HESI Health Assessment

What causes false high diastolic readings?

poor fitting cuff deflating too slowly inflating the cuff too slowly

Cardiac output =

stroke volume x heart rate

BMI =

weight (kg) / height (m^2)

Mini Nutritional Assessment (MNA)

Assessment of Pmts who are 65 years or older who are at risk of becoming malnourished

What do the fingers of a patient with chronic lack of oxygen (ie with heart disease or lung disease) look like?

clubbing

Kausmal Breathing

deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure.

Auscultation at the left fifth ICS at the sternal border for the

tricuspid valve.

NANDA-I Nursing Diagnosis: Components

label, related factors, defining characteristics

Which landmark used to auscultate the tricuspid valve?

at the left fifth ICS at the sternal border for the tricuspid valve.

What do the fingers of a patient with anemia look like?

concave curving of a nail, which is known as koilonychia

crackles

Crackles are abnormal breath sounds described as soft, crackling, bubbling sounds produced by air moving across fluid in the alveoli.

Bruit

A bruit is an audible vascular blowing sound associated with turbulent blood flow through a carotid artery.

Rhonchi breath sounds

Rhonchi are abnormal breath sounds heard over the large airways of the lungs. They consist of a low pitch and are caused by the movement of secretions in the larger airways; they usually clear with coughing.

What causes false high systolic readings

too small of a bp cuff

What are the different types of fevers?

Remittent: temp spikes and falls, while still staying febrile, without a return to normal temp levels Sustained: constant body temp above 38 degrees with little fluctuation Intermittent: fever spikes are interspersed with normal temp levels Relapsing: periods of febrile episodes and periods with acceptable temperature values (often for longer than 24 hours)

A client with a head injury underwent a physical examination. The nurse observes that the client's temperature assessments do not correspond with the client's condition. An injury to which part of the brain may be the reason for this condition? Pons Medulla Thalamus Hypothalamus

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

Describe skin lesions of: - Venous stasis ulcers - Arterial insufficiency - Staphylococcal infection - Herpes Simplex

Venous: characterized by deep loss of skin surface that extends to the dermis and is associated with frequent bleeding. Arterial: The appearance of shiny and translucent skin with loss of normal furrow Staph: the skin lesion is similar to that of vesicle, but is filled with pus instead of serous fluid. Herpes: Circumscribed elevated skin lesions filled with serous fluid smaller than 1 cm are called vesicles.

Thallium Scan

a cardiac stress test using intravenous thallium injection to diagnose ischemia and perfusion

Which suggest pT has heart disease based on color ? 1. Red-face, area of trauma, sacrum, shoulders 2. blue- nail beds, lips, mouth, skin 3.pallor- face, conjunctivae, nail beds, palms of hands 4. yellow/orange- sclera, mucous membranes, skin

client 2 -at risk for heart disease because the nail beds, lips, mouth, and skin show cyanosis or a bluish color, due to an increased amount of deoxygenated hemoglobin, which may be due to heart or lung disease. Client 1- may indicate fever or trauma. client 3- may be due to anemia. client 4 -may be due to jaundice or liver disease.

Cheyne-Stokes respiration

pattern of breathing characterized by a gradual increase of depth and sometimes rate to a maximum level, followed by a decrease, resulting in apnea

Auscultation at the left second ICS at the sternal border is best to hear the

pulmonic valve

Which site should be monitored for a pulse to assess the status of circulation to the foot?

Dorsalis pedis artery Posterior tibial artery

A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful? 1 Clear breath sounds 2 Positive pedal pulses 3 Normal potassium level 4 Decreased urine specific gravity

1 Excess fluid can move into the lungs, causing crackles; clear breath sounds support that treatment was effective. Although it may make palpation more difficult, excess fluid will not diminish pedal pulses. A normal potassium level can be maintained independently of fluid excess correction. As the client excretes excess fluid, the urine specific gravity will increase, not decrease.

While assessing the eyes of a client, a healthcare provider notices there is an obstruction to the outflow of aqueous humor. Which additional finding might be noted to support a diagnosis of glaucoma? 1 Blurred central vision 2 Increased opacity of the lens 3 Elevated intraocular pressure 4 Changes in retinal blood vessels

3 In glaucoma, there is an obstruction of the outflow of aqueous humor due to an intraocular structural damage, which may result from elevated intraocular pressure. - Blurred central vision is seen in macular degeneration. - Increased opacity of the lens may be seen in cataracts. - Retinopathy may result from the changes in retinal blood vessels.

While assessing a client who experienced an accident, the nurse found that the client is unable to move eyelids laterally. Which nerve damage led to this condition in the client? Optic nerve Facial nerve Abducens nerve Oculomotor nerve

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

lordosis

excessive inward curvature of the lumbar spine

Breathing sounds of Inflamed Pleura

The breathing sounds in a pleural rub or an inflamed pleura are of a dry or grating quality that is heard in the lower portion of the anterior lateral lung High-pitched, continuous musical sounds heard all over the lung are wheezing breath sounds heard when there is a high-velocity airflow through severely narrowed or an obstructed airway. Loud, low-pitched, rumbling coarse sounds heard in the trachea and bronchi are rhonchi, which are observed during muscular spasm or when fluid or mucus is present the in larger airways. Fine crackles, medium crackles, and coarse crackles are heard in lung bases due to random and sudden reinflation of groups of alveoli, which causes a disruptive passage of air through the small airways.

The community nurse is assessing an elderly client who lives alone at home. the client refrains from physical activity for fear of falling when walking. Which interventions by the nurse are most beneficial to promote a healthy lifestyle?

Encourage the client to wear nonskid shoes. Suggest that the client use an assistive device. Help the client rearrange furniture in the house.

Which landmark is correct to use when auscultating the pulmonic valve?

left second intercostal space at sternal border

If the skin is blue (cyanosis is occurring), what is the most likely cause? 1 Heart disease 2 Anemia

heart disease; anemia skin would have pallor

A nursing student under the supervision of a registered nurse is performing a pulse assessment. While preparing to assess the client, the registered nurse asks the nursing student to check the apical pulse after assessing the radial pulse. What could be the reason behind for this change? 1 The client may have a dysrhythmia 2 The client may have physiologic shock 3 The client underwent surgery earlier in the day 4 The client may have peripheral artery disease

1 A client with dysrhythmia may have an intermittent or abnormal radial pulse. For this condition, the registered nurse should advise the nursing student to assess the apical pulse because it will be more accurate. If the client is in shock, then assessing the carotid or femoral pulse would be appropriate. The femoral pulse is preferred to assess a client with peripheral artery disease.

A nurse is assessing a client who was admitted with a head injury that occurred 4 days ago and is diagnosed with an injury to the speech center in the cerebral cortex. Upon further assessment, the nurse finds that the client is unable to understand written or verbal speech. Which condition does the nurse suspect? 1 Aphasia 2 Dysarthria 3 Borborygmi 4 Tactile fremitus

1 Aphasia of the receptive type is a condition in which the client cannot understand written or verbal speech. This may be due to injury to the cerebral cortex. Dysarthria is a motor speech disorder in which the client has difficulty speaking caused by impairment of the muscles used in speech. Borborygmi are rumbling noises made by the movement of fluid and gas in the intestine. Tactile fremitus is the vibration created during speech by the vocal cords when sound is transmitted through the lung to the chest wall.

A client suspected to have a prostate disorder is encouraged to have a rectal examination. What position of the client will facilitate a rectal examination by the registered nurse (RN)? 1 Sims position 2 Prone position 3 Dorsal recumbent position 4 Lateral recumbent position

1 In Sims position, hips and knees are flexed, which results in exposure of the rectal area. Therefore Sims position is most suitable for performing rectal examinations. A prone position helps in assessing extension of hips, skin, and buttocks. The dorsal recumbent position is predominantly indicated for abdominal assessment because it promotes abdominal muscle relaxation. The lateral recumbent position is indicated for detecting heart murmurs.

The nurse is assessing a client who reports breathlessness. Which activity best ensures that the nurse obtains accurate and complete data to prevent a nursing diagnostic error? 1 Assess the client's lungs. 2 Assess the client for pain. 3 Obtain details of smoking habits. 4 Ask about the onset of breathlessness.

1 The nurse should assess the client's lungs to gather **objective data** that will support subjective data provided by the client. The nurse can obtain objective data for this client by auscultating for lung sounds, assessing the respiratory rate, and measuring the client's chest excursion. The nurse should review the data for accuracy and completeness before grouping the data into clusters. The nurse may also assess the client for pain, which is subjective data. The client may provide details about smoking habits, which is also subjective data. It is important for the nurse to identify what causes breathlessness; however, the client's statement is subjective data. All subjective data must be supported by measurable objective data.

A client with a history of cardiac dysrhythmias is admitted to the hospital due to a fluid volume deficit caused by a pulmonary infection. The registered nurse is assessing the vital signs recorded by the student nurse. Which vital sign assessments require reassessment based on the data given by the student nurse? Select all that apply. 1 Respiratory rate of 14 breaths/minute 2 Blood pressure of 120/80 mmHg 3 Oxygen saturation of 95% 4 Temporal temperature of 37.4 °C 5 Radial pulse rate of 72 and irregular

1,2,3 In pulmonary infections, the respiratory rate may increase and oxygen saturation may decrease. In fluid volume deficit, the blood pressure may be decreased. A respiratory rate of 14 breaths/minute, a blood pressure of 120/80 mmHg, and an oxygen saturation of 95% are normal readings. Therefore, the registered nurse should reassess these vital signs. The normal temperature range is 36 to 38 0C; this range is unaffected by a pulmonary infection. Therefore, the nurse does not need to reassess the temperature. Cardiac dysrhythmias are associated with a pulse deficit in which the radial pulse would be irregular. Therefore reassessment would not be required.

A nurse assesses the vital signs of a 50-year-old female client and documents the results. Which of the following are considered within normal range for this client? Select all that apply. 1 Oral temperature of 98.2° F (36.8° C) 2 Apical pulse of 88 beats per minute and regular 3 Respiratory rate of 30 per minute 4 Blood pressure of 116/78 mm Hg while in a sitting position 5 Oxygen saturation of 92%

1,2,4 The client's temperature, pulse, and blood pressure are within normal ranges for a 50-year-old female. The client's respirations are mildly elevated, and the oxygen saturation level is below normal. A normal respiratory rate for a female client in this age group would be 12 to 20 per minute, and oxygen saturation level should be 95%.

A nurse is teaching a client about measures to promote health. Which statements made by the client indicate effective learning? Select all that apply. 1 "I will assess my own pulse rate after exercising." 2 "I will follow my hypertension treatment plan consistently." 3 "I will recalibrate my aneroid sphygmomanometer once a year." 4 "I will perform a self-assessment of my heart rate using the carotid pulse." 5 "I will ask my caretaker to check my blood pressure at a different time every day."

1,2,4 Assessing the pulse rate after exercising is helpful in knowing the impact of exercise on the pulse rate. Following the hypertension treatment plan consistently will help the client stay healthy. Performing a heart rate self-assessment using the carotid pulse is also effective in promoting health. This action will also help the client to know if there are any abnormalities related to the pulse rate. An aneroid sphygmomanometer is a sophisticated device that requires recalibration more than once a year. Blood pressure should be measured at the same time every day for accurate results.

A nurse is caring for an older adult with a hearing loss secondary to aging. What can the nurse expect to identify when assessing this client? Select all that apply. 1 Dry cerumen 2 Tears in the tympanic membrane 3 Difficulty hearing high pitched voices 4 Decrease of hair in the auditory canal 5 Overgrowth of the epithelial auditory lining

1,3 Cerumen (ear wax) becomes drier and harder as a person ages. Generally, female voices have a higher pitch than male voices; older adults with presbycusis (hearing loss caused by the aging process) have more difficulty hearing higher pitched sounds. There is no greater incidence of tympanic tears caused by the aging process. The hair in the auditory canal increases, not decreases. The epithelium of the lining of the ear becomes thinner and drier.

A registered nurse instructed the nursing assistive personnel (NAP) to measure the temperature of a client who reports chills and coldness. The nurse believes that the reading is inaccurate. What observations may have led to this conclusion? Select all that apply. 1 The client has a habit of breathing through his or her mouth. 2 The client smoked 40 minutes after his or her temperature was taken. 3 The client ingested juice 30 minutes before his or her temperature was taken. 4 The client ingested food 20 minutes after having his or her temperature was taken. 5 The client ingested medications 10 minutes after having his or her temperature was taken.

1,3 Habitual mouth breathing may result in inaccurate temperature readings. A client who ingested any fluids or food orally or smoke should wait for 20 to 30 minutes his or her temperature was taken. Smoking, ingesting foods, or ingesting mediations after a temperature measurement will not give any false readings.

While assessing a client's hair, a nurse notices that the client has head lice. The nurse teaches the client about hair hygiene and lice control. Which statements made by the client indicates an understanding of the teaching? Select all that apply. 1 "I will clean my comb in ammonia water." 2 "I should use lindane-containing shampoo." 3 "I should shampoo my hair in a tub or shower." 4 "I should use a dilute vinegar solution to loosen the nits." 5 "I should use a shampoo treatment once every 24 hours."

1,4,5 Lindane may be used to treat lice and scabies, but it may cause serious side effects. Clients with lice are instructed not to wash their hair in a tub or shower because this action may cause the lice to migrate to other sites. Ammonia water should be used to clean combs and other hair accessories to enhance lice control. Nits are loosened by the use of dilute vinegar solution. Shampooing should be continued once every 24 to 48 hours.

A registered nurse notices that a student nurse who is assessing the blood pressure in a client is deflating the cuff too rapidly. What is the probable reading of blood pressure that the student nurse could have obtained if the actual blood pressure of the client is 140/90 mm Hg?

130/100 mm Hg Deflating the cuff too quickly will result in false low systolic and false high diastolic readings. Therefore the client's systolic readings decreased to 130 mm Hg while the diastolic readings increased to 100 mm Hg. If the bladder or cuff is too wide, it results in false low readings in the client, as in the blood pressure of 130/80 mm Hg. If the bladder or cuff is too narrow or too short or if the cuff is wrapped too loosely or unevenly, the result is a false high, as in the blood pressure of 150/100 mm Hg. Deflating the cuff too slowly results in false high diastolic readings, such as the blood pressure of 140/100 mm Hg.

While assessing the nails of a client with diabetes, the nurse finds that the skin on the client's hands and feet are dry due to infection. What could be the reason for this dryness? 1 Applying moisturizing lotion between toes 2 Cutting nails after soaking them for 10 minutes in warm water 3 Cutting nails straight across and even with the tops of the fingers or toes 4 Using sharp objects to poke or dig under the toenail or around the cuticle

2 Normally, nails should be cut after soaking them in warm water for 10 minutes. This action should not be performed for diabetic patients because soaking the nails will dry out the hands and feet, which may lead to infection. Applying moisturizing lotion between the toes will promote microorganism growth; it will not dry the skin. Cutting nails straight across and even with the tops of the fingers or toes is the proper way to maintain nail hygiene. Diabetic clients are advised not to use sharp objects to poke or dig under the toenails or around the cuticles to avoid injury to the skin.

A registered nurse is teaching a nursing student about the third heart sound (S 3). Which statement given by the nursing student indicates a need for further education? 1 "S 3 is heard in clients with heart failure." 2 "S 3 is normal in pregnant women." 3 "S 3 is abnormal in adults over 30 years of age." 4 "S 3 is normal in children and young adults."

2 The third heart sound (S 3) can be heard when the heart attempts to fill an already distended ventricle. This sound may be common and normal in the last stages of pregnancy, but not in all stages. This sound may be heard in heart failure clients. The S 3 sound is abnormal in adults over the age of 30. This sound is normally heard in children and young adults.

The community nurse is assessing an elderly client who lives alone at home. The nurse finds that the client refrains from physical activity for fear of falling when walking. Which interventions by the nurse are most beneficial to promote a healthy lifestyle? Select all that apply. 1 Instruct the client to apply bed side rails. 2 Encourage the client to wear nonskid shoes. 3 Suggest that the client use an assistive device. 4 Ask the client to install hand rails in the bathroom. 5 Help the client rearrange furniture in the house.

2,3,5 Why not 1,4? The bed side rails protect the client from falling from the bed. The hand rails in the bathroom assist provide support while using the bathroom.

A client with severe bleeding due to a motor vehicle accident was admitted to the emergency department. The nurse assessed that the client was unconscious and the healthcare provider diagnosed the client with a hand fracture. The client is receiving oxygen therapy as well as intravenous fluids through the antecubital fossa. Which sites should be used to obtain the client's pulse rate? Select all that apply. 1 Apical 2 Carotid 3 Brachial 4 Femoral 5 Popliteal

2,4 Clients with severe bleeding may develop hypovolemic shock. The carotid and femoral pulses are easily accessible sites to measure pulses in clients with hypovolemic shock. The apical pulse may not be palpable in a client with hypovolemic shock. Because the client is diagnosed with a hand fracture and is receiving intravenous fluids through the antecubital fossa, the brachial artery cannot be accessed to measure the pulse rate. The popliteal site is used to assess the status of the circulation in the lower leg.

While assessing a pediatric client, an ophthalmologist notices that the child is unable to focus on an object with both eyes simultaneously. Which other findings in the client confirms the diagnosis as strabismus? Select all that apply. 1 Impaired near vision 2 Crossed appearance of eyes 3 Elevated intraocular pressure 4 Impaired extraocular muscles 5 Degeneration of central retina

2,4 Strabismus is a congenital condition in which both eyes do not focus on an object simultaneously, resulting in a crossed appearance of the eyes. This condition is caused by impaired extraocular muscles. Impaired near vision is associated with hyperopia or presbyopia. Elevated intraocular pressure results in glaucoma. Macular degeneration is caused by degeneration of the central retina.

The triage nurse in the emergency department receives four clients simultaneously. Which of the clients should the nurse determine can be treated last? 1 Multipara in active labor 2 Middle-aged woman with substernal chest pain 3 Older adult male with a partially amputated finger 4 Adolescent boy with an oxygen saturation of 91%

3 Although a client with a partially amputated finger needs control of bleeding, the injury is not life threatening, and the client can wait for care. A woman in active labor should be assessed immediately, because birth may be imminent. A woman with chest pain may be experiencing a life-threatening illness and should be assessed immediately. An adolescent with significant hypoxia may be experiencing a life-threatening illness and should be assessed immediately.

A senior high school student, whose immunization status is current, asks the school nurse which immunizations will be included in the precollege physical. Which vaccine should the nurse tell the student to expect to receive? 1 Hepatitis C (HepC) 2 Influenza type B (HIB) 3 Measles, mumps, rubella (MMR) 4 Diphtheria, tetanus, pertussis (DTaP)

3 Individuals born after 1956 should receive one additional dose of MMR vaccine if they are students in postsecondary educational institutions. Currently there is no vaccine for hepatitis C. The HIB immunization is unnecessary. If the student received an additional DTaP at age 12, it is not necessary. A booster dose of tetanus toxoid (Td) should be received every 10 years.

After recovery from a modified neck dissection for oropharyngeal cancer, the client receives external radiation to the operative site. For which most critical reaction to the radiation should the nurse assess the client? 1 Dry mouth 2 Skin reactions 3 Mucosal edema 4 Bone marrow suppression

3 The mucosal lining of the oral cavity, oropharynx, and esophagus is sensitive to the effects of radiation therapy; the inflammatory response causes mucosal edema that may progress to an airway obstruction. A decrease in salivary secretions resulting in dry mouth may interfere with nutritional intake, but it is not life threatening. Erythema of the skin may cause dry or wet desquamation, but it is not life threatening. Radiation to the neck area should not produce as significant bone marrow suppression as radiation to the other sites.

A nurse is assigned to care for a newly admitted client. The nurse performs a physical assessment and reviews the admission form and the primary healthcare provider's prescriptions which says the pt has the following: 56 y/o male, hx of emphysema, terminally ill with esphageal cancer, soft diet, oxygen at 2LPM, Posural drainage 2x daily, weak, anorexic, dyspneic, emaciated. What should the nurse identify as the priorities in this client's plan of care? 1 Intake and output 2 Diet and nutrition 3 Hygiene and comfort 4 Body mechanics and posture

3 Because the client's condition is terminal, the nursing priority should be directed toward providing basic care and comfort. Although intake and output, diet and nutrition, and body mechanics and posture are important aspects of nursing care, provision of comfort is the priority when caring for a dying client.

A nurse is caring for a client who underwent cardiac catheterization. The client's skin was found to be blanched, and there was formation of edema of 15.2 cm (1-6 inches) at the site of catheterization. Upon further assessment, the skin was found to be cool, and the client complains of tenderness. Which condition does the nurse expect? 1 Phlebitis 2 Infection 3 Infiltration 4 Circulatory overload

3 The client with blanched skin, edema of 15.2 cm, cool temperature, and pain at the site of catheterization has symptoms of grade 2 infiltration. Phlebitis is an inflammation of the inner layer of the vein. The findings for this include redness, tenderness, pain, and warmth along the course of the vein starting at the access site. If there is infection, there will be findings that include redness, heat, swelling at catheter-skin entry point, and possible purulent drainage. Circulatory overload can occur if intravenous solutions are infused too rapidly or in great amounts.

A 50-year-old client with a 30-year history of smoking reports a chronic cough and shortness of breath related to chronic obstructive pulmonary disease (COPD). The clinical data on admission are as follows: a heart rate of 100, a blood pressure of 138/82, a respiratory rate of 32, a tympanic temperature 36.8 °C, and an oxygen saturation of 80%. Which vital signs obtained by the nurse during the therapy indicates a positive outcome? Select all that apply. 1 Radial pulse: 70 2 Temperature: 37 °C 3 Respiratory rate: 14 4 Blood pressure: 110/70 5 Oxygen saturation: 96%

3,4,5 Why not 1&2? The radial pulse indicates a positive outcome of the therapy if the client has a history of heart disease. A body temperature reading of 36.8 °C is considered normal and not a sign of COPD.

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency? Select all that apply. 1 Diplopia 2 Skin rash 3 Leg cramps 4 Tachycardia 5 Muscle weakness

3,5 Leg cramps occur with hypokalemia because of potassium deficit. Muscle weakness occurs with hypokalemia because of the alteration in the sodium potassium pump mechanism. Diplopia does not indicate an electrolyte deficit. A skin rash does not indicate an electrolyte deficit. Tachycardia is not associated with hypokalemia; bradycardia is.

While conducting an assessment, the nurse finds that the client shivers uncontrollably and experiences memory loss, depression, and poor judgment. What might the client's body temperature be? 29° C 33° C 36° C 38° C

33 C Explain:A body temperature in the range of 36° to 38 ° C is normal. When skin temperature drops below 35° C, the client may exhibit uncontrolled shivering, loss of memory, depression, and poor judgment as a result of hypothermia. A body temperature lower than 30° C represents severe hyperthermia. In this condition, the client will demonstrate a lack of response to stimuli and extremely slow respiration and pulse. Based on the signs given, the client's temperature is most likely 33° C.

While assessing an immobilized client, the nurse notes that the client has shortened muscles over a joint, preventing full extension. What is this condition known as? 1 Osteoarthritis 2 Osteoporosis 3 Muscle atrophy 4 Contracture

4 Immobilized clients are at high risk for the development of contractures. Contractures are characterized by permanent shortening of the muscle covering a joint. Osteoarthritis is a disease process of the weight-bearing joints caused by wear and tear. Osteoporosis is a metabolic disease process in which the bones lose calcium. Muscle atrophy is a wasting and/or decrease in the strength and size of muscles because of a lack of physical activity or a neurologic or musculoskeletal disorder.

Which diagnosis made by the nurse is helpful in providing the right nursing interventions for the client? 1 The nurse understands that the client has pain due to a tracheostomy. 2 The nurse identifies that the client is anxious about the cardiac catheterization. 3 The nurse realizes that the client has diarrhea and needs the bedpan frequently. 4 The nurse identifies that the client is not aware of perineal care and has impaired skin integrity.

4 The nurse observes that the client has impaired skin integrity due to lack of knowledge about perineal care. The nurse identifies the need for educating the client about perineal care. This nursing diagnosis is correct as it will help enhance the client's health outcomes. The nursing diagnosis should identify the problem caused by a treatment such as tracheostomy, not the treatment itself. A tracheostomy is a medical condition and should not be included in the nursing diagnosis. This client is likely to have pain following the trauma of the surgical incision. The nursing diagnosis should contain the client's response to the medical procedure rather than the medical procedure itself. The client is probably anxious due to lack of knowledge about the need for cardiac catheterization or the outcome of the procedure rather than the catheterization itself. A correct diagnosis helps the nurse put the client at ease by providing necessary teaching. The nurse should plan nursing interventions after identifying the client's problem. Therefore, the nurse should identify that the client has diarrhea due to food intolerance. This helps the nurse select appropriate interventions rather than just one intervention of offering bedpan.

Which client needs immediate nursing interventions? A. age 70-pulmonary infection- RR=28 bpm, O2 sat= 70% B.age 50-fractured hand- RR= 14 bpm, BP= 140/86 C. age 60- COPD- RR-20- O2 sat= 90 bpm D. age 45- breast cancer- RR-16 BP=128/62

Client A Client A has a respiratory rate of 28 breaths/min, which indicates tachypnea, a common manifestation of pulmonary disorders. An SpO 2 of 70% indicates low oxygen saturation. These findings in the client indicate highly unstable vitals; therefore client A needs immediate intervention. Client B indicates slightly unstable vitals, but these do not require immediate intervention when compared to client A. Client C and client D's vital signs are within the normal range.

A nursing student has prepared pulse assessment plans for several clients. Which client's assessment plan is correct and will yield effective results? Client A- ulnar- ulnar side of forearm at wrist- cardiac arrest when other sites are not palpable Client B- coratid- along medial edge of sternocleidomastoid muscle in neck- presence of ulnar blood flow Client C- dorsalis pedis- along top of foot- status of circulation to foot Client D- posterior tibial- above the medial malleolus- status of circulation to foot

Client C The dorsalis pedis is located along the top of the foot. This site is used to assess the status of circulation in the foot. The ulnar site, found on the ulnar side of the forearm at the wrist, is used to assess the status of circulation to the hand and to perform the Allen test. The carotid site is found along the medial edge of the sternocleidomastoid muscle of the neck. It is easily accessible in times of physiological shock or cardiac arrest when other sites are not palpable. The posterior tibial site is found below (not above) the medial malleolus. It is used to assess the status of circulation in the foot.

While assessing a 7-month-old infant, the nurse advises the mother to avoid regular cow's milk. Which of these are valid reasons for the suggestion? Select all that apply. Cow's milk is not tolerated by infants. Cow's milk is a potential source of botulism toxin. Cow's milk increases the risk of milk product allergies. Cow's milk is a poor source of iron and vitamins C and E. Cow's milk is too concentrated for an infant's kidneys to manage.

Cow's milk increases the risk of milk product allergies. Cow's milk is a poor source of iron and vitamins C and E Cow's milk is too concentrated for an infant's kidneys to manage Regular cow's milk is avoided in infants during the first year of life because it is too concentrated for an infant's kidneys to manage. It also increases the risk of milk product allergies and is also a poor source of iron and vitamins C and E. Honey and corn syrup are potential sources of botulism toxin. Most infants are not allergic to or intolerant of cow's milk.

The nurse is caring for a client with a family history of diabetes mellitus. The client has been following a diet regimen recommended by the dietician and walking for 45 minutes daily for the past eight months. How should the nurse document the client's stage based on the transtheoretical model of health behavior change? Action Preparation Maintenance Contemplation

The client is in the maintenance stage of human behavior change. During this stage, the client has managed to incorporate the changes in to the lifestyle. This stage begins six months after the action has started and continues indefinitely. The action stage lasts for six months from the time the client has incorporated the changes in to the lifestyle. During the preparation stage, the client begins to realize that the advantages of the change outweigh the disadvantages. The client starts making small changes in preparation for major changes the following month. During the contemplation stage, the client is still considering whether to incorporate changes in the next six months.

A nurse is assessing a client during a regular checkup. The client complains of a moderate decrease in food intake over the past 3 weeks, a 4-kilogram weight loss, and a decrease in mobility. The client had a bout of acute bronchitis 1 month ago and has recently been diagnosed with mild dementia. The body mass index of the client is 21. What is the total score of the client according to the mini nutritional assessment (MNA)? Record your answer as a whole number. ___________

The mini nutritional assessment (MNA) is a tool used to identify malnutrition. It measures the nutritional status and assigns a numerical score for each of the questionnaire areas. The score for a moderate decrease of food intake over the past 3 weeks is 1. The score assigned for a weight loss of 4 kg is 0. A score of 1 is assigned for the decrease in mobility (chair or bed bound). The score for a history of acute bronchitis is 0. A score of 1 is assigned to mild dementia, and a score of 2 is assigned to a body mass index of 21. Therefore, the total score of the client according to the MNA is 5.

What causes false low diastolic readings?

poor fitting cuff deflating cuff too quickly applying the stethoscope too firmly against the antecubital fossa

When teaching about aging, the nurse explains that older adults usually have what characteristic? Inflexible attitudes Periods of confusion Slower reaction times Some senile dementia

slower rxn times

convert 109 F to C

Fahrenheit is converted to Celsius by subtracting 32 from the Fahrenheit reading and multiplying the obtained value by 5/9. C = (F - 32)(5/9) C = (109 - 32)(5/9) C = 42.8

A nurse is teaching a client about different prevention and detection practices to ensure breast health. Which statement made by the client indicates the need for further teaching? 1 "I will increase my meat consumption." 2 "I will perform a self-breast examination every week." 3 "I will schedule routine mammograms." 4 "I will reduce my caffeine and theophylline intake."

1 Meat consumption should be reduced to prevent breast cancer; a high meat consumption may lead to obesity, which is a risk factor for breast cancer. Performing self-breast examinations is an effective way to feel changes or any abnormal growth in the breast. The client should undergo mammograms regularly to check for early signs and abnormalities of the breast. Although the approach of reduced intake of caffeine and theophylline is controversial, these actions may reduce the symptoms of benign breast disease.

What type of interview is most appropriate when a nurse admits a client to a clinic? 1 Directive 2 Exploratory 3 Problem solving 4 Information giving

1 The first step in the problem-solving process is data collection so that client needs can be identified. During the initial interview a direct approach obtains specific information, such as allergies, current medications, and health history. The exploratory approach is too broad, because in a nondirective interview the client controls the subject matter. Problem solving and information giving are premature at the initial visit.

The nurse is assessing a client following abdominal surgery. Which assessment findings should the nurse use to form a data cluster? Select all that apply. 1 The client reports pain with movement. 2 The client has pain over the surgical area. 3 The client wants to know when he can go home. 4 The client rates the pain as 8 on a scale of 0 to 10. 5 The client has concerns about caring for the wound.

1,2,4 The nurse groups all information that contains a defining characteristic such as pain. The nurse clusters all assessments related to pain. The client reports pain with movement. The clinical criteria are observable and verifiable. The nurse learns that the pain is over the surgical area and not an underlying pain. The nurse verifies and measures the data by rating the pain as 8 on a scale of 0 to 10. The client wants to know when he can go home, but this assessment is not related to the pain. The client is also worried about caring for the wound, but this assessment will belong to a different cluster.

An older adult client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which nursing actions have specific gerontologic implications the nurse must consider? Select all that apply. 1 Assessment of skin turgor 2 Documentation of vital signs 3 Assessment of intake and output 4 Administration of antiemetic drugs 5 Replacement of fluid and electrolytes

1,4,5 When skin turgor is assessed, the presence of tenting may be related to loss of subcutaneous tissue associated with aging rather than to dehydration; skin over the sternum should be used instead of skin on the arm for checking turgor. Older adults are susceptible to central nervous system side effects, such as confusion, associated with antiemetic drugs; dosages must be reduced, and responses must be evaluated closely. Because many older adults have delicate fluid balance and may have cardiac and renal disease, replacement of fluid and electrolytes may result in adverse consequences, such as hypervolemia, pulmonary edema, and electrolyte imbalance. Vital signs can be obtained as with any other adult. Intake and output can be measured accurately in older adults.

A client reports vomiting and diarrhea for 3 days. Which clinical indicator is most commonly used to determine whether the client has a fluid deficit? 1 Presence of dry skin 2 Loss of body weight 3 Decrease in blood pressure 4 Altered general appearance

2 Dehydration is measured most readily and accurately by serial assessments of body weight; 1 L of fluid weighs 2.2 lb (1 kg). Although dry skin may be associated with dehydration, it also is associated with aging and some disorders (e.g., hypothyroidism). Although hypovolemia eventually will result in a decrease in blood pressure, it is not an accurate, reliable measure because there are many other causes of hypotension. Altered appearance is too general and not an objective determination of fluid volume deficit.

A client who is suspected of having tetanus asks a nurse about immunizations against tetanus. Before responding, what should the nurse consider about the benefits of tetanus antitoxin? 1 It stimulates plasma cells directly. 2 A high titer of antibodies is generated. 3 It provides immediate active immunity. 4 A long-lasting passive immunity is produced.

2 Tetanus antitoxin provides antibodies, which confer immediate passive immunity. Antitoxin does not stimulate production of antibodies. It provides passive, not active, immunity. Passive immunity, by definition, is not long-lasting.

The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply. 1 Dyspnea 2 Flushed face 3 Precordial pain 4 Increased pulse rate 5 Increased blood pressure

2,4 Increased body heat dilates blood vessels, causing a flushed face. The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may not cause difficult breathing. Pain is not related to fever. Blood pressure is not expected to increase with fever.

Which age-related change should the nurse consider when formulating a plan of care for an older adult? Select all that apply. 1 Difficulty in swallowing 2 Increased sensitivity to heat 3 Increased sensitivity to glare 4 Diminished sensation of pain 5 Heightened response to stimuli

3,4 Changes in the ciliary muscles, decrease in pupil size, and a more rigid pupil sphincter contribute to an increased sensitivity to glare. Diminished sensation of pain may make an older adult unaware of a serious illness, thermal extremes, or excessive pressure. There should be no interference with swallowing in older adults. Older adults tend to feel the cold and rarely complain of the heat. There is a decreased response to stimuli in older adults.

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply. 1 Tetany 2 Seizures 3 Diarrhea 4 Weakness 5 Dysrhythmias

3,4,5 Because of potassium's role in the sodium/potassium pump, hyperkalemia will cause diarrhea, weakness, and cardiac dysrhythmias. Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are associated with low calcium or sodium levels.

What clinical finding indicates to the nurse that a client may have hypokalemia? 1 Edema 2 Muscle spasms 3 Kussmaul breathing 4 Abdominal distention

4 Hypokalemia diminishes the magnitude of the neuronal and muscle cell resting potentials. Abdominal distention results from flaccidity of intestinal and abdominal musculature. Edema is a sign of sodium excess. Muscle spasms are a sign of hypocalcemia. Kussmaul breathing is a sign of metabolic acidosis.

While performing a physical assessment of a client, a nurse notices patchy areas with loss of pigmentation on the skin, hands, and arms. What is the probable etiology for this condition? 1 Anemia 2 Pregnancy 3 Lung disease 4 Autoimmune disease

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

A nurse is teaching a male client about measures to maintain sexual health and prevent transmission of sexually transmitted infections (STI). Which statement of the client indicates effective learning? 1 "I will use condoms when having sex with an infected partner." 2 "I will perform a genital self-examination every month before bathing." 3 "I will refrain from getting the human papilloma virus vaccine (HPV) before the age of 27 years." 4 "I will consult with my primary healthcare provider when there is a rash or ulcer on my genitalia."

4 The client should consult a primary healthcare provider when there is a rash or ulcer on genitalia because these are the warning signs of a sexually transmitted infection (STI). Having sex with an infected partner with or without using condoms may increase the risk of contracting an STI. A male client should perform a genital self-examination every month after taking a bath, when the scrotal skin is less thick. The human papilloma virus vaccine (HPV) vaccine should be taken between 9 and 26 years of age.

Which client is at an increased risk for right-sided heart failure? Client A: R Jugular Venous Pressure: 2.5 cm L Jugular Venous Pressure: 3.0 cm Client B: RJVP = 2.0 LJVP = 1.5 Client C: RJVP = 1.5 LJVP = 1.0

Client A Bilateral pressures higher than 2.5 cm are considered elevated and are a sign of right-sided heart failure. Client A has both right and left jugular venous pressure above 2.5 cm. Therefore this client is at risk for right-sided heart failure. why not B/C: One-sided pressure elevation is caused by obstruction, as observed in clients B, C

Glascow Coma Scale (GCS)

Neurologic assessment of a patient's best verbal response, eye opening, and motor function. 3=lowest score 15=highest score 8=coma Pt 4-scale for eye opening 5- scale verbal response 6- scale best motor response

Which features distinguish nursing diagnoses from medical diagnoses? Select all that apply. 1 Nursing diagnoses involve the client when possible. 2 Nursing diagnoses are based on results of diagnostic tests and procedures. 3 Nursing diagnoses are the identification of a disease condition in the client. 4 Nursing diagnoses involve the sorting of health problems within the nursing domain. 5 Nursing diagnoses involve clinical judgment about the client's response to health problems.

Nursing diagnoses involve (client participation) the client when possible. Nursing diagnoses involve the sorting of health problems within the nursing domain. Nursing diagnoses involve clinical judgment about the client's response to health problems. WRONG ANSWER: Nursing diagnoses are based on results of diagnostic tests and procedures. WRONG ANSWER: Nursing diagnoses are the identification of a disease condition in the client.

How is the strength of a pulse measured?

The strength of a pulse is a measurement of the force at which blood is ejected against the arterial wall. 0 indicates an absent pulse 1+ indicates a diminished pulse that is barely palpable 2+ rating is an expected or normal pulse 3+ rating indicates a full increased pulse 4+ rating is a bounding pulse

While assessing a client's skin, a nurse notices that the skin is dry. What is the probable etiology of the condition? Select all that apply.

The use of hard soap and frequent bathing may result in dry skin. A skin allergy may result in skin rashes, but not dry skin. Using tanning pills and petroleum products may result in skin cancer.

Pressure Ulcers and stages

stage I pressure ulcer- an area of persistent redness with no break in skin integrity. stage II pressure ulcer-partial-thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater stage III pressure ulcer- full-thickness tissue loss with visible subcutaneous fat. Bone, tendon, and muscle are not exposed. stage IV- full thickness tissue loss with exposed bone, tendon, muscle, bone (slough or eschar may be present within wound bed) unstageable- contains necrotic tissue, necrotic tissue must be removed before the wound can be staged.

What clinical finding indicates to the nurse that a client may have hypokalemia? Edema Muscle spasms Kussmaul breathing Abdominal distention

Ab distortional Hypokalemia diminishes the magnitude of the neuronal and muscle cell resting potentials. Abdominal distention results from flaccidity of intestinal and abdominal musculature. Edema is a sign of sodium excess. Muscle spasms are a sign of hypocalcemia. Kussmaul breathing is a sign of metabolic acidosis.

The nurse recognizes that which are important components of a neurovascular assessment? Select all that apply. Orientation Capillary refill Pupillary response Respiratory rate Pulse and skin temperature Movement and sensation

Capillary refill pulse and skin temp movement and sensation Explain: A neurovascular assessment involves evaluation of nerve and blood supply to an extremity involved in an injury. The area involved may include an orthopedic or soft tissue injury. A correct neurovascular assessment should include evaluation of capillary refill, pulses, warmth and paresthesias, and movement and sensation. Orientation, pupillary response, and respiratory rate are components of a neurologic assessment.

While assessing a client, the nurse finds inflammation of the skin at the bases of the client's nails. What might be the reason behind this condition? Trauma Trichinosis Pulmonary disease Iron-deficiency anemia

Trauma explain: Paronychia is an abnormality of the nail bed. The condition is marked by inflammation of the skin at the base of the nail; this condition may be caused by trauma or a local infection. Trichinosis is associated with red or brown linear streaks in the nail bed. Pulmonary diseases can cause changes in the angle between nail and nail base, which is a phenomenon known as clubbing. Koilonychia, a concave curvature of the nails, may occur as a result of iron-deficiency anemia.

A client with a recent history of head trauma is at risk for orthostatic hypotension. Which assessment findings observed by the nurse would relate to this diagnosis? Select all that apply. Fainting Headache Weakness Lightheadedness Shortness of breath

fainting, weakness, lightheadedness explain: shortness of breath and headaches are symptoms of hypertension

The Glascow Coma Scale (GCS) A client is admitted to the hospital after an accident. The nurse uses the Glasgow Coma Scale (GCS) with the client. The client is alert and opens his or her eyes when there is a sound or when someone talks. When questions are asked, the client answers in a confused manner. The client obeys commands, such as being asked to move a leg. What would be the client's total score? Record your answer using a whole number. ___________

used to measure the level of a client's consciousness and assigns a numerical score for each area of neurological status. The score for opening eyes on sound or speech is a 3. The score assigned for confused verbal responses is a 4. A score of 6 is assigned to the motor response of obeying commands. Therefore, the total score of the client is 13.

Edema Pitting Scale

0+ No pitting 1+ Mild pitting. 2mm 2+ Moderate. 4mm 3+ Moderate/Severe. 6mm, 4+ Severe. 8mm,

A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? Select all that apply. 1 Pain history, including location, intensity, and quality of pain 2 Client's purposeful body movement in arranging the papers on the bedside table 3 Pain pattern, including precipitating and alleviating factors 4 Vital signs, such as increased blood pressure and heart rate 5 The client's family statement about increases in pain with ambulation

1 & 3 Why not others?? Physiological responses such as elevated blood pressure and heart rate are most likely to be absent in the client with chronic pain. Pain is a subjective experience, and therefore the nurse has to ask the client directly instead of accepting the statement of the family members.

Which client is most at risk of developing breast cancer? 1 Age 60, family history, 2 children, menopause at 45 2 Age 60, family history, 0 children, menopause at 50 3 Age 60, no fam hx, 0 children, menopause at 50 4 Age 60, no fam hx, 0 children, menopause at 50

2 Women over 40 years of age with a personal or family history of breast cancer, late-age menopause (after age 50), who have not had children or who conceived after the age of 30 years, or women with excessive oral contraceptives use are at risk of developing breast cancer. Client B has all the criteria that increase the risk of developing breast cancer, such as age over 60 years, positive family history, no children, and menopause at a later age. Therefore she is at the highest risk of developing breast cancer compared to clients A, C, and D. Client A has children and therefore has a relatively lower risk of developing breast cancer. Client C has negative family history and therefore has a relatively lower risk of developing breast cancer. Client D has children and also has a negative family history, and therefore has a relatively lower risk of developing breast cancer.

Which statement is true for collaborative problems in a client receiving healthcare? 1 They are the identification of a disease condition. 2 They include problems treated primarily by nurses. 3 They are identified by the primary healthcare provider. 4 They are identified by the nurse during the nursing diagnosis stage.

4 The nurse assesses the client to gather information to reach diagnostic conclusions. Collaborative problems are identified by the nurse during this process. If the client's health problem requires treatment by other disciplines such as medical or physical therapy, the client has a collaborative problem. A medical diagnosis is the identification of a disease condition. Problems that require treatment by the nurse are referred to as nursing diagnoses. A medical diagnosis is identified by the primary healthcare provider based on the results of diagnostic tests.

Which landmark is correct for a nurse to use when auscultating the mitral valve?

Left fifth intercostal space, midclavicular line

A registered nurse is teaching a nursing student about the third heart sound (S 3). Which statement given by the nursing student indicates a need for further education? "S 3 is heard in clients with heart failure." "S 3 is normal in pregnant women." "S 3 is abnormal in adults over 30 years of age." "S 3 is normal in children and young adults."

S 3 is normal in pregnant women The third heart sound (S 3) can be heard when the heart attempts to fill an already distended ventricle. This sound may be common and normal in the last stages of pregnancy, but not in all stages. This sound may be heard in heart failure clients. The S 3 sound is abnormal in adults over the age of 30. This sound is normally heard in children and young adults.

What should the nurse assess to determine whether a 75-year-old individual is meeting the developmental tasks associated with aging? Achievement of a personal philosophy Adaptation to the children leaving home Attainment of a sense of worth as a person Adjustment to life in an assisted-living facility

Sense of self worth as a person Explanation:Developing and participating in meaningful activities and satisfaction with past accomplishments increase feelings of self-worth. Achievement of a personal philosophy is a task of early adulthood. Adaptation to the children leaving home is a task of middle adulthood. Adjustment to life in an assisted-living facility is not a developmental task of older adults; not all older adults live in assisted-living facilities.

Shigellosis

Shigellosis is a food-borne disease and may be due to the ingestion of milk products, seafood, or salad. The symptoms of infection include abdominal cramps and severe diarrhea and can occur 12 hours after ingestion.

A client is admitted with a suspected malignant melanoma on the arm. When performing the physical assessment, what would the nurse expect to find? Large area of petechiae Red birthmark that has recently become lighter in color Brown or black mole with red, white, or blue areas Patchy loss of skin pigmentation

brown, or black mole with red, white... Melanomas have an irregular shape and lack uniformity in color. They may appear brown or black with red, white, or blue areas. Petechiae are pinpoint red dots that indicate areas of bleeding under the skin. A red birthmark is a vascular birthmark and often fades over time. A patchy loss of skin pigmentation indicates vitiligo.

A nurse is assessing a client during a regular checkup. The client complains of a moderate decrease in food intake over the past 3 weeks, a 4-kilogram weight loss, and a decrease in mobility. The client had a bout of acute bronchitis 1 month ago and has recently been diagnosed with mild dementia. The body mass index of the client is 21. What is the total score of the client according to the mini nutritional assessment (MNA)? Record your answer as a whole number. ___________

5 The mini nutritional assessment (MNA) is a tool used to identify malnutrition. It measures the nutritional status and assigns a numerical score for each of the questionnaire areas. The score for a moderate decrease of food intake over the past 3 weeks is 1. The score assigned for a weight loss of 4 kg is 0. A score of 1 is assigned for the decrease in mobility (chair or bed bound). The score for a history of acute bronchitis is 0. A score of 1 is assigned to mild dementia, and a score of 2 is assigned to a body mass index of 21. Therefore, the total score of the client according to the MNA is 5.

How does the World Health Organization (WHO) define "health"?

A state of complete physical, mental, and social well-being

Right sided heart failure risk

Bilateral pressures higher than 2.5 cm are considered elevated and are a sign of right-sided heart failure. Client A has both right and left jugular venous pressure above 2.5 cm. Therefore this client is at risk for right-sided heart failure. One-sided pressure elevation is caused by obstruction, as observed in clients B, C, and D. in clients B,C, D the right jugular venous pressure is .5 cm high than the left jugular venous pressure

Which factor can elevate the oxygen saturation during an assessment? Nail polishes Carbon monoxide Intravascular dyes Skin pigmentation

Carbon monoxide Carbon monoxide artificially elevates the oxygen saturation during assessment. Nail polishes interfere with the ability of the oximeter. Intravascular dyes will artificially lower the oxygen saturation. Skin pigmentation will overestimate the saturation.

kyphosis

excessive outward curvature of the spine that causes hunching of the back (posterior curvature of the thoracic spine)

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client? 1 Skin turgor 2 Intake and output results 3 Client's report about fluid intake 4 Blood lab results

4 Blood lab results provide objective data about fluid and electrolyte status, as well as about hemoglobin and hematocrit. Skin turgor is not a reliable indicator of hydration status for the elderly client because it is generally decreased with age. Intake and output results provide data only about fluid balance, but do not present a comprehensive picture of the client's fluid and electrolyte status; therefore this is not the best answer. The client's report about fluid intake is subjective data in general and not reliable because this client has dementia and therefore has memory problems .

An adolescent is taken to the emergency department of the local hospital after stepping on a nail. The puncture wound is cleansed and a sterile dressing applied. The nurse asks about tetanus immunization. The adolescent responds that all immunizations are up to date. Penicillin is administered, and the client is sent home with instructions to return if there is any change in the wound area. A few days later, the client is admitted to the hospital with a diagnosis of tetanus. Legally, what is the nurse's responsibility in this situation?

Assessment by the nurse was incomplete, and as a result the treatment was insufficient.

An older adult client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which nursing actions have specific gerontologic implications the nurse must consider? Select all that apply. Assessment of skin turgor Documentation of vital signs Assessment of intake and output Administration of antiemetic drugs Replacement of fluid and electrolytes

Assessment of skin turgor Administration of antiemetic drugs Replacement of fluid and electrolytes Explain: When skin turgor is assessed, the presence of tenting may be related to loss of subcutaneous tissue associated with aging rather than to dehydration; skin over the sternum should be used instead of skin on the arm for checking turgor. Older adults are susceptible to central nervous system side effects, such as confusion, associated with antiemetic drugs; dosages must be reduced, and responses must be evaluated closely. Because many older adults have delicate fluid balance and may have cardiac and renal disease, replacement of fluid and electrolytes may result in adverse consequences, such as hypervolemia, pulmonary edema, and electrolyte imbalance. Vital signs can be obtained as with any other adult. Intake and output can be measured accurately in older adults.

What is gamma globulin and when is it used?

Gamma globulin, which is an immune globulin, contains most of the antibodies circulating in the blood. When injected into an individual, it prevents a specific antigen from entering a host cell. So the antigen is neutralized by the antibodies gamma globulin supplies. Used when a pt is exposed to Hep A

Heart Murmur Grading

Grade 2- intensity is characterized by quiet and clearly audible murmurs. Grade 3-A moderately loud murmur without a thrill Grade 4-loud murmurs with an associated thrill. Grade 5-intensity is characterized by an easily palpable thrill.

A client complains of difficulty breathing. The nurse auscultates wheezing in the anterior bilateral upper lobes. What could be the possible reason for this sound? Inflammation of the pleura Muscular spasms in the larger airways Sudden reinflation of groups of alveoli High velocity airflow through an obstructed airway

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

An older adult is found to have a thin white ring around the margin of the iris. What condition does this denote? 1 Cataract 2 Arcus senilis 3 Conjunctivitis 4 Macular degeneration

In older adults, the iris becomes faded and a thin white ring (known as arcus senilis) appears around the margin of the iris. A cataract is a condition involving increased opacity of the lens that blocks light rays from entering the eye. The presence of redness indicates allergic or infectious conjunctivitis. Macular degeneration is marked by a blurring of central vision caused by progressive degeneration of the center of the retina.

Which client is suspected of having hypertension based on the given data? 1 Decreased Cardiac Output, Normal Peripheral Resistance, Decreased Hematocrit 2 Increased CO, Increased PR, Increased Hematocrit 3 Decreased CO, Normal PR, Normal Hematocrit 4 Normal CO, Increased PR, Normal Hematocrit

The blood pressure (BP) in a client rises when the client's cardiac output, peripheral resistance, and hematocrit are increased. Because all of these parameters are increased in client B, then that client is suspected to have hypertension. The BP falls when cardiac output is decreased. So, clients A and C may be at risk of hypotension. Client D's cardiac output may not be at risk of hypertension.

A client with a history of hypothyroidism reports giddiness, excessive thirst, and nausea. Which parameter assessed by the nurse confirms the diagnosis as heat stroke? Increased heart rate Increased blood pressure Decreased respiratory rate Increased circulatory damage

increased heart rate explain:Prolonged exposure to the sun or a high environmental temperature overwhelms the body's heat-loss mechanisms. These conditions cause heat stroke, which manifests as giddiness, excessive thirst, and nausea. An increased heart rate (HR) characterizes a heat stroke. A low blood pressure (BP), increased respiratory rate, and increased circulatory and tissue damage are not indicators of heat stroke.

What causes false low systolic readings?

inflating the cuff inadequately too big of a blood pressure cuff