmol/L). D. 0300 blood glucose 200 mg/dL (11.1 mmol/L) and 0700 blood glucose 100 mg/dL (8.5 mmol/L). Instruct to increase amount of evening insulin.

Correct Answers: A Rationale:With the Somogyi effect, hyperglycemia occurs in the morning as a result of hypoglycemia during the night from too much evening insulin. Treatment includes having a bedtime snack, decreasing the amount of evening insulin, or both. Thus, option 1 is the correct answer (hypoglycemia during the night and hyperglycemia in the morning, which is treated by decreasing the evening dose of insulin). Option 2 is incorrect because it instructs the client to increase the evening dose of insulin. Options 3 and 4 are incorrect because the nighttime blood glucose levels indicate hyperglycemia, which would indicate dawn phenomenon.

The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply. A.Set the room temperature at a comfortable level. B.Remove distracting objects from the interviewing area. C.Place a chair for the client across from the nurse's desk. D.Ensure comfortable seating at eye level for the client and nurse. E.Provide seating for the so that the faces a strong light. F.Ensure that the distance between the client and the nurse is at least 7 feet.

Correct Answers: A, B, and D Rationale:When preparing the physical environment for an interview, the nurse would set the room temperature at a comfortable level. The nurse would provide sufficient lighting for the client and nurse to see each other. The nurse would avoid having the client face a strong light because the client would have to squint into the full light. Distracting objects and equipment need to be removed from the interview area. The nurse would arrange seating so that the nurse and client are seated comfortably at eye level, and the nurse avoids facing the client across a desk or table, because this creates a barrier. The distance between the nurse and the client would be set by the nurse at 4 to 5 feet (1.2 to 1.5 meters). If the nurse places the client any closer, the nurse will be invading the client's private space and may create anxiety in the client. If the nurse places the client farther away, the nurse may be seen as distant and aloof by the client.

The nurse is teaching the client with viral hepatitis about the stages of the disease. The nurse would explain to the client that the second stage of this disease is characterized by which specific assessment findings? Select all that apply. A. Jaundice B. Flu-like symptoms C. Clay-colored stools D. Elevated bilirubin levelsE. Dark or tea-colored urine

Correct Answers: A, C,D, E Rationale:There are three stages associated with viral hepatitis. The first (preicteric) stage includes flu-like symptoms only. The second (icteric) stage includes the appearance of jaundice and associated symptoms such as elevated bilirubin levels, dark or tea-colored urine, and clay-colored stools. The third (posticteric) stage, also known as the recovery stage, occurs when the jaundice decreases and the colors of the urine and stool return to normal.

The nurse is caring for a pediatric client who just arrived at the emergency department with an extremity fracture. The nurse uses the five "Ps" to assess the extent of the client's injury. What are some of the five "Ps"? Select all that apply. A.Pallor B. Pain and point of tenderness C.Paralysis distal to the fracture site D.Pulses proximal to the fracture siteE.Sensation distal to the fracture site

Correct Answers: A,B,C, E Rationale:If a child sustains a fracture, the extent of the injury is immediately assessed using the five "P's"—pain and point of tenderness, pulses distal (not proximal) to the fracture site, pallor, paresthesia (sensation) distal to the fracture site, and paralysis (movement distal to fracture site).

The nurse is assessing a client who is experiencing seizure activity. The nurse understands that it is necessary to determine information about which items as part of routine assessment of seizures? Select all that apply. A.Postictal Status B.Duration of Seizure C.Changes in the Pupil Size or Eye Deviation D.Seizure progression and type of Movements E.What the client ate in the 2 hours preceding seizure activity

Correct Answers: A,B,C,D Rationale:Typically seizure assessment includes the time the seizure began, parts of the body affected, type of movements and progression of the seizure, change in pupil size or eye deviation or nystagmus, client condition during the seizure, and postictal status. Determining what the client ate 2 hours prior to the seizure is not a component of seizure assessment.

A client with cirrhosis has ascites and excess fluid volume. Which assessment findings does the nurse anticipate to note as a result of increased abdominal pressure? Select all that apply. A.Orthopnea and dyspnea B.Petechiae and ecchymosis C.Inguinal or umbilical hernia D.Poor body posture and balance E.Abdominal distention and tenderness

Correct Answers: A,B,C,E Rationale:Excess fluid volume, related to the accumulation of fluid in the peritoneal cavity and dependent areas of the body, can occur in the client with cirrhosis. Ascites can cause physical problems because of the overdistended abdomen and resultant pressure on internal organs and vessels. These problems include respiratory difficulty, petechiae and ecchymosis, development of hernias, and abdominal distention and tenderness. Poor body posture and balance are unrelated to increased abdominal pressure.

The nurse is conducting a health history of a client with a primary diagnosis of heart failure. Which conditions reported by the client could play a role in exacerbating the heart failure? Select all that apply. A.Emotional Stress B.Atrial Fibrillation C.Nutritional Anemia D.Peptic Ulcer Disease E.Recent Upper Respiratory Infection

Correct Answers: A,B,C.E Rationale:Heart failure is precipitated or exacerbated by physical or emotional stress, dysrhythmias, infections, anemia, thyroid disorders, pregnancy, Paget's disease, nutritional deficiencies (thiamine, alcoholism), pulmonary disease, and hypervolemia. Peptic ulcer disease is not an exacerbating factor

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. A.The client is aphasic. B.The client has weakness on the right side of the body. C.The client has complete bilateral paralysis of the arms and legs. D.The client has weakness on the right side of the face and tongue. E.The client has lost the ability to move the right arm but is able to walk independently. F.The client has lost the ability to ambulate independently but is able to feed and bathe self without assistance.

Correct Answers: A,B,D Rationale:Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic: unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.

A nurse is reviewing the assessment findings for a client who was admitted to the hospital with a diagnosis of diabetes insipidus. The nurse understands that which manifestations are associated with this disorder? Select all that apply. A.Polyuria B.Polydipsia C.Concentrated Urine D.Complaints of Excessive Thrist E.Specific Gravity lower than 1.005

Correct Answers: A,B,D,E Rationale: A triad of clinical symptoms—polyuria, polydipsia, and excessive thirst—often occurs suddenly in the client with diabetes insipidus. The urine is dilute, with a specific gravity lower than 1.005, and the urine osmolality is low (50 to 200 mOsm/L).

The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicate effective coping? Select all that apply. A.Looking at old photographs of family B.Participating in a senior citizens program C.Neglecting personal grooming D.Visiting the spouse's grave once a month E.Decorating a wall with the spouse's pictures and awards received

Correct Answers: A,B,D,E Rationale:Coping mechanisms are behaviors used to decrease stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some cases may be harmful to the individual physically or psychologically. Neglecting personal grooming is indicative of a behavior that identifies ineffective coping in the grieving process. The remaining options identify appropriate and effective coping echanisms

A client is at risk for vasovagal attacks that cause bradydysrhythmias. The nurse would tell the client to avoid which actions to prevent this occurrence? Select all that apply. A. Applying pressure on the eyes B. Raising the arms above the head C. Taking stool softeners on a daily basis D. Bearing down during a bowel movementE. Simulating a gag reflex when brushing the teeth

Correct Answers: A,B,D,E Rationale:Vasovagal attacks or syncope occurs when the client faints because the body overreacts to certain triggers. The vasovagal syncope trigger causes the heart rate and blood pressure to drop suddenly. That leads to reduced blood flow to the brain, causing the client to briefly lose consciousness. The client at risk would be taught to avoid actions that stimulate the vagus nerve. Actions to avoid include raising the arms above the head, applying pressure over the carotid artery, applying pressure over the eyes, stimulating a gag reflex when brushing the teeth or putting objects into the mouth, and bearing down or straining during a bowel movement. Taking stool softeners is an important measure to prevent the bearing down and straining during a bowel movement.

The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings would the nurse expect to note? Select all that apply. A.Dental decay B.Moist, oily skin C.Loss of tooth enamel D.Electrolyte imbalances E.Body weight well below ideal range

Correct Answers: A,C,D Rationale:Clients with bulimia nervosa initially may not appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. On further inspection, a client exhibits dental decay and loss of tooth enamel if the client has been inducing vomiting. Electrolyte imbalances are present. Dry, scaly skin (rather than moist, oily skin) is present.

A client diagnosed with chronic kidney disease (CKD) is scheduled to begin hemodialysis. The nurse determines that which neurological and psychosocial manifestations, if exhibited by this client, are related to the CKD? Select all that apply. A. Agitation B. Euphoria C. Depression D. Withdrawal E. Labile Emotions

Correct Answers: A,C,D,E Rationale: The client with CKD often experiences a variety of psychosocial changes. These changes are related to uremia and to the stress associated with living with a chronic disease that is life threatening. Euphoria is not part of the clinical picture for the client in renal failure. Clients with CKD may have labile emotions or personality changes and may exhibit withdrawal, depression, or agitation, which are used as coping mechanisms for a major life change. Delusions and psychosis also can occur.

The nurse is caring for a client diagnosed with osteomyelitis. Which data noted in the client's record are supportive of this diagnosis? Select all that apply. A.Pyrexia B.Elevated Potassium Level C.Elevated white blood cell count D.Elevated erythrocyte sedimentation rate E.Bone scan impression indicative of infection

Correct Answers: A,C,D,E Rationale:Osteomyelitis is an infection of the bone, bone marrow, and surrounding tissue. Clinical data indicative of osteomyelitis include pyrexia, elevated white blood cell count, elevated erythrocyte sedimentation rate, and a bone scan, computed tomography scan, or magnetic resonance imaging scan indicative of infection. Elevated potassium level is not specifically associated with osteomyelitis.

he nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder? A.A 25-year-old woman who runs B.A 36-year-old man who has asthma C.A 70-year-old man who consumes excess alcohol D.A sedentary 65-year-old woman who smokes cigarettes

Correct Answers: D Rationale: Risk factors for osteoporosis include female gender, being postmenopausal, advanced age, a low-calcium diet, excessive alcohol intake, being sedentary, and smoking cigarettes. Long-term use of corticosteroids, anticonvulsants, and/or furosemide also increases the risk.

The nurse caring for a client who has undergone kidney transplantation is monitoring the client for organ rejection. Which findings are consistent with acute rejection of the transplanted kidney? Select all that apply. A.Oliguria B.Hypotension C.Fluid retention D.Temperature of 99.6° F (37.6° C) E. Serum creatinine of 3.2 mg/dL (282 mcmol/L)

Correct Answers: A,C,E Rationale: Rejection is the most serious complication of transplantation and the leading cause of graft loss. In rejection, a reaction occurs between the tissues of the transplanted kidney and the antibodies and cytotoxic T-cells in the recipient's blood. These substances treat the new kidney as a foreign invader and cause tissue destruction, thrombosis, and eventual kidney necrosis. Acute rejection is the most common type that occurs with kidney transplants and occurs 1 week to any time postoperatively. It occurs over days to weeks. Findings consistent with acute rejection include oliguria or anuria; temperature higher than 100° F (37.8° C); increased blood pressure; enlarged, tender kidney; lethargy; elevated serum creatinine, blood urea nitrogen, and potassium levels; and fluid retention.

The nurse is caring for a client with an intracranial aneurysm who has been alert. Which signs and symptoms are an early indication that the level of consciousness (LOC) is deteriorating? Select all that apply. A.Mild Drowsiness B.Drooping Eyelids C.Ptosis of the left eyelids D.Slight Slurring of speech E.Less frequent spontenous Speech

Correct Answers: A,D,E Rationale:Early changes in LOC relate to orientation, alertness, and verbal responsiveness. Mild drowsiness, slight slurring of speech, and less frequent spontaneous speech are early signs of decreasing LOC. Ptosis (drooping) of the eyelid is caused by pressure on and dysfunction of cranial nerve III. Once ptosis occurs, it is ongoing; it does not relate to LOC.

The nurse is assessing a dark-skinned client for signs of anemia. The nurse would focus the assessment on which structures? Select all that apply. A. Lips B. Tongue C. Earlobes D. Conjunctiva E. Mucous membranes

Correct Answers: A,D.E Rationale:Changes in skin color can be difficult to assess in the dark-skinned client. Color changes are most easily seen in areas of the body where the epidermis is thin and in areas where pigmentation is not influenced by exposure to sunlight. The nurse needs to assess the lips, conjunctiva, and oral mucous membranes for signs of anemia in the dark-skinned client. Signs of anemia are less easily observed in the tongue and...

A client with severe coronary artery disease who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem? A.Hypovolemia B.Acute kidney injury C.Glomerulonephritis D.Heart Failure

Correct Answers: B Rationale: The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal injury is signaled by decreased urine output and increased blood urea nitrogen (BUN) and creatinine levels. Normal reference levels are BUN, 10 to 20 mg/dL (3.6 to 7.1 mmol/L), and creatinine, male 0.6 to 1.2 mg/dL (53 to 106 mcmol/L) and female 0.5 to 1.1 mg/dL (44 to 97 mcmol/L). The client may need medications to increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis. No data in the question indicate the presence of hypovolemia, glomerulonephritis, or heart failure.

A home health nurse is visiting a client with type 1 diabetes mellitus. The client states to the nurse "I am not feeling well and had a respiratory problem for the past week, which seems to be getting worse." After interviewing the client, what would be the initial nursing action? A.Document the assessment data. B.Check the client's blood glucose. C.Notify the primary health care provider (PHCP). D.Obtain the client's sputum for culture and sensitivity.

Correct Answers: B Rationale: Uncontrolled hyperglycemia may lead to the production of ketones, thus leading to diabetic ketoacidosis (DKA), a life-threatening condition. The most common precipitating factor for development of DKA is infection. Assessment data need to be documented but are not a priority. The PHCP may need to be notified if the client's blood glucose is elevated and the client has other symptoms of DKA or a respiratory infection. After determining the client's blood glucose, the nurse would obtain a sputum sample if the client is expectorating yellow, green, or bloody secretions.

The nurse is performing a physical examination on an assigned client. Which item would the nurse select to test the function of cranial nerve II? A. Flashlight B. Snellen Chart C. Reflex Hammer D. Cotton Ball

Correct Answers: B Rationale:Cranial nerve II (the optic nerve) is responsible for visual acuity. This may be tested by using a Snellen chart to assess distant vision. Another item that may be used to evaluate the optic nerve function is a Rosenbaum card to evaluate near vision. This is a hand-held card used to test visual acuity. The nurse records the smallest line seen as well as the distance that the card is held from the client. A flashlight is used to test the pupillary reaction. A reflex hammer is used to test reflexes. An cottonball is used to test the facial nerves.

The nurse is testing the coordinated functioning of cranial nerves III, IV, and VI. To do this correctly, what would the nurse test? A.The corneal reflex B.The six cardinal fields of gaze C.The pupillary response to light D.Pupillary response to light and accommodation

Correct Answers: B Rationale:Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) have only motor components and control, in a coordinated manner, the six cardinal fields of gaze. This is tested by moving an object in six directions (involving horizontally and diagonally). Corneal reflex is the function of the trigeminal nerve (cranial nerve V). Pupillary response to light and accommodation is the function of cranial nerve III (oculomotor) alone.

The nurse is caring for a client after a craniotomy and monitors the client for signs of increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate an early sign of increased ICP? A.Bradycardia B.Confusion C.Sluggish Pupils D.Widened Pulse Pressure

Correct Answers: B Rationale:Early manifestations of increased ICP are subtle and often may be transient, lasting for only a few minutes in some cases. These early clinical manifestations include episodes of confusion, drowsiness, and slight pupillary and breathing changes. Later manifestations include a further decrease in the level of consciousness, a widened pulse pressure, and bradycardia. Cheyne-Stokes respiratory pattern, or a hyperventilation respiratory pattern, and pupillary sluggishness and dilatation appear in the late stages.

A client with a history of asthma comes to the emergency department complaining of itchy skin and shortness of breath after starting a new antibiotic. What is the first action the nurse would take? A.Place the client on 100% oxygen and prepare for intubation. B.Assess for anaphylaxis and prepare for emergency treatment. C.Teach the client about the relationship between asthma and allergies. D.Obtain an arterial blood gas and immunoglobulin E (IgE) blood level.

Correct Answers: B Rationale:Hypersensitivity or allergy is excessive inflammation occurring in response to the presence of an antigen to which the person usually has been previously exposed. If a client is experiencing an allergic or hypersensitivity response, the nurse's initial action is to assess for anaphylaxis. Promptly notifying the health care provider and preparing emergency equipment, including medication such as epinephrine and possible corticosteroids, is essential in preventing progression of anaphylaxis. Laboratory work is not a priority in this situation. The nurse would expect the IgE level to be elevated; the client may be hypoxic. The nurse would give the client supplemental oxygen; however, 100% is not given unless prescribed, and based on the information in the question, intubation is not the first thing the nurse would prepare this client for. Teaching the client is important; however, this is not the right time. When the client is stabilized, the nurse needs to teach or reinforce that allergies, including some medications, are common triggers for asthma attacks and that people with asthma are predisposed to more allergies than people without asthma.

The nurse is reviewing the health care record of a client with a new diagnosis of rheumatoid arthritis (RA). The nurse understands that which is an early clinical manifestation of RA? A. Anemia B. Anorexia C. Amenorrhea D. Night sweats

Correct Answers: B Rationale:Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. Early clinical manifestations of RA include complaints of fatigue, generalized weakness, anorexia, and weight loss. Anemia, amenorrhea, and night sweats are not early manifestations of RA.

The nurse is assessing a client who suffered a head injury involving the limbic system of the brain. Which finding would the nurse suspect relates to this injury? A.Client is disoriented to person, place, and time. B.Affect is flat, with periods of emotional lability. C.Cannot recall what was eaten for breakfast today. D.Demonstrates inability to add and subtract; does not know who is the president of the United States

Correct Answers: B Rationale:The limbic system is responsible for feelings (affect) and emotions. Calculation ability and knowledge of current events relate to function of the frontal lobe. The cerebral hemispheres, with specific regional functions, control orientation. Recall of recent events is controlled by the hippocampus.

Which assessment finding would the nurse expect to note in the client hospitalized with a diagnosis of brain attack (stroke) who has difficulty chewing food? A.Dysfunction of vagus nerve (cranial nerve X) B.Dysfunction of trigeminal nerve (cranial nerve V) C.Dysfunction of hypoglossal nerve (cranial nerve XII) D.Dysfunction of spinal accessory nerve (cranial nerve XI)

Correct Answers: B Rationale:The motor branch of cranial nerve V is responsible for the ability to chew food. The vagus nerve is active in parasympathetic functions of the autonomic nervous system. The hypoglossal nerve aids in swallowing. The spinal accessory nerve is responsible for shoulder movement, among other things.

A 56-year-old client with heart failure is taking digoxin for treatment of the health problem. The nurse auscultates the client's apical heart rate before administering digoxin and notes that the heart rate is 52 beats/min. The nurse would make which interpretation of this information? A.Normal, because of the client's age B.Abnormal, requiring further assessment C.Normal, as a result of the effects of digoxin D.Normal, because this is the reason the client is receiving digoxin

Correct Answers: B Rationale:The normal heart rate is 60 to 100 beats/min in an adult. On auscultating a heart rate that is less than 60 beats/min, the nurse would not administer the digoxin and would report the finding to the primary health care provider for further instruction. The remaining options are incorrect interpretations because the heart rate of 52 beats/min is not normal.

A client who visits the primary health care provider's office for a routine physical examination reports new onset of intolerance to cold. Knowing that this is a frequent complaint associated with hypothyroidism, the nurse would check for which manifestations? A.Weight loss and thinning skin B.Complaints of weakness and lethargy C.Diaphoresis and increased hair growth D.Increased heart rate and respiratory rat

Correct Answers: B Rationale:Weakness and lethargy are common complaints associated with hypothyroidism. Other common symptoms include weight gain, bradycardia, decreased respiratory rate, dry skin, and hair loss.

The nurse is performing an admission assessment on a client at high risk for suicide. Which assessment question will best elicit data related to this risk? A."What are you feeling right now?" B."Do you have a plan to commit suicide?" C."How many times have you attempted suicide in the past?" D."Why were your attempts at suicide unsuccessful in the past?"

Correct Answers: B Rationale:When assessing for suicide risk, the nurse must determine whether the client has a suicide plan. Clients who have a definitive plan pose a greater risk for suicide. Although the other options are questions that may provide information that will be helpful in planning care for the client, these questions will not provide information regarding the risk of suicide.

A client complains of calf tenderness, and thrombophlebitis is suspected. The nurse would next assess the client for which finding? A.Bilateral edema B.Increased calf circumference C.Diminished distal peripheral pulses D.Coolness and pallor of the affected limb

Correct Answers: B Rationale:The client with thrombophlebitis, also known as deep vein thrombosis, exhibits redness or warmth of the affected leg, tenderness at the site, possibly dilated veins (if superficial), low-grade fever, edema distal to the obstruction, and increased calf circumference in the affected extremity. Peripheral pulses are unchanged from baseline because this is a venous, not an arterial, problem. Often thrombophlebitis develops silently; that is, the client does not present with any signs and symptoms unless pulmonary embolism occurs as a complication.

Which client situation is most appropriate for the nurse to consult with the Rapid Response Team (RRT)? A. A 56-year-old client, fourth hospital day after coronary artery bypass procedure, sore chest, pain with walking, temperature 97° F (36.1° C), heart rate 84 beats/min, respirations 22 breaths/min, blood pressure 122/78 mm Hg, bored with hospitalization. B. A 45-year-old client, 2 years after kidney transplant, second hospital day for treatment of pneumonia, no urine output for 6 hours, temperature 101.4° F (38.6° C), heart rate 98 beats/min, respirations 20 breaths/min, blood pressure 168/94 mm Hg C. A 72-year-old client, 24 hours after removal of a chest tube that was used to drain pleural fluid (effusion), temperature 97.8° F (36.6° C), heart rate 92 beats/min, respirations 28 breaths/min, blood pressure 136/86 mm Hg, anxious about going home D. An 86-year-old client, 48 hours after operative repair of fractured hip, alert, oriented, using patient-controlled analgesia pump, temperature 96.8° F (36° C), heart rate 60 beats/min, respirations 16 breaths/min, blood pressure 120/82 mm Hg, talking with child.

Correct Answers: B Rationale:The role of an RRT is to provide internal consultative services to staff nurses to detect client problems early. Absence of urine output and temperature and blood pressure elevation describe a client who may be rejecting a transplanted kidney. The constellation of symptoms described indicates possible rejection. Internal consultation could validate that assessment. The remaining options indicate expected characteristics of the clients described and provide no indication of need for RRT consultation.

A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How would the nurse interpret this behavior as a cue to modify the treatment plan? A.Suggesting a reduction of medication B.Allowing increased "in-room" activities C.Increasing the level of suicide precautions D.Allowing the client off-unit privileges as needed

Correct Answers: C Rationale: A client who is moderately depressed and has only been in the hospital 2 days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is likely that the client may have made the decision to harm self. Suicide precautions are necessary to keep the client safe. The remaining options are therefore incorrect interpretations.

The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse would assess the client for which sign(s)/symptom(s) of duodenal ulcer? A.Weight loss B.Nausea and vomiting C.Pain relieved by food intake D.Pain radiating down the right arm

Correct Answers: C Rationale: A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or "hungry" pain that often localizes in the mid-epigastric area. The client with duodenal ulcer usually does not experience weight loss or nausea and vomiting. These symptoms are more typical in the client with a gastric ulcer.

The nurse reviews the assessment data of a client admitted to the hospital with a diagnosis of anxiety. The nurse would assign priority to which assessment finding? A.Tearful, self-isolated B.Affect bland, withdrawn C.Fist clenched, pounding table, fearful D.Temperature 98.4° F (36.8° C); respirations 18 breaths/min

Correct Answers: C Rationale: Anxiety signs and symptoms may take a physical form and if abnormal need to be addressed as a priority for the client. A temperature of 98.4° F and respirations 18 breaths/min are normal vital signs. Tearfulness, self-isolation, a bland affect, and a withdrawn state are abnormal findings but are commonly associated with anxiety. These findings are not life threatening, although they should be monitored. Fist clenched, pounding the table, and exhibiting fear indicate a possible threat to safety of the client or others

The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding indicates the presence of this complication? A.Flat neck veins B.A pulse rate of 160 beats/minute C.Muffled or distant heart sounds D.Wheezing on auscultation of the lungs

Correct Answers: C Rationale: Assessment findings associated with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention with clear lung sounds, and a falling blood pressure accompanied by pulsus paradoxus (a drop in inspiratory blood pressure greater than 10 mm Hg). The other options are not signs of cardiac tamponade.

The nurse notes that a client's cardiac rhythm shows absent P waves, no PR interval, and an irregular rhythm. How would the nurse interpret this rhythm? A.Bradycardia B.Tachycardia C.Atrial Fibrillation D.Normal Sinus Rhythm (NSR)

Correct Answers: C Rationale: In atrial fibrillation, the P waves are absent and replaced by fibrillatory waves. There is no PR interval, and the QRS duration usually is normal and constant and the rhythm is irregular. Bradycardia is a slowed heart rate, and tachycardia is a fast heart rate. In NSR, a P wave precedes each QRS complex, the rhythm is essentially regular, the PR interval is 0.12 to 0.20 second, and the QRS interval is 0.06 to 0.10 second.

Which piece of subjective data obtained during assessment of a severely anxious client would indicate the possibility of post-traumatic stress disorder? A."I'm always crying." B."I'm afraid to go outside." C."I keep reliving the abuse." D."I keep washing my hands over and over."

Correct Answers: C Rationale: In post-traumatic stress disorder, the client relives the traumatic experience. Only the correct option includes the defining characteristic symptom of post-traumatic stress disorder. Fear of going outside is characteristic of a phobia, while always crying may indicate depression. Excessive handwashing is a characteristic of obsessive-compulsive disorder.

Which action would the nurse take to test cranial nerve XI, the spinal accessory nerve? A.Ask the client to clench the teeth. B.Ask the client to read the letters in a line on a Snellen chart. C.Ask the client to shrug the shoulders against the nurse's resistance. D.Ask the client to close the eyes, occlude one nostril, and identify a specific odor such as coffee.

Correct Answers: C Rationale: The spinal accessory nerve, cranial nerve XI, controls strength of the neck and shoulder muscles. One method of testing this nerve is to palpate and inspect the trapezius muscle as the client shrugs the shoulders against the nurse's resistance. Option 1 tests cranial nerve V, the trigeminal nerve. Option 2 tests cranial nerve II, the optic nerve. Option 4 tests cranial nerve I, the olfactory nerve.

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse would assess the client for which signs and symptoms characteristic of this disorder? A.Bradycardia and hyperactivity B.Decreased respiratory rate and depth C.Headache, restlessness, and confusion D.Bradypnea, dizziness, and paresthesias

Correct Answers: C Rationale: When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache; restlessness; mental status changes, such as drowsiness and confusion; visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias. Options 1, 2, and 4 are not specifically associated with this disorder.

The nurse would perform which action to assess for a pulse deficit? A.Count the carotid pulsations for 1 full minute. B.Measure the blood pressure in both the arm and leg. C.Auscultate the apical heartbeat while palpating the radial artery. D.Place the diaphragm of the stethoscope directly over the skin at the mitral area.

Correct Answers: C Rationale:A pulse deficit is the difference between the apical and peripheral pulses and could indicate a dysrhythmia. If an irregularity in the pulse is noted, the nurse would check for a pulse deficit. To check for a pulse deficit the nurse would auscultate the apical heart rate and rhythm while palpating a peripheral artery and assess for a difference in the rates. A difference in the rates indicates a pulse deficit. Therefore, options 1, 2, and 4 are incorrect actions.

A client sustained a burn from cutaneous exposure to lye. At the site of injury, copious irrigation to the site was performed for 1 hour. On admission to the hospital emergency department, the nurse assesses the burn site. Which findings would indicate that the chemical burn process is continuing? A.Eschar B.Intact blisters C.Liquefaction necrosis D.Cherry-red, firm tissue

Correct Answers: C Rationale:Alkalis, such as lye, cause a liquefaction necrosis, and exposure to fat results in formation of a soapy coagulum. Thick, leathery eschar forms with exposure to acids or heat. Intact blisters indicate a partial-thickness thermal injury. Cherry-red, firm tissue can occur as a result of thermal injury.

Which client is most at risk for developing a Candida urinary tract infection (UTI)? A. An obese client B. A client with diabetes insipidus C. A client on antibiotic therapy D. A paraplegic client on intermittent catheterization

Correct Answers: C Rationale:Candida infections, which are fungal infections, develop in persons who are on long-term antibiotic therapy because an alteration of normal flora occurs. These infections also are commonly seen in clients with blood dyscrasias, diabetes mellitus, cancer, or immunosuppression and in those with a drug addiction.

Correct Answers: D Rationale: The best indicator that the behavior is controlled is the fact that the client exhibits no signs of aggression after partial release of restraints. The remaining options do not ensure that the client has controlled the behavior

Correct Answers: C Rationale:Coronary care unit (CCU) psychosis occurs in some clients in the critical care milieu. The ability to focus fluctuates over the course of a day. It usually is directly caused by sensory deprivation or underlying medical conditions or is medication-related. There are no data in the question to indicate that dementia exists. The question presents no data directly indicating that alcohol is a concern.

The clinic nurse is performing an assessment on a client with a diagnosis of rheumatoid arthritis (RA). The nurse checks for which assessment finding that is associated with RA? A. Age of onset is generally 65 years of age or older B. Complaint of pain that is more severe after activity C. Systemic symptoms such as fatigue, anorexia, and weight loss D. Joint pain is asymmetrical and associated with past injuries to the joint

Correct Answers: C Rationale:In clients diagnosed with RA, systemic symptoms such as fatigue, anorexia, weight loss, and nonspecific aching and stiffness may appear before joint manifestations. RA is characterized by chronic joint pain of variable intensity, which is more severe on rising in the morning. The age of onset for RA is most commonly between 30 and 50 years of age. A complaint of pain that is more severe after activity and asymmetrical joint pain associated with past injuries to the joint are more commonly seen in osteoarthritis.

The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 120 mg/dL (6.8 mmol/L), temperature of 101° F (38.3° C), pulse of 102 beats/minute, respirations of 22 breaths/minute, and blood pressure of 142/72 mm Hg. Which finding would be the priority concern to the nurse? A.Pulse B.Respiration C.Temperature D.Blood Pressure

Correct Answers: C Rationale:In the client with type 2 diabetes mellitus, an elevated temperature may indicate infection. Infection is a leading cause of hyperosmolar hyperglycemic syndrome in the client with type 2 diabetes mellitus. The other findings are within normal limits or are expected.

The nurse notes documentation that a newly admitted client experiences flashbacks. What diagnosis would this notation support? A.Anxiety B.Agoraphobia C.Post-traumatic stress disorder D.Schizophrenia

Correct Answers: C Rationale:The major clinical manifestation associated with post-traumatic stress disorder (PTSD) is client experience of flashbacks. Flashbacks are not specifically associated with anxiety, agoraphobia, or schizophrenia.

The nurse is performing an abdominal assessment on a client. The nurse determines that which finding needs to be reported to the primary health care provider (PHCP)? A.Absence of a bruit B.Concave, midline umbilicus C.Pulsation between the umbilicus and the pubis D.Bowel sound frequency of 15 sounds per minute

Correct Answers: C Rationale:The presence of pulsation between the umbilicus and the pubis could indicate an abdominal aortic aneurysm and needs to be reported to the PHCP. Bruits normally are not present. The umbilicus would be in the midline with a concave appearance. Bowel sounds vary according to the timing of the last meal and usually range in frequency from 5 to 35 per minute.

A client with an acute respiratory infection is admitted to the hospital with a diagnosis of sinus tachycardia. Which nursing action would be included in the client's plan of care? A.Limiting oral and intravenous fluids B.Measuring the client's pulse each shift C.Providing the client with short, frequent walks D.Eliminating sources of caffeine from meal trays

Correct Answers: D Rationale: Sinus tachycardia often is caused by fever, physical and emotional stress, heart failure, hypovolemia, certain medications, nicotine, caffeine, and exercise. Fluid restriction and exercise will not alleviate tachycardia. Measuring the pulse each shift will not decrease the heart rate. In addition, the pulse needs to be taken more frequently than each shift.

The nurse is preparing to test the sensory function of cranial nerve V in a client. The nurse would obtain which item to test the sensory function of this nerve? A. Coffee beans B. A tuning fork C. A wisp of cotton D. Flashlight

Correct Answers: C Rationale:To assess the sensory function of cranial nerve V (the trigeminal nerve), the nurse would ask the client to close the eyes and then with a wisp of cotton lightly touch the client's forehead, cheeks, and chin, noting whether the touch is felt equally on both sides of the face. Cranial nerve I (the olfactory nerve) is assessed by testing the sense of smell (using a non-noxious aromatic substance such as coffee beans) in a client who reports the loss of smell. A tuning fork would be used to assess cranial nerve VIII (the acoustic nerve). A flashlight would be used to assess the PEARLA and cardinal movements of gaze.

The nurse is reviewing laboratory test results for the client with liver cancer and notes that the client's albumin level is low. Which nursing action is focused on the consequence of low albumin levels? A. Evaluating for asterixis B. Inspecting for petechiae C. Palpating for peripheral edema D. Evaluating for decreased level of consciousness

Correct Answers: C Rationale:Albumin is responsible for maintaining the osmolality of the blood. When there is a low albumin level, there is decreased osmotic pressure, which in turn can lead to peripheral edema. The remaining options are incorrect and are not associated with a low albumin level.

The nurse is caring for a client just admitted to the mental health unit; the client is displaying immobile and mute behaviors and is withdrawn. The client is lying on the bed in a fetal position. Which is the most appropriate nursing intervention? A.Ask direct questions to encourage talking. B.Leave the client alone so as to minimize external stimuli. C.Sit beside the client in silence with occasional open-ended questions. D.Take the client into the dayroom with other clients so that they can help watch the client.

Correct Answers: C Rationale:Clients who are withdrawn may be immobile and mute and may require consistent, repeated approaches. Communication with withdrawn clients requires much patience from the nurse. Interventions include the establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions rather than direct questions, and pausing to provide opportunities for the client to respond. While overstimulation is not appropriate, there is no therapeutic value in ignoring the client. The client's safety is not the responsibility of other clients.

The nurse is assessing a client's muscle strength. The nurse asks the client to hold the arms up and supinated, as if holding a tray, and then asks the client to close the eyes. The client's left hand turns and moves downward slightly. The nurse interprets this to mean that the client has which condition? A. Ataxia B. Nystagmus C. Pronator Drift D. Hyperreflexia

Correct Answers: C Rationale:Pronator drift occurs when a client cannot maintain the hands in a supinated position with the arms extended and the eyes closed. This assessment may be done to detect small changes in muscle strength that might not otherwise be noted. Ataxia is a disturbance in gait. Nystagmus is characterized by fine, involuntary eye movements. Hyperreflexia is an excessive reflex action.

The nurse is caring for a client after the application of a plaster cast for a fractured left radius. The nurse would suspect impairment with the neurovascular status of the client's casted extremity if which findings are noted? Select all that apply. A.Capillary refill less than 3 seconds B.Pulses present and with swollen, pink fingers C.Client report of severe, deep, unrelenting pain D.Client report of pain as nurse assesses finger movement E.Client report of numbness and tingling sensation in the fingers

Correct Answers: C,D,E Rationale:The pressure in compartment syndrome, if unrelieved, will cause permanent damage to nerve and muscle tissue distal to the pressure. Circulatory damage may result in necrosis. Nerve and muscle damage may result in permanent contractures, deformity of the extremity, and functional impairment. Normal capillary refill time is 3 seconds or less. Pink appearance and a pulse indicate adequate blood flow; swelling is expected after a fracture. Client report of severe, deep, unrelenting pain; client report of numbness and tingling sensation; and client report of pain as the nurse assesses finger movement are indicative of development of compartment syndrome

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection to remove a cancerous tumor. Which are the expected assessment findings? Select all that apply. A.Excessive bubbling in the water seal chamber B.Vigorous bubbling in the suction control chamber C.Drainage system maintained below the client's chest D.50 mL of drainage in the drainage collection chamber E.Occlusive dressing in place over the chest tube insertion site F. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

Correct Answers: C,D,E,F Rationale:The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has reexpanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling would be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70 to 100 mL/hour is considered excessive and requires notification of the primary health care provider. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.

HE NURSE IS CARING FOR A CLIENT WITH OSTEOARTHRITIS. THE NURSE PERFORMS AN ASSESSMENT KNOWING THAT WHICH CLINICAL MANIFESTATIONS ARE ASSOCIATED WITH THE DISORDER? SELECT ALL THAT APPLY .A. ELEVATED WHITE BLOOD CELL COUNT B. A DECREASED SEDIMENTATION RATE C. JOINT PAIN THAT DIMINISHES AFTER REST D. ELEVATED ANTINUCLEAR ANTIBODY LEVELS E. JOINT PAIN THAT INTENSIFIES WITH ACTIVITY

Correct Answers: C,E Rationale:The stiffness and joint pain that occur in osteoarthritis diminish after rest and intensify with activity. No specific laboratory findings are useful in diagnosing osteoarthritis. The client may have a normal or slightly elevated sedimentation rate. Morning stiffness lasting longer than 30 minutes occurs in rheumatoid arthritis. Elevated white blood cell counts, platelet counts, and antinuclear antibody levels occur in rheumatoid arthritis.

When would the nurse determine that it will be safe to remove the restraints from a client who demonstrated violent behavior? A.Administered medication has taken effect. B.The client verbalizes the reasons for the violent behavior. C.The client apologizes and tells the nurse that it will never happen again. D.No aggressive behavior has been observed for 1 hour after the release of two of the extremity restraints.

Correct Answers: D Rationale: The best indicator that the behavior is controlled is the fact that the client exhibits no signs of aggression after partial release of restraints. The remaining options do not ensure that the client has controlled the behavior

The nurse is caring for a client with ulcerative colitis. Which finding does the nurse determine is consistent with this diagnosis? A.Hypercalcemia B.Hypernatremia C.Frothy, fatty stools D.Decreased hemoglobin

Correct Answers: D Rationale: Ulcerative colitis is an inflammatory disease of the large colon. Findings associated with ulcerative colitis include diarrhea with up to 10 to 20 liquid bloody stools per day, weight loss, anorexia, fatigue, increased white blood cell count, increased erythrocyte sedimentation rate, dehydration, hyponatremia, and hypokalemia (not hypercalcemia). Because of the loss of blood, clients with ulcerative colitis commonly have decreased hemoglobin and hematocrit levels. Clients with ulcerative colitis have bloody diarrhea, not steatorrhea (fatty, frothy, foul-smelling stools)

The nurse is caring for a client diagnosed with Alzheimer's disease who is demonstrating characteristics of agnosia. Which client behavior supports the presence of this cognitive deficiency? A.The client has difficulty with balance when rising from the chair. B.The client has lost the cognitive ability to fold their own clothes. C.The client recognizes children but has difficulty calling them by name. D.When asked to pick up the cup, the client consistently fails to identify the cup.

Correct Answers: D Rationale: When illness (Alzheimer's disease) affects the temporal-parietal-occipital association cortex, the client may experience the inability to identify well-known objects and people. This is called agnosia. Ataxia describes altered motor function. The client also may experience difficulty finding the right word to use, called aphasia, and an inability to perform familiar skilled activities, called apraxia.

Which is the priority assessment in the care of a client who is newly admitted to the hospital for acute arterial insufficiency of the left leg and moderate chronic arterial insufficiency of the right leg? A.Monitor oxygen saturation with pulse oximetry. B.Assess activity tolerance before and after exercise. C.Observe the client's cardiac rhythm with telemetry. D.Assess peripheral pulses with an ultrasonic Doppler device.

Correct Answers: D Rationale:Acute arterial insufficiency is associated with interruption of arterial blood flow to an organ, tissue, or extremity. It is associated with an acutely painful pasty-colored leg. The priority is for the nurse to perform a comprehensive assessment of peripheral circulation. When pulses are difficult to palpate, the Doppler device is useful to determine the presence of blood flow to the area. The Doppler directs sound waves toward the artery being examined, which emits an audible sound. The nurse must document that the pulse was present via Doppler and not palpation. Although the remaining options may be components of the assessment, they are not the priority.

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The primary health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube? A.Checking for normal serum electrolyte levels B.Checking for normal pH of the gastric aspirate C.Checking for proper nasogastric tube placement D.Checking for the presence of bowel sounds in all 4 quadrants

Correct Answers: D Rationale:Distention, vomiting, and abdominal pain are a few of the symptoms associated with intestinal obstruction. Nasogastric tubes may be used to remove gas and fluid from the stomach, relieving distention and vomiting. Bowel sounds return to normal as the obstruction is resolved and normal bowel function is restored. Discontinuing the nasogastric tube before normal bowel function may result in a return of the symptoms, necessitating reinsertion of the nasogastric tube. Serum electrolyte levels, pH of the gastric aspirate, and tube placement are important assessments for the client with a nasogastric tube in place but would not assist in determining the readiness for removing the nasogastric tube.

he nurse observes the client's sacrum and notes the following. How will the nurse document this in the client's medical record?A.Deep tissue injuryB.Stage II pressure injuryC.Stage III pressure injuryD.Stage IV pressure injury

Correct Answers: D Rationale:In a stage IV pressure injury, there is full-thickness tissue loss with exposed bone, tendon, or muscle. Eschar or slough may be present in some parts of the wound. In a stage II pressure injury, there is partial-thickness loss of the dermis manifesting as a shallow open ulcer with a pink/red wound bed and no slough. In a stage III pressure injury, there is full-thickness tissue loss with subcutaneous fat visible but no exposure of tendon or muscle, and slough may be present. Deep tissue injury appears as localized areas of purple or maroon discolored intact skin or a blood-filled blister.

The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action? A.Incessant talking and sexual innuendos B.Grandiose delusions and poor concentration C.Outlandish behaviors and inappropriate dress D.Nonstop physical activity and poor nutritional intake

Correct Answers: D Rationale:Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. The client's mood is predominantly elevated, expansive, or irritable. All of the options reflect a client's possible symptoms. However, the correct option clearly presents a problem that compromises physiological integrity and needs to be addressed immediately

The nurse preparing to admit a client with a diagnosis of obsessive-compulsive disorder to the mental health unit would expect to note which behaviors in the client? A.Sad and tearful B.Suspicious and hostile C.Frightened and delusional D.Rigidness in thought and inflexibility

Correct Answers: D Rationale:Rigid and inflexible behaviors are characteristic of the client with obsessive-compulsive disorder (OCD). Clients with this disorder usually are not hostile unless they are prevented from engaging in the obsession or compulsion because this behavior is what decreases the anxiety. None of the other options are associated with OCD.

The community health nurse is visiting a homeless shelter and is assessing the clients in the shelter for the presence of scabies. Which assessment finding would the nurse expect to note if scabies is present? A.Brown-red macules with scales B.Pustules on the trunk of the body C.White patches noted on the elbows and knees D.Multiple straight or wavy thread-like lines underneath the skin

Correct Answers: D Rationale:Scabies can be identified by the multiple straight or wavy thread-like lines beneath the skin. The skin lesions are caused by the female, which burrows beneath the skin to lay its eggs. The eggs hatch in a few days, and the baby mites find their way to the skin surface, where they mate and complete the life cycle. Options 1, 2, and 3 are not characteristics of scabies.

The nurse is monitoring a hospitalized client who abuses alcohol. Which findings would alert the nurse to the potential for alcohol withdrawal delirium? A.Hypotension, ataxia, hunger B.Stupor, lethargy, muscular rigidity C.Hypotension, coarse hand tremors, lethargy D.Hypertension, changes in level of consciousness, hallucinations

Correct Answers: D Rationale:Symptoms associated with alcohol withdrawal delirium typically include anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of consciousness, agitation, fever, and delusions.

The nurse is assessing a client with a history of cardiac valve problems. Where would the nurse place the stethoscope to hear the first heart sound (S1) the loudest? A.Over the second intercostal space at the left sternal border B.Over the fourth intercostal space at the right sternal border C.Over the second intercostal space at the right sternal border D.Over the fifth intercostal space in the left midclavicular line

Correct Answers: D Rationale:The first heart sound (S1) is heard loudest at the lower left sternal border or the apex of the heart. The apex is located at the fifth intercostal space in the left midclavicular line. Therefore, the locations in the remaining options are incorrect.

A client recovering from an exacerbation of left-sided heart failure is experiencing activity intolerance. Which change in vital signs during activity would be the best indicator that the client is tolerating mild exercise? A.Oxygen saturation decreased from 96% to 91%. B.Pulse rate increased from 80 to 104 beats per minute. C.Blood pressure decreased from 140/86 to 112/72 mm Hg. D.Respiratory rate increased from 16 to 19 breaths per minute.

Correct Answers: D Rationale:Vital signs that remain near baseline indicate good cardiac reserve with exercise. Only the respiratory rate remains within the normal range. In addition, it reflects a minimal increase. A pulse rate increase to a rate more than 100 beats per minute during mild exercise does not show tolerance, nor does a decrease of 5 percentage points in oxygen saturation levels. In addition, blood pressure decreasing by more than 10 mm Hg is not a sign indicating tolerance of activity.

The nurse is performing an assessment on a client with a diagnosis of Cushing's syndrome. Which would the nurse expect to note on assessment of the client? A.Skin Atrophy B.The presence of Sunken Eyes C.Drooping on one side of the Face D.A rounded "moonlike" appearance of the face.

Correct Answers: D Rationale:With excessive secretion of adrenocorticotropic hormone (ACTH) and chronic corticosteroid use, the person with Cushing's syndrome develops a rounded moonlike face; prominent jowls; red cheeks; and hirsutism on the upper lip, lower cheek, and chin. The remaining options are not associated with the assessment findings in Cushing's syndrome.

A client is admitted to the hospital with a diagnosis of benign prostatic hyperplasia, and a transurethral resection of the prostate is performed. Four hours after surgery, the nurse takes the client's vital signs and empties the urinary drainage bag. Which assessment finding indicates the need to notify the primary health care provider (PHCP)? A.Red, Bloody Urine B.Pain rated as 4 on a 0 to 10 scale C.Urine out put of 150 ml higher than intake D.Blood Pressure , 100/50 mm Hg; Pulse 130 beats per minute.

Correct Answers: D Rationale: Frank bleeding (arterial or venous) may occur during the first day after surgery. Some hematuria is usual for several days after surgery. A urinary output of 200 mL more than intake is adequate. A client pain rating of 2 on a 0 to 10 scale indicates adequate pain control. A rapid pulse with a low blood pressure is a potential sign of excessive blood loss. The PHCP needs to be notified.

The nurse is performing a respiratory assessment and is auscultating the client's breath sounds. On auscultation, the nurse hears a grating and creaking type of sound. The nurse interprets this to mean that client has which type of sounds? A.Wheezes B.Rhonchi C.Crackles D.Pleural Friction Rub

Correct Answers: D Rationale:A pleural friction rub is characterized by sounds that are described as creaking, groaning, or grating. The sounds are localized over an area of inflammation on the pleura and may be heard in both the inspiratory and the expiratory phases of the respiratory cycle. Wheezes are musical noises heard on inspiration, expiration, or both and are the result of narrowed airway passages. Rhonchi are usually heard on expiration when there is an excessive production of mucus that accumulates in the air passages. Crackles have the sound that is heard when a few strands of hair are rubbed together and indicate fluid in the alveoli.

The nurse is caring for a client admitted for a fractured hip that was sustained from a fall at home. On assessment of the client's affected lower extremity, which signs/symptoms would most likely be noted? A.Shortening and abduction B.Abduction and internal rotation C.Shortening and internal rotation D.Shortening and external rotation

Correct Answers: D Rationale:Signs of a hip fracture include shortening and deformity. The affected leg externally rotates as a result of discontinuation of the femur and loss of alignment and muscle control. The remaining options are not findings associated with a fractured hip.

When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply. A. An irregularly shaped lesion B. A small papule with a dry, rough scale C. A firm, nodular lesion topped with crust D. A pearly papule with a central crater and a waxy border E. Location in the bald spot atop the head that is exposed to outdoor sunlight

Correct Answers: D,E Rationale:Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border. Exposure to ultraviolet sunlight is a major risk factor. A melanoma is an irregularly shaped pigmented papule or plaque with a red-, white-, or blue-toned color. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale. Squamous cell carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration.