HESI Practice- Fundaments of Skill and Assessment

A nurse teaches a client about wearing thigh-high antiembolism elastic stockings. What would be appropriate to include in the instructions?

"You will need to apply them in the morning before you lower your legs from the bed to the floor." Applying antiembolism elastic stockings in the morning before the legs are lowered to the floor prevents excessive blood from collecting and being trapped in the lower extremities as a result of the force of gravity. Elastic stockings are worn to prevent the formation of emboli and thrombi, especially in clients who have had surgery or who have limited mobility, by applying constant compression. It is contraindicated for antiembolism elastic stockings to be applied and worn at night, rolled down, or applied after the legs are lowered to the floor.

What principal components are associated with a nurse's time management skill? Select all that apply.

3 principal components of time management: Goal setting, priority setting, and interruption control Autonomy is an important component in the decision-making process. Right communication is considered one of the rights of delegation.

A nurse assesses drainage on a surgical dressing and documents the findings. Which documentation is most informative?

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

A nurse assesses a client with dry and brittle hair, flaky skin, a beefy-red tongue, and bleeding gums. The nurse recognizes that these clinical manifestations are most likely a result of what?

A nutritional deficiency

The home healthcare nurse visits a client who has two grandchildren living in the household. The client's adult child is a single-parent who is in prison serving a 15-year sentence. The children accompany the grandparent on 2-hour contact visits on weekends as often as possible. Which term does the nurse use to define this family form?

A skip-generation family form is a kind of alternative family form where the grandparents care for the grandchildren. Divorce, working parents, incarcerated parents, and single parenthood are some of the reasons that lead to such family forms. A nuclear family consists of two parents and one or more children. An extended family consists of the nuclear family and relatives such as aunts, uncles, cousins, or grandparents. A single-parent family is formed when one parent leaves the household due to death, divorce, incarceration, or desertion. It may also occur when a single person decides to have or adopt a child.

Which professional standard does the nurse feel is most important for critical thinking?

An evaluation criterion is an important professional standard required for critical thinking. Logical thinking, accurate knowledge, and relevant information are important intellectual standards required for critical thinking.

During a home visit, the nurse finds that a healthy elderly person is actively practicing laughing therapy to maintain good health without pressure or insistence from family members. What does the nurse infer from these findings?

An intrinsically motivated individual participates in an activity because it is inherently interesting or enjoyable rather than because of obligations or outside pressure from family members. If the person is not motivated, he or she would be unlikely to participate in the activity. An extrinsically motivated individual with or without self-determination may practice laughing therapy upon suggestion or pressure created by other individuals.

Which statement is true for attachment in the newborn?

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

While inspecting the external eye structure of a client, a nurse finds bulging of the eyes. Which condition can be suspected in the client?

Bulging eyes may indicate hyperthyroidism. Tumors are characterized by abnormal eye protrusions. Hypothyroidism can be revealed by the coarseness of the hair of the eyebrows and the failure of the eyebrows to extend beyond the temporal canthus. Crossed eyes or strabismus may result from neuromuscular injury or inherited abnormalities.

A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by doing what?

Cold causes the blood vessels to constrict, which reduces the leakage of fluid into the tissues and prevents swelling and therefore muscle spasms. Cold does promote analgesia but not circulation. It may numb nerves but does not dilate blood vessels. Cold therapy also may numb the nerves and surrounding tissues, thus reducing pain.

A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution?

Covering the infected site with a dressing will contain secretions and set up a barrier, thus decreasing the risk for transmission to others. Contact precautions must be used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment. Draping the client with a sheet marked biohazardous does not protect the client's privacy. A wound infected with MRSA can be transmitted to others via contact, not the airborne route; thus a mask is unnecessary.

The nurse assesses bilateral +4 peripheral edema while assessing a client with heart failure and peripheral vascular disease. What is the pathophysiological reason for the excessive edema?

Edema is defined as the accumulation of fluid in the interstitial spaces. When the heart is unable to maintain adequate blood flow throughout the circulatory system, the excess fluid pressure within the blood vessels can cause shifts into the interstitial spaces. Weakening of the cell wall may cause leakage of fluid, but this is not the pathologic reason related to heart failure. Increased intravascular compliance would prevent fluid from shifting into the tissue. Intracellular volume is maintained within the cell and not in the tissue.

Which critical thinking skill in nursing practice requires the nurse to possess knowledge and experience for choosing care strategies for clients?

Explanation requires knowledge and experience for choosing strategies for care of clients. Analysis is a critical thinking skill that requires open-mindedness while looking at the client's information. The skill of inference is associated with noticing relationships in the findings. Interpretation is associated with an ordered data collection.

Which physiologic changes may occur during the first trimester of pregnancy? Select all that apply.

Fatigue, morning sickness, and breast enlargement are observed during the first trimester of pregnancy. Increased libido is observed during the second trimester of pregnancy. Braxton Hicks contractions are observed during the third trimester of pregnancy.

Which developmental changes should be evaluated in girls around 12 years of age?

Girls around the age of 12 years of age may develop scoliosis (a lateral curvature of the spine); therefore, skeletal growth should be evaluated. Motor skills should be evaluated in preschool children. Visual acuity should be evaluated in school-age children. Hormonal changes should be evaluated in adolescents.

Which psychophysiologic factors can influence communication between a nurse and a client? Select all that apply.

Growth and development and emotional status are two psychophysiologic factors that influence communication between a nurse and a client. Privacy level is an environmental factor. Information exchange is a situational factor. Level of caring expressed is a relational factor.

Which clinical condition will result in changes in the integrity of the arterial walls and small blood vessels?

In atherosclerosis, there may be changes in the integrity of the walls of the arteries and smaller blood vessels. Contusion- Direct manipulation of vessels or localized edema that impairs blood flow Thrombosis- Blood clotting that causes mechanical obstruction to blood flow Tourniquet effect- may be caused by the application of constricting devices, which may lead to impaired blood flow to areas below the site of constriction.

Which term refers to the exaggeration of the posterior curvature of the thoracic spine?

Kyphosis is an excessive outward curvature of the spine that causes hunching of the back. Lordosis is the excessive inward curvature of the lumbar part of the spine. Scoliosis is the abnormal lateral curvature of the spine. Osteoporosis is characterized by a loss of bone mass and a deterioration of bone tissues.

A nurse is assessing a client's nails and finds a slight convex curve at the angle from the skin to nail base of about 160 degrees. Which condition does the nurse suspect?

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

Which concept refers to respecting the rights of others?

Open-mindedness refers to respecting the rights of others and being tolerant of different viewpoints. Maturity refers to reflecting on one's own judgments and having cognitive maturity. Systematicity refers to being organized and focused. Inquisitiveness refers to acquiring knowledge.

Which nursing interventions would be beneficial for providing safe oxygen therapy? Select all that apply.

Oxygen tubing should be checked for kinks during oxygen use. "No smoking" signs should be posted in the clients' rooms. Wires should not be kept under carpeting because heat buildup or friction can cause a fire. Oxygen tanks should be placed in an upright position in their carts or flat on floors. Being familiar with the phrase "Stop, drop, and roll" helps to describe when clothing or skin is burning.

When monitoring a client 24 to 48 hours after abdominal surgery, the nurse should assess for which problem associated with anesthetic agents?

Paralytic ileus After abdominal or pelvic surgery clients are at risk for paralytic ileus as a result of receiving an anesthetic agent. The nurse can prevent or minimize paralytic ileus by increasing movement as soon as possible after surgery, through actions such as turning and early ambulation. Evidence of bowel function returning to normal includes auscultation of bowel sounds and passing of flatus and stool. Colitis, stomatitis, and gastrocolic reflux are not postoperative complications related to anesthetic agents.

Which theory focuses on developing the interpersonal relationships between the nurse, client, and the client's family?

Peplau's theory focuses on interpersonal relationships between the nurse, the client, and the client's family by developing the nurse-client relationship. Orem's theory focuses on the client's self-care needs. Leininger's theory recognizes the importance of culture and its influence on everything that involves the client and the providers of nursing care. Henderson's theory focuses on assisting the individual in the performance of activities that he or she can perform unaided that will contribute to health, recovery, or a peaceful death.

The nurse receives information about a client through another nurse. The nurse then finds that information has some missing facts. Which critical thinking attitude would the nurse use to clarify the information after talking to the client directly?

Perseverance requires the nurse to be cautious of an easy answer. If the nurse clarifies some information after talking to the client directly, he or she demonstrates perseverance. Fairness requires the nurse to listen to both the sides in any discussion. Humility is associated with recognizing the need for more information for making a decision. When the nurse is thoroughly aware of what is required and manages his or her time effectively, he or she uses discipline.

What does a nurse consider the most significant influence on many clients' perception of pain when interpreting findings from a pain assessment?

Previous experience and cultural values

What are physiologic symptoms assessed in a client with sleep deprivation? Select all that apply.

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

Which caring intervention helps to provide comfort, dignity, respect, and peace to a client?

Relieving pain and suffering is not just about giving medications but providing comfort, dignity, respect, and peace to a client. Listening helps to obtain meaningful interactions with clients. Spiritual caring helps clients find balance between their own life values, goals, and belief systems. Providing presence helps to convey closeness and a sense of caring.

Which right of delegation refers to the giving of clear, concise descriptions of a task to the delegatee?

Right communication refers to the giving of clear and concise descriptions of a task, including its objectives, limits, and expectations while delegating a task. Right task refers to delegating a task that is repetitive, requires less supervision, and has predictable results. Right person is delegating a task to the correct person who has the ability to perform said task. Right supervision refers to providing appropriate monitoring, evaluation, and feedback of the delegated task.

Which nursing action would be considered a part of self-regulation in the decision-making process?

Self-regulation requires the nurse to reflect on his or her own experiences. Explanation requires looking at all situations objectively. Findings and conclusions are supported by explanation. Analysis requires the nurse to not make any careless assumptions.

A new mother said to the nurse, "I would like to care for my baby independently rather than depending on the baby's grandparents." What does the nurse infer from this information?

The client is of North American culture The people who belong to United States and Western Europe culture possess individualistic characteristics. The people who belong to Asia, Africa, and Latin America do not possess individualistic characteristics; instead, they have a collectivistic approach. The new mother who belongs to any of these cultures other than the North American culture may depend on elder family members for child-rearing.

While assessing the pupils of a client, a healthcare professional notices pupillary dilatation. Which drug intake might have resulted in this condition?

The intake of eye medications such as atropine will cause dilatation of the pupils. Heroin, morphine, and pilocarpine cause pupillary constriction.

Which statement is true for collaborative problems in a client receiving healthcare?

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.

What should the community nurse teach about the risk of adolescent pregnancy?

The nurse should teach the community that adolescent pregnancy often leads to premature births. Adolescent pregnancy may lead to low birth weight babies due to lack of nutrition and prematurity. Older women have difficulty in becoming pregnant and they are more likely to have babies with chromosomal defects. An adolescent mother is not at risk for increased weight gain because she is more likely to be affected from lack of nutrition, and exposure to alcohol, drugs, and tobacco.

The nurse is assessing a client after surgery. Which assessment finding does the nurse obtain from the primary source?

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

Which stage of Piaget's theory of cognitive development does the nurse observe in a preschooler?

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

How should the nurse prevent footdrop in a client with a leg cast?

To prevent footdrop (plantar flexion of the foot because of weakness or paralysis of the anterior muscles of the lower leg) in a client with a cast, the foot should be supported with 90 degrees of flexion. Bed rest can cause footdrop, and 45 degrees is not enough flexion to prevent footdrop. Application of an elastic stocking for support also will not prevent footdrop; a firmer support is required.

Which approach is a comforting approach that communicates concern and support?

Touch is a comforting approach that involves reaching out to clients to communicate concern and support. Mirroring is physically replicating the client's nonverbal behavior; although it can convey a connection to the client, it does not necessarily communicate concern or support. Knowing the client involves both the nurse's understanding of a specific client and his or her subsequent selection of interventions. Providing presence is a person-to-person encounter that can convey a closeness and sense of caring if it is positive.

What type of functional health pattern would the nurse explain describes values and goals?

Value-belief pattern describes a pattern of values, beliefs, and goals. These guide the client for making choices or decisions. The role-relationship pattern includes the description of the client's patterns in role engagements and relationships. In the self-perception-self-concept pattern, the nurse may describe the client's self-concept pattern and perceptions of self. It involves self-concept/worth, emotional patterns, and body image. Health perception-health management pattern is associated with the description of the client's self report of health and well-being.

What are the goals of care when working with families according to the family health system? Select all that apply.

When working with families, the goals of care are to improve family health or well-being, assist the family in managing the illness conditions, and achieve health outcomes related to the family's areas of concern. In the developmental stage, the nurse should help the family prepare for later transitions and promote positive family behavior to achieve essential tasks.

A nurse understands that the primary purpose for a client to undergo reconstructive surgery is to do what?

to restore function and/or appearance Replacement of a tissue or organ is known as transplant Surgery to relieve or reduce symptoms is known as palliative Surgery to remove or excise an organ or tissue is known as resection.

A client who underwent a physical examination reports itching after 2 days. Which condition should the nurse suspect?

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

While performing a physical assessment, the nurse notices a minute, nonpalpable change in the skin color of a client. What might be the type of skin lesion involved?

A macule- flat, nonpalpable change in skin color, smaller than 1 cm. Wheals- irregular in shape, elevated surface- localized edema, usually caused by a mosquito bite Papules are palpable, circumscribed solid elevations in the skin, smaller than 1 cm. Vesicles- small, circumscribed skin elevation, filled with serous fluid.

Erikson's theory of psychosocial development stages of life in order

According to Erikson's theory of psychosocial development, individuals need to accomplish a particular task successfully before progressing to the next one. Every task is framed with opposing conflicts. 1. Trust vs. Mistrust- birth up to 1 year. 2. Autonomy vs. Sense of Shame and Doubt- 1 to3 years 3. Initiative vs. guilt- 3 to 6 years 4. Industry vs. Inferiority- 6 to 11 years of age 5. Identity vs. Role Confusion- puberty 6. Intimacy vs. Isolation- young adult

A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L (122 mmol/L) and a potassium level of 3.6 mEq/L (3.6 mmol/L). Based on the lab results and symptoms, what is the client experiencing?

Hyponatremia The normal range for serum sodium is 135 to 145 mEq/L (135 to 145 mmol/L), and for serum potassium it is 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Vomiting and use of diuretics, such as furosemide (Lasix), deplete the body of sodium. Without intervention, symptoms of hyponatremia may progress to include neurologic symptoms such as confusion, lethargy, seizures, and coma. Hypernatremia results when serum sodium is greater than 145 mEq/L (145 mmol/L); hyperkalemia results when serum potassium is greater than 5.0 mEq/L (5.0 mmol/L); hypokalemia results when serum potassium is less than 3.5 mEq/L (3.5 mmol/L).

A nurse is assessing a client's degree of edema and finds 8 mm of depth. How does the nurse document this condition?

If the Edemahas a depth of 8 mm, then it is 4+. If the edema has a depth of 2 mm, then it is 1+. If the edema has a depth of 4 mm, it is 2+. If the edema has a depth of 6 mm, then it is 3+.

The nurse noticed the breathing rate as regular and slow while assessing a client for respiration. What could be the condition of the client?

In bradypnea the breathing rate is regular, but it is abnormally slow. Respirations cease for several seconds in apnea. The rate of breathing is regular, but abnormally rapid in tachypnea. In hyperpnea, the respirations are labored, the depth is increased, and the rate is increased.

Which theories are most relevant to development in adults? Select all that apply.

Stage-Crisis theory, and Life Span approach The Stage-Crisis theory and the Life Span approach are theories related to adult development. Piaget's theory is associated with children's cognitive development. Erikson's theory is associated with the psychoanalytical/psychosocial development. Kohlberg's theory is related to moral development.

A client complains of pain in the ear. While examining the client, a nurse finds swelling in front of the left ear. Which lymph node does the nurse expect to be involved?

The pre-auricular lymph node is located in front of the ear and in this situation would be edematous. The mastoid or posterior auricular lymph node is present behind the ear. The occipital lymph nodes are located in the back of the head, near the occipital bone of the skull. Submental lymph nodes are located below the chin.

Which response by the nurse during a client interview is an example of back channeling?

"All right, go on..." Back channeling involves the use of active listening prompts such as "Go on...", "all right", and "uh-huh." Such prompts encourage the client to complete the full story. The nurse uses probing by asking the client, "What else is bothering you?" Such open-ended questions help to obtain more information until the client has nothing more to say. The statement, "Tell me what brought you here" is an open-ended statement that allows the client to explain his health concerns in his or her own words. Closed-ended questions such as, "How would you rate your pain on a scale of 0 to 10?" are used to obtain a definite answer. The client answers by stating a number to describe the severity of pain.

Arrange the order of steps involved in the evidence-based practice process.

1. Ask a clinical question. 2. Collect the most relevant and best evidence. 3. Critically appraise the evidence you gather. 4. Integrate all evidence with one's clinical expertise and client preferences and values in making a practice decision or change. 5. Evaluate the practice decision or change. 6. Share the outcomes of evidence-based practice. Evidence-based practice is a problem-solving approach that integrates the conscientious use of best evidence in combination with a clinician's expertise, client preferences, and client values to make decisions about client care. First, the nurse should ask a clinical question and collect the most relevant and best evidence. Then, the nurse critically appraises the gathered evidence and integrates the evidence with his or her clinical expertise along with the client's preferences and values to make a decision or change. Then the nurse evaluates the practice decision or change and shares the outcomes of the evidence-based practice changes with his or her team.

Arrange in order how the items of personal protection equipment (PPE) should be removed after exiting a medical or surgical isolation area.

1. Gloves 2. Face shield 3. Gown 4. Mask 5. Hand washing According to the Centers for Disease Control and Prevention, gloves should be removed first when exiting medical or surgical isolation in order to avoid those gloves touching and possibly contaminating other equipment outside of the isolation area. Next, the nurse removes the face shield, followed by the gown and then the mask. Handwashing is the next step that should occur after removing all personal protection equipment (PPE).

Arrange these fine-motor skills in ascending order as the infant develops them.

1. Reflexive grasp 2. Looks at and plays with fingers 3. Pulls feet to the mouth 4. Bangs objects together 5. Uses pincer grasp 6. Places objects into containers The infant begins to develop fine-motor skills within the first month of its birth. The reflexive grasp is seen in the first month. By the age of two to four months, the infant begins to look at his fingers and play with them. The infant is able to bring objects from the hand to the mouth. At four to six months, the infant begins to pull his or her feet to his or her mouth to explore. By the age of six to eight months, the infant is able to hold objects and bang them together. The infant begins to crawl by the age of eight to 10 months and use a pincer grasp to pick up small objects. At this age, the infant also shows a hand preference. The infant is able to pick up objects and place them in containers by the age of 10 to 12 months.

Arrange the sequence of events occurring during a fever secondary to pyrogens in chronological order.

1. The setpoint of the hypothalamus is raised 2. Pyrogens are destroyed 2. Immune system response is triggered 4. Body temperature is increased 5. Heat loss responses are initiated A true fever results from an alteration in the hypothalamic set point. Pyrogens act as antigens that trigger the immune system response. The hypothalamus reacts by raising the set point, thereby increasing the body temperature. Once the pyrogens are removed, the third phase of a febrile episode occurs. Heat loss responses are initiated when the hypothalamus set point drops.

Which intellectual factor would the nurse find appropriate as a dimension for gathering data for a client's health history?

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

What is the appropriate blood pressure of a 12-year-old client?

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

An advanced practice registered nurse (APRN) is caring for a pregnant woman. Which type of APRN would care for this client?

A certified nurse midwife (CNM) is qualified and has the skills to care for a pregnant woman. A clinical nurse specialist (CNS) is an advanced practice registered nurse (APRN) who is an expert clinician in a specialized area of practice. A certified nurse practitioner (CNP) is an APRN who provides healthcare to a group of clients, usually in an outpatient, ambulatory care, or community-based setting. A certified registered nurse anesthetist (CRNA) is an APRN with an advanced education in a nurse anesthesia accredited program.

While examining a client, a nurse finds a circumscribed elevation of the skin filled with serous fluid on the cheek. The lesion is 0.6 cm in diameter. What does the nurse suspect the finding to be?

A circumscribed elevation of the skin that is filled with serous fluid and a lesion size of less than 1 cm describes a vesicle. A papule is palpable, circumscribed, and has a solid elevation and a size smaller than 1 cm. A nodule is an elevated solid mass, deeper and firmer than a papule and of 1-2 cm in diameter. A pustule is a circumscribed elevation of the skin that is similar to a vesicle but filled with pus and varies in siz

When teaching about aging, the nurse explains that older adults usually have what characteristic?

A decrease in neuromuscular function slows reaction time. The ability to be flexible has less to do with age than with character. Confusion is not necessarily a process of aging, but it occurs for various reasons such as multiple stresses, perceptual changes, or medication side effects. Most older adults do not have organic mental disease.

The nurse at the well baby clinic is assessing the gross motor skills of a five-month-old infant. Which finding is a cause for concern?

A normal five-month-old infant should be able to sit up without a head lag. This finding should cause the nurse to conduct a further assessment. A baby should be able to turn from the side to the back by four months of age. At five months of age, the baby should be able to turn from the abdomen to the back. The baby should be able to support much of his own weight when pulled to stand by the age of five to six months.

When planning discharge teaching for a young adult, the nurse should include the potential health problems common in this age group. What should the nurse include in this teaching plan?

Accidents are common during young adulthood because of immature judgment and impulsivity associated with this stage of development. Kidney dysfunction is not a problem specific to any one stage of growth. Cardiovascular disease is a common health problem in middle adulthood. Glaucoma is a common health problem in older adults.

While assessing the muscle tone of a client, the client demonstrates a full range of muscle motion against gravity with some resistance. What score on the Lovett scale can be given to the client?

According to the Lovett score, a full range of motion against gravity with some resistance can be categorized as G (good). F (fair) can be given if the client exhibits a full range of motion with no resistance. T (trace) score is given when the client exhibits slight contractility with no movement. N (normal) on the Lovett scale indicates full range of motion against gravity with full resistance.

Which integumentary assessment finding should the nurse attribute to skin texture?

Assessing for texture refers to the skin surface character. Assessing for elastic adaptability (elasticity) determines the skin turgor and not texture. Assessing for peripheral vascularity determines skin circulation and not texture. Pigmentation type indicates an observable skin color rather than a texture.

A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte?

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

Which factor can elevate the oxygen saturation during an assessment?

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.

While assessing a neonate's temperature, the nurse observes a drop in the body temperature. What is the most appropriate reason for this temperature drop?

Decreased nonshivering thermogenesis Neonates are susceptible to heat loss or cold stress. Nonshivering thermogenesis is a natural mechanism of heat production that occurs to minimize heat loss in a neonate. This mechanism's failure may lead to a drop in body temperature. The basal metabolic rate (BMR) accounts for heat production; an increased BMR may raise the body temperature. Shivering is an involuntary movement that produces heat, which may not be seen in neonates. Voluntary movements cause increases in body temperature.

The nurse is gathering a client's health history. Which information does should the nurse classify as biographical information? Select all that apply.

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

The nurse tells a client undergoing diuretic therapy to avoid working in the garden on hot summer days. What condition is the nurse trying to prevent in this client?

Clients undergoing diuretic therapy are at risk of heatstroke when exposed to temperatures higher than 40° C. Frostbite occurs when the body is exposed to ice-cold temperatures. Hypothermia is a condition in which the skin temperature drops below 36° C. Hyperthermia occurs when the body is exposed to temperatures higher than 38.5° C.

A client becomes anxious after being scheduled for a colostomy. What is the most effective way for the nurse to help the client?

Communication is important in relieving anxiety and reducing stress. Administering the prescribed PRN sedative does not acknowledge the client's feelings and does not address the source of the anxiety. Learning is limited when anxiety is too high. The focus should be on the client, not others. Reassurance may cut off communication and deny emotions.

Which intrinsic factor is associated with the fall of an older adult? (Intrinsic: belonging naturally/ independent of other things)

Intrinsic risk factors associated with the fall of an older adult may include deconditioning. (Deconditioning: reversal of previously conditioned behavior) Wet floors, poor lighting, and inappropriate footwear are extrinsic risk factors.

A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documented as what?

Crackles are abnormal breath sounds described as soft, crackling, bubbling sounds produced by air moving across fluid in the alveoli. Vesicular breath sounds are normal. They are quiet, soft, and inspiration sounds that are short and almost silent on expiration. They are heard over the lung periphery. Bronchial breath sounds are normal and consist of a full inspiration and expiratory phase with the expiratory phase being louder. They are heard over the trachea and large bronchi of the lungs. 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.

The client reports difficulty in breathing. The nurse auscultates lung sounds and assesses the respiratory rate. What is the purpose of the nurse's action?

Data Collection The nurse is gathering objective data to support the subjective data. The client's report of difficulty breathing is subjective data that needs to be supported by data from physical examination. The nurse reviews the database after data collection to decide if it is accurate and complete. This step is called data validation. Grouping of data that forms a pattern is called data clusters. The nurse uses critical thinking to interpret the data and analyze it before it is classified and organized into data clusters.

When caring for a client with venous insufficiency, the nurse would implement which nursing measure?

Elevate the client's legs above heart level Venous insufficiency occurs when vascular damage impedes the body's ability to move blood from the legs toward the heart. This causes blood to pool in the legs, where it can cause swelling; pain; and, in some cases, leaking fluid in the skin or ulcers. Elevation of the legs above the level of the heart makes use of gravitational forces to drain blood through the veins toward the heart. Clients should not wear tight restrictive pants and should avoid wearing a girdle or garter, which may impede venous return. Compression stockings prevent blood pooling. Elevating the upper extremities will not decrease edema in lower extremities.

What does the professional nurse consider to be the center of decision-making when providing client care?

Ethics of care A professional nurse always follows the ethics of care and considers caring to be the center of decision-making. The nurse must know what behavior is ethically appropriate while caring for a client. A nurse's effectiveness in performing tasks is important to client care; however, client satisfaction comes from the effective dimension of care. Because ethics of care are unique to each client, the nurse should not base decision-making only on analytical skills. The nurse should not provide client care based only on intellectual principles or research knowledge. Caring is the most important factor because it considers client preferences and values.

A registered nurse instructs a nursing student to use knowledge and experience to choose proper strategies to use to care for clients. Which critical-thinking skill does the registered nurse refer to?

Explanation The critical-thinking skill of explanation involves using knowledge and experience to provide client care. The nursing practice of assessing whether the obtained data is true is called analysis. Using criteria such as expected outcomes, pain characteristics, and learning objectives to determine results of nursing actions is an evaluation skill. The nursing practice of being orderly in data collection and looking for patterns to categorize data refers to interpretation.

Which statement defines the term family resiliency?

Family resiliency is the ability of the family to cope with expected and unexpected stressors. Family diversity is the uniqueness of each family. Family durability is the interfamilial support system that extends beyond the walls of the household. The parents of this family may remarry or children may leave the home as adults, however, the family is capable of transcending inevitable lifestyle changes.

Which description is most appropriate for the family centered care approach?

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

The nurse's response is, "Let's go back to what we were just talking about." What therapeutic communication technique did the nurse use?

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

A client with a recent history of head trauma is at risk for orthostatic hypotension (action of standing from sitting/laying). Which assessment findings observed by the nurse would relate to this diagnosis? Select all that apply.

Head trauma may cause blood loss and clients with recent blood loss are at risk for orthostatic hypotension. Symptoms of hypotension include fainting, lightheadedness, and weakness. Headaches and shortness of breath are symptoms of hypertension.

Which statement is true about the nursing model "team nursing"?

Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members. In team nursing, there is an existence of hierarchical communication from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members. In the nursing model "total client care," the registered nurse is responsible for all aspects of client care, care can be delegated from the registered nurse to other healthcare team members, and the registered nurse works directly with the client, family members, and healthcare team members.

Which type of breathing pattern alteration is manifested with hypercarbia?

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

A student nurse is assessing the blood pressure of a client with the client's arm unsupported. What are the expected errors in the obtained readings?

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

Which definition is involved in the caring process called knowing according to Swanson's theory of caring?

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

The nurse finds that the client's fever spikes and falls without a return to a normal level. Which pattern of fever is this a characteristic of?

In a remittent pattern, fever spikes and falls without returning to normal temperature levels. Periods of febrile (nervous excitement) episodes coupled with periods of acceptable temperature values are called a relapsing pattern. A constant body temperature continuously above 38° C (100.4° F) with little fluctuation refers to a sustained pattern. In an intermittent pattern, fever spikes are interspersed with normal temperature levels.

Which intervention reflects the nurse's approach of "family as a context"?

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

To prevent thrombophlebitis in the immediate postoperative period, which action is most important for a nurse to include in the client's plan of care? (blood clot in vein: surface-layer; poor blood flow area)

In the immediate postoperative period, mobility is encouraged because veins require the assistance of the surrounding muscle beds to help pump blood toward the heart. This reduces venous stasis and the risk of thrombophlebitis. Increased fluid intake, if not contraindicated, will prevent dehydration and venous stasis. Therefore restriction of fluids may promote venous stasis and increase risk. Elevating the knee gatch of the bed will impede venous blood flow and increase the risk for thrombophlebitis.

A nurse is preparing a community health program for senior citizens. The nurse teaches the group that what physical findings are typical in older adults?

Increased blood pressure and decreased cardiac output With aging, narrowing of the arteries causes some increase in the systolic and diastolic blood pressures. Decreases occur in diastolic pressure, diastolic filling, and beta-adrenergic stimulation; increases occur in arterial pressure, systolic pressure, wave velocity, and left ventricular end diastolic pressure. Decreased cardiac output and cardiac reserve decrease the older adult's response to stress. Changes in libido may occur. Testosterone appears to influence the frequency of nocturnal erections; however, low testosterone levels do not affect erections produced by erotic stimuli. There is a loss of skin elasticity. By the age of 60, gastric secretions decrease 70% to 80% of those of the average adult. A decrease in pepsin may hinder protein digestion. There may be a decrease in subcutaneous fat and decreasing body warmth. Some swallowing difficulties occur because older people are susceptible to fluid loss and electrolyte imbalance. This results from decreased thirst sensation, difficulty swallowing, chronic disease, reduced kidney function, diminished cognition, or adverse drug reactions.

Which activity would the nurse explain can be performed by infants of aged 6 to 8 months?

Infants of aged 6 to 8 months may be able to transfer objects from hand to hand. Infants of aged 10 to 12 months may be able to hold a pencil. Infants of aged 8 to 10 months may show a hand preference. Infants of aged 10 to 12 months may be able to place objects into a container.

Which skill in critical thinking requires to be orderly in data collection?

Interpretation is involved in the orderly collection of data. When information about a client is collected with an open mind, then the skill called analysis is being used. When the data collected about the client helps in solving an existing problem, then the skill called inference is being used. Evaluation is used when the results of nursing actions are determined.

A client shows an increase in rate respirations that are abnormally deep and regular. What condition would the nurse expect?

Kussmaul's respiration is an alteration in the breathing process that is characterized by an increased and abnormal deep and regular rate of respiration. A client suffering from hypoventilation would have an abnormally low respiratory rate and the depth of ventilation is depressed. In Biot's respiration, respirations are abnormally shallow for two to three breaths, followed by irregular periods of apnea. An irregular respiratory rate and depth characterized by alternating periods of apnea and hyperventilation would be observed in a client with Cheyne-Stokes respiration.

A nurse is assessing a middle-aged client whose children have left home in search of work. The client is trying to adjust to these family changes. Which family life-cycle stage is the client going through?

Launching children and moving on The client is adjusting to a reduction in family size after the adult children have left home in search of work. The client is going through the launching children and moving on stage of the family life-cycle stage. An individual going through the family in later life stage deals with retirement and the loss of a spouse, siblings, or other peers. The family in the adolescents stage of the family lifecycle involves establishing flexible boundaries to accommodate the growing child's independence. An individual experiencing the unattached young adult stage begins to differentiate themselves from his or her family of origin. The young adult establishes him or herself at work while the young adult's parents experience the launching children and moving on stage.

Which action correlates with the relevance strategy of the motivational learning model proposed by John Keller?

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

A nurse is assessing an older adult during a regular checkup. Which findings during the assessment are normal? Select all that apply.

Loss of tugor, decreased night vision, decreased mobility of ribs In older adults, the skin loses its turgor or elasticity and there is fat loss in the extremities. Visual acuity declines with age; therefore, decreased night vision is a normal finding in older adults. Decreased mobility of the ribs is found in older adults due to calcification of the costal cartilage. Urinary incontinence is an abnormal finding in older adults. In older adults, diminished sensitivity to odor, not increased sensitivity, is often found.

What would be the behavioral characteristic of a slow-to-warm up child according to the theory related to temperament?

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

A nurse assesses for hypocalcemia in a postoperative client. What is one of the initial signs that might be present?

Normally, calcium ions block the movement of sodium into cells. When calcium is low, this allows sodium to move freely into cells, creating increased excitability of the nervous system. Initial symptoms are paresthesias(tingling/prickling sensation). This can lead to tetany if untreated. (seizure- involuntary muscle contraction) Headache, pallor, and blurred vision are not signs of hypocalcemia.

An older adult with a history of diabetes reports giddiness, excessive thirst, and nausea. During an assessment, the nurse notices the client's body temperature as 105° F. Which condition does the nurse suspect in the client?

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

A child is being treated with oral ampicillin for otitis media. What should be included in the discharge instructions that the nurse provides to the parents of the client?

Once antibiotic therapy is initiated, the antibiotics start to destroy specific bacterial infections that the healthcare provider is trying to treat. Antibiotic therapy takes a specific dose and number of days to completely eliminate the bacteria. If the caregivers start a dose and stop it before the course is complete, the remaining bacteria have a chance to grow again, become resistant to antibiotic treatment, and multiply. The nurse should not discourage use of herbal fever remedies; however, the herbal treatment should be reviewed to see if it is contraindicated. Ampicillin should be taken 1 to 2 hours after meals. Antibiotic therapy should be completed as prescribed.

What is the inflammation of the skin at the base of the nail called?

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

Two nurses are planning to help a client with one-sided weakness move up in bed. What should the nurses do to conform to a basic principle of body mechanics?

Positioning the nurses on either side of the bed with their feet apart, gathering the pull sheet close to the client, turning toward the head of the bed, and then moving the client places both nurses in a stable position in functional alignment, thereby minimizing stress on muscles, joints, ligaments, and tendons. The client should be instructed to fold the arms across the chest; this keeps the client's weight toward the center of the mass being moved and keeps the arms safe during the move up in bed. The nurses should assist the client in flexing the knees and placing the feet flat on the bed; this enables the client to push the body upward using a major muscle group. The client's assistance to the best of his or her ability reduces physical stress on the nurses as they move the client up in bed. On the count of three, weight should be shifted from the back to the front leg, not the front to the back leg. This action generates movement in the direction that the client is being moved.

An 82-year-old retired schoolteacher is admitted to a nursing home. During the physical assessment, the nurse may identify which ocular problem common to persons at this client's developmental level?:

Presbyopia is the decreased accommodative ability of the lens that occurs with aging. Tropia (eye turn) generally occurs at birth. Myopia (nearsightedness) can occur during any developmental level or be congenital. Hyperopia (farsightedness) can occur during any developmental level or be congenital.

Which position is indicated to assess the musculoskeletal system and is contraindicated in clients with respiratory difficulties?

Prone position is indicated to assess the musculoskeletal system in clients, but it is indicated with caution in clients with respiratory difficulties because they cannot tolerate this position well. Sims position is indicated to assess the rectum and vagina. Supine position is indicated for general examination of head and neck, anterior thorax, breast, axilla, and pulses. Knee-chest position is indicated for rectal assessment.

The nurse is caring for a client who had a hip replacement 2 days prior. After removing a bedpan from under the client, what is a priority nursing intervention?

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

Which physical assessment of the skin indicates that a client is addicted to phencyclidine?

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

Which nursing practice is associated with the self-regulation skill?

Reflecting on one's experience Self-regulation involves reflecting on the nurse's experience. Evaluation involves reflecting on the nurse's own behavior. Explanation involves supporting findings and conclusions. Interpretation involves clarifying any data about which the nurse is uncertain.

Which action made by the client indicates that they are in the precontemplation stage of Transtheoretical Model of Change?

Refuses to think about changing The Transtheoretical Model of Change model defines changing patterns in an individual in five stages based on beliefs of readiness to change. The phases are precontemplation, contemplation, preparation, action, and maintenance. The client refuses and does not think about the change in the precontemplation stage. The client intends to change in next 60 days in the preparation stage. The client recognizes the beneficial effects of the change and thinks about the change within 6 months in the contemplation stage. In the maintenance stage, the client sustains the changed action for 6 months and follows preventive measures to prevent relapse.

The nurse is developing a plan of care for the client who has activity intolerance. In determining the desired client outcomes, what should the nurse do?

Set priorities and outcomes using the client's and family input. Outcomes should be set with the client and family, if feasible, just as priorities of interventions are considered with the client and family when possible. Physical needs should be met before psychosocial needs. Outcomes may be developed using two methods: writing specific outcome statements or choosing outcomes from the NOC.

Which therapeutic communication technique involves using a coping strategy to help the nurse and client adjust to stress?

Sharing humor is a therapeutic communication technique that involves using a coping strategy that adds perspective and helps the nurse and client adjust to stress. Nurses should recognize that hope is essential for healing and communicate a sense of possibility. Sharing empathy is the ability to understand and accept another person's reality, accurately perceive feelings, and communicate this understanding to the other. Sharing observations often helps a client to communicate without the need for extensive questioning, focusing, or clarification.

The nurse recognizes that which is the mental process most sensitive to deterioration with aging?

Short-term memory During the aging process there is a progressive atrophy of the convolutions of the brain with a decrease in its blood supply, which may produce a tendency to become forgetful, a reduction in short-term memory, and susceptibility to personality changes. There should be little or no change in judgment. There is little or no intellectual deterioration; intelligence scores show no decline. Creativity is not affected by aging; many people remain creative until very late in life.

Culture Conditions

The client with neurasthenia may feel a lack of energy but not necessarily from following a strict diet to maintain body image. Shenjing shuairuo is a condition associated with Chinese culture that focuses on a weakness of nerves and is not associated with eating disorders or body image. Ataque de nervios is a Latino-Caribbean culture-bound syndrome and is not associated with body image

When assessing a client's fluid and electrolyte status, the nurse recalls that the regulator of extracellular osmolarity is what?

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

A client experiencing chills and fever is admitted to the hospital. After assessing the client's vitals and medical history, the nurse concluded that the client's fever pattern is remittent. Which assessment finding led to this conclusion?

The client's fever spikes and falls without a return to normal temperature levels In a remittent pattern of fever, the fever spikes and falls without a return to normal temperature levels. If the temperature returns to an acceptable value at least once in a 24 hour interval, the fever has an intermittent pattern. Periods of febrile episodes and periods with acceptable temperature values is a relapsing type of fever. In a sustained fever, the body temperature is constantly above 38°C and has little fluctuation.

A client presents to the healthcare facility with abdominal pain. Which question should the nurse ask the client to obtain information about concomitant symptoms?

Symptoms that accompany the primary symptom of the illness and worsen the health condition are called concomitant symptoms. An example is nausea that may accompany the primary symptom of pain. The nurse assesses the quality of the pain by asking the client to describe it. The nurse gathers information about the location of the illness by asking the client to identify the exact location. The nurse tries to understand the precipitating factors by asking the client about the activities that aggravate the pain.

A client who wakes up after a surgery spits out the oral airway placed during the recovery from anesthesia. What does this behavior indicate to the nurse?

The ability to spit out the oral airway indicates that the normal gag reflex has returned, and the client can protect his or her airway. Confusion due to anesthesia may be manifested as disorientation. The ability to spit put the airway does not mean that the client is nauseated. Oral airway is meant to keep the airway patent; it may not obstruct the airway.

The nurse is performing nursing care therapies and including the client as an active participant in the care. Which basic step is involved in this situation?

The basic step implementation involves performing nursing care therapies and including the client as an active participant in the care. Planning involves nursing processes such as developing an individualized care plan. Evaluation involves nursing processes such as identifying the success in meeting desired outcomes. Assessment involves nursing processes such as collecting data about a client's physical, psychological, social culture.

A client with a leg prosthesis and a history of syncopal episodes is being admitted to the hospital. When formulating the plan of care for this client, the nurse should include that the client is at risk for what?

The client is at risk for falls related to the leg prosthesis and history of syncope. There is no evidence or contributing factors in the client scenario of impaired cognition, imbalanced nutrition, or impaired gas exchange.

A client has relocated to a new city for work. The client is unable to continue the practice of walking for 30 minutes daily and exercising five days a week. Which stage of the transtheoretical model of health behavior change is the client experiencing?

The client is experiencing a relapse while attempting to make behavioral changes to his or her lifestyle. When relapse occurs, the client returns to the contemplation or precontemplation stage before attempting to change again. The action stage lasts for up to six months during which the client is actively engaged in strategies to change behavior. During the preparation stage, the client begins to believe that advantages outweigh disadvantages of behavior change. The maintenance stage begins six months after the change has started and continues indefinitely.

Which feature is characteristic of a risk nursing diagnosis?

The diagnosis does not have related factors. A risk nursing diagnosis describes human responses to health conditions that may develop in a vulnerable individual, family, or community. Risk diagnoses do not have related factors or defining characteristics because they have not occurred yet. A risk diagnosis has risk factors that help the nurse plan preventive measures. A health promotion nursing diagnosis can be applied to any individual with a desire to enhance health behaviors in any health state. An actual diagnosis is formed when the defining characteristics support the diagnostic judgment. There must be sufficient nursing assessment data to establish an actual diagnosis. A health promotion nursing diagnosis is a clinical judgment of an individual's readiness to increase well-being.

Which caring process is defined as "facilitating the other's passage through life transitions and unfamiliar events" according to Swanson's theory of caring?

The enabling process facilitates another's passage through life transitions and unfamiliar events such as birth and death. The knowing process involves understanding an event in terms of what it means to the life of another. Doing for caring involves doing for others as one would want for oneself, if possible. The caring process "being with" is defined as being emotionally present for someone else.

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?

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

Which nursing process involves delegation and verbal discussion with the healthcare team?

The implementation process involves delegation and verbal discussion with the healthcare team. Planning involves interpersonal or small group healthcare team sessions. Evaluation involves the acquisition of verbal and nonverbal feedback. Assessment involves verbal interviewing and a history of talking with the clients.

What would be the respiratory rate in two-year-old child?

The normal range for the respiratory rate in a two-year-old kid (toddler) is between 25 and 32 breaths per minute. Twenty breaths per minute is the normal respiratory rate in adolescents and adults. The normal respiratory rate in newborns is 40. The normal respiratory rate in infants is 50 breaths per minute.

The nurse is assessing a client who is undergoing chemotherapy. The nurse notes that the client is using a scarf to cover the head. The nurse asks the client about coping with the altered body image. Which functional pattern does the assessment include?

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

Which interventions should the nurse perform when caring for an actively dying client? Select all that apply.

The nurse should provide comfort care for a client who is actively dying by managing the client's symptoms and reassuring the client and family during the dying process. Reassuring the client and family by providing simple bits of information and using therapeutic communication during the dying process can help to reduce their emotional anxiety. Symptom management maximizes the client's quality of life and improves the client family experience with the dying process of a loved one. The client should not be admitted to hospice care while actively dying; there will likely not be enough time and this action could be traumatic for the client and family. A client is admitted to hospice care if they are not actively dying and death is expected within 6 months. The client does not require laboratory tests while actively dying. The client should be repositioned as needed for comfort; for example, placing the head of the bed in the highest position can facilitate breathing comfort.

Which nurse collaborates directly with the client to establish and implement a basic plan of care after admission?

The primary nurse provides or oversees all aspects of care, including assessment, implementation, and evaluation of that care. A clinician is an expert teacher or healthcare provider in the clinical area. The nurse coordinator oversees all the staff and clients on a unit and coordinates care. Clinical nurse specialist is a title given to a nurse specially prepared for one very specific clinical role. It requires a master's degree level of education.

Which body temperature measurement sites would be considered safe, inexpensive, and least invasive? Select all that apply.

The skin and axilla are the body temperature measurement sites that are considered safe, inexpensive, and least invasive. The oral route is an easily accessible site for temperature measurement, but it is invasive and increases the nurse's risk for body fluid exposure. The rectal route is also considered invasive, it is often not easily accessible, and it poses an increased risk of body fluid exposure. The tympanic route is an easily accessible site for temperature measurement, but it is invasive, and care should be taken when used in neonates, infants, and children.

Which pulse site is used to perform Allen's test? (assess' arterial blood supply of hand)

The ulnar pulse site is used to perform Allen's test. The brachial pulse site is used to assess the status of circulation to the lower arm and to auscultate blood pressure. The femoral site is used to assess the character of the pulse during physiological shock or cardiac arrest. The dorsalis pedis site is used to assess the status of circulation in the foot.

A client who is scheduled for a surgical resection of the colon and creation of a colostomy for a bowel malignancy asks why preoperative antibiotics have been prescribed. The nurse explains that the primary purpose is to do what?

To decrease the possibility of contamination, the bacteria count in the colon is lowered with antibiotics before surgery. Preoperative antibiotics do not have an effect on peristalsis, electrolyte balance, or treating inflammation.

Why does the nurse establish "moderately hard" client-centered goals? Select all that apply.

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