N333 Exam 1

Actual nursing diagnosis

A nursing diagnosis that indicates the client is currently experiencing the stated problem or has a dysfunctional pattern

One advantage for an institution to use an integrated cued/cllecklist type of assessment data form is that it A. allows a comprehensive and thorough picture of the client's symptoms. B. may be easily used by different levels of caregivers, which enhances communication. C. provides for easy and rapid documentation across clinical settings and populations. D. includes the 11 health care patterns in an easily readable format.

B. may be easily used by different levels of caregivers, which enhances communication.

The nurse is planning to interview a client who has demonstrated manipulative behaviors during past clinic visits. During the interview process, the nurse should plan to A. give the client rules with which he must agree to comply. B. provide structure and set limits with the client. C. tell the client that the nurse is aware of his past behaviors. D. approach the client in an authoritative manner.

B. provide structure and set limits with the client.

During an interview with an adult client for the first time, the nurse can clarify the client's statements by A. offering a "laundry list" of descriptors. B. rephrasing the client's statements. C. repeating verbatim what the client has said. D. inferring what the client's statements mean.

B. rephrasing the client's statements.

Waist circumference guidelines may not be accurate for adult clients who are shorter than five feet in height. This restriction is also a concern for which other anthropometric measurement? A. Ideal weight B. Mid-arm circumference C. Body mass index D. Triceps skin-fold measurements

C. Body mass index

One disadvantage of the open-ended assessment form is that it A. doesn't allow for individualization. B. asks standardized questions. C. requires a lot of time to complete. D. doesn't provide a total picture of the client.

C. requires a lot of time to complete.

Analysis of data

Diagnostic phase of the nursing process

Cognitive abilities

The fact or condition of knowing something with familiarity gained through experience or association

Health promotion nursing diagnosis

a nursing diagnosis that indicates the client has an opportunity to enhance a health status

culture

a shared set of values beliefs and learned pattern of behavior

A female client is assessed to have a score of 8 points on the AUDIT. This would alert the nurse that this client a. has a hazardous alcohol consumption b. is a heavy drinker c. is an at risk drinker d. is not at any risk for alcohol harm

a. has a hazardous alcohol consumption

Before beginning a physical assessment of a client, the nurse should first a. wash both hands with soap and water b. determine wether the client is anxious c. ask the client to remove all clothing d. request a family member to be present

a. wash both hands with soap and water

Knowledge

aptitude involving the act or process of knowing

Alert

awake and oriented

a normal pulse pressure rand for an adult client is typically a. 20-40 b. 30-50 c. 40-60 d. 60-80

b. 30-50

Which of the following is a collaborative problem a. risk for skin breakdown b. risk for osteoporosis c. risk for stress d. risk for rape trauma syndrome

b. risk for osteoporosis

A client of Chinese origin enters your office to be seen. You can assume a. the client will avoid direct eye contact because this conveys respect. b. the client will expect a larger interpersonal distance than you are used to. c. the client doe snot speak english d. the client may be well acculturated

d. the client may be well acculturated

skin color, hygiene, posture, gait, physical build, and development

overall impression

Dorsal surface of hand

part of examiners had used for temperature

difference between systolic and diastolic pressure

pulse pressure

Intuition

quick and ready insight

Sims position

side laying

Sittin position

sitting up

Obtunded

slow response, mumbles and incoherent, opens eyes to loud voice

Bell of stethoscope

smaller end of stethoscope used for low pitched sounds

Standing position

standing up

WHO definition of health

state of complete physical, mental, and social well being

highest pressure exerted on artery wall

systolic blood pressure

What is the most common measurement used to determine abdominal visceral fat? A. Waist circumference B. Body mass index (BMI) C. Subcutaneous fat determination D. Triceps skin-fold thickness

A. Waist circumference

Loss of connection with one's spiritual support most often leads to A. a new-found sense of liberation. B. spiritual distress. C. improved sense of health and well-being. D. increased adherence to religious practices.

B. spiritual distress.

Stupor

awakens to painful stimuli and then goes back to sleep

5 degrees C lower than oral temperature

axillary temperature

while assessing an older adult clients respirations, the nurse can anticipate that the respiratory pattern may exhibit a a. shorter inspiratory phase b. longer inspiratory phase c. shorter expiratory phase d. longer expiratory phase

b. observe for equal bilateral chest expansion

the path one pursues in the search for lives meaning and purpose a. religion b. spirituality c. denomination d. philosophy

b. spirituality

Which of the following is a stage in Walkers cycle of violence a. reporting the problem b. hiding the abuse c. period of reconciliation d. ending the relationship

c. period of reconciliation

During a comprehensive assessment, the primary technique used by the nurse throughout the examination is a. palpaiton b. percussion c. asucultation d. inspeciton

d. inspeciton

While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using a. inspection b. palpation c. doppler magnification d. percussion

d. percussion

While performing a physical examination on an older adult, the nurse should plan to a. complete the examination as quickly as possible b. ask the client to change positions frequently c. provide only minimal teaching related to health care d. use minimal position changes

d. use minimal position changes

Lithotomy position

laying on back with knees bent and feet in stirrups

Prone position

laying on stomach

Diagnostic phase

A nursing diagnosis that indicates the client is currently experiencing the stated problem or has a dysfunctional pattern

The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write A. "Bilateral lung sounds clear." B. "The client's lung sounds were clear on both sides." C. "Client's lung sounds were auscultated with stethoscope and were clear on both sides." D. "After listening to client's lung sounds, both lungs appeared clear."

A. "Bilateral lung sounds clear."

The nurse is caring for an adult client who tells the nurse "For weeks now, I just can't get to sleep at night because of all the noise in my neighborhood." An actual nursing diagnosis for this client is A. Fatigue related to excessive noise levels as manifested by client's statements of chronic fatigue. B. Sleep deprivation related to noisy neighborhood and inability to sleep. C. Chronic fatigue syndrome related to excessive levels of noise in neighborhood. D. Readiness for enhanced sleep related to control of noise level in the home.

A. Fatigue related to excessive noise levels as manifested by client's statements of chronic fatigue.

The nurse is beginning a health history interview with an adult client who expresses anger at the nurse. The best approach for dealing with an angry client is for the nurse to A. allow the client to ventilate his or her feelings. B. offer reasons why the client shouldn't feel angry. C. provide structure during the interview. D. refer the client to a different health care provider.

A. allow the client to ventilate his or her feelings.

An assessment form commonly used in long-term care facilities is the nursing minimum data set. One primary advantage to this type of assessment form is that it A. establishes comparability of nursing data across clinical populations. B. clusters all the nursing and medical diagnoses in one place. C. allows for individualization for each client in the health care setting. D. uses a flow chart format for easy documentation of objective data.

A. establishes comparability of nursing data across clinical populations.

The nurse is caring for an adult female client whose body mass index is 38.7. The nurse should instruct the client that she is at greater risk for: A. heart attack. B. osteoporosis. C. rheumatoid arthritis. D. stomach cancer.

A. heart attack.

Because the nurse realizes that spirituality varies, information gained will assist the nurse in A. individualizing interventions to meet specific needs. B. diagnosing the client with spiritual distress. C. teaching strict adherence to rituals and practices to improve outcomes. D. providing an overview of widely held beliefs from the major religions

A. individualizing interventions to meet specific needs.

The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form A. prevents missed questions during data collection. B. covers all the data that a client may provide. C. clusters the assessment data with nursing diagnoses. D. establishes comparability of data across populations.

A. prevents missed questions during data collection.

The nurse is planning to assess a newly admitted adult client. While gathering data ft-om the client, the nurse should A. validate all data before documentation of the data. B. document the data after the entire exa~nination process. C. record the nurse's understanding of the client's problem. D. use medical terms that are comn~onlyu sed in health care settings.

A. validate all data before documentation of the data.

The nurse documents that a 45-yearold male is 5 feet 10 inches tall and weighs 215 pounds. He tells the nurse that he "has a good appetite, but doesn't get much exercise because of his busy work schedule." An appropriate NANDA nursing diagnosis for this client is A. Normal body nutrition related to healthy eating patterns and good appetite. B. Altered nutrition, more than body requirements related to intake greater than calories expended. C. Risk for altered nutrition, more than body requirements related to lack a routine exercise. D. Obesity related to lack of exercise.

B. Altered nutrition, more than body requirements related to intake greater than calories expended.

Based only on anthropometric measurements, which set of clients listed below is at the greatest risk for diabetes and cardiovascular disease? A. Clients with a body mass index of 23 B. Females with 35 inches or greater waist circumference C. Males with 35 inches or greater waist circumference D. Clients with a body mass index of 20

B. Females with 35 inches or greater waist circumference

The nurse is preparing to document assessment findings in a client's record. The nurse should A. write in complete sentences with few abbreviations. B. avoid slang terms or labels unless they are direct quotes. C. record how the data were collected. D. use the term normal for normal findings.

B. avoid slang terms or labels unless they are direct quotes.

While interviewing an adult client about her nutrition habits, the nurse should A. ask the client for a 3-day recall of food intake. B. review the food pyramid with the client. C. ask the client about limitations to activity. D. encourage the client to drink three to four glasses of water daily.

B. review the food pyramid with the client.

Knowledge of the client's beliefs in the cause of illness can be useful to the nurse in order to A. encourage new beliefs. B. dispel religious teachings if they conflict with the nurse's belief system. C. promote harmony between health and spirituality. D. raise doubt and point out flaws in one's faith.

C. promote harmony between health and spirituality.

The nurse is preparing to measure the triceps skin-fold of an adult client. The nurse should A. ask the client to assume a sitting position. B. measure the triceps skin-fold in the dominant arm. C. repeat the procedure three times and average the measurements. D. pull the skin toward the muscle mass of the arm.

C. repeat the procedure three times and average the measurements.

Suzie is a 16-yearold daughter in the Hanes family. She is the youngest of five children. She has had a series of illnesses and does not seem to be regaining her strength. She likes school but is falling behind a bit. Her mother is very attentive to her needs but does not seem overly concerned with the continuing pattern of illness. Which of the following is most likely a Hanes family belief? A. Fathers are not involved with their children. B. Education is highly valued for sons and daughters. C. the family values taking sick roles and caregiver roles D. self care is highly valued int he Hanes family

C. the family values taking sick roles and caregiver roles

During the interview between a nurse and a client, the nurse and the client collaborate to identify problems and goals. This occurs during the phase of the interview termed A. introductory. B. ongoing. C. working. D. closure.

C. working.

While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is A. "Do you feel stress at work?" B. "How often do you feel stressed?" C. "Is stress a problem in your life?" D. "How do you manage your stress?"

D. "How do you manage your stress?"

If the nurse makes an error while documenting findings on a client's record, the nurse should A. erase the error and make the correction. B. obliterate the error and make the correction. C. draw a line through the error and have it witnessed. D. draw a line through the error, writing "error" and initialing.

D. draw a line through the error, writing "error" and initialing.

The nurse is preparing to interview an adult client for the first time. The nurse observes that the client appears very anxious. The nurse should A. allow the client time to calm down. B. avoid discussing sensitive issues. C. set time limits with the client. D. explain the role and purpose of the nurse.

D. explain the role and purpose of the nurse.

The nurse is planning to interview a client who is being treated for depression. When the nurse enters the examination room, the client is sitting on the table with shoulders slumped. The nurse should plan to approach this client by A. providing the client with simple explanations. B. offering to hold the client's hand. C. using a highly structured interview process. D. expressing interest in a neutral manner.

D. expressing interest in a neutral manner.

In some health care settings, the institution uses an assessment form that assesses only one part of a client. These types of forms are termed A. progressive. B. specific. C. checklist. D. focused.

D. focused.

During a client interview, the nurse asks questions about the client's past health history. The primary purpose of asking about past health problems is to A. determine whether genetic conditions are present. B. summarize the family's health problems. C. evaluate how the client's current symptoms affect lifestyle. D. identifv risk factors to the client and his or her significant others

D. identifv risk factors to the client and his or her significant others

While recording the subjective data of an adult client who complains of pain in his lower back, the nurse should include the location of the pain and the A. cause of the pain. B. client's caregiver. C. client's occupation. D. pain relief measures.

D. pain relief measures.

Before the nurse analyzes the data collected, the nurse should A. determine collaborative problems with the health care team. B. group the data into clusters or groups of problems. C. generate possible hypotheses for the client's problems. D. perform the steps of the assessment process accurately.

D. perform the steps of the assessment process accurately.

A common error for beginning nurses who are formulating nursing diagnoses during data analysis is to A. formulate too many nursing diagnoses for the client and family. B. include too much data about the client in the history, C. obtain an insufficient number of cues and cluster patterns. D. quickly make a diagnosis without hypothesizing several diagnoses.

D. quickly make a diagnosis without hypothesizing several diagnoses.

During a thorough spiritual assessment, the nurse understands that the questions asked are designed to A. encourage the client to explore other religions. B. cause the client to question long-held beliefs. C. determine if the client and nurse have similar beliefs. D. reveal beliefs that might affect client care.

D. reveal beliefs that might affect client care.

One characteristic of a nurse who is a critical thinker is the ability to A. form an opinion quickly. B. offer advice to clients C. be right most of the time. D. validate information and judgments.

D. validate information and judgments.

An example of an objective finding in an adult client is A. a client's symptom of pain. B. family history data. C. genetic disorders. D. vital signs.

D. vital signs.

Because body mass index (BMI) is calculated using only height and weight, the nurse knows that inaccurate findings would most likely occur in a client A. with diabetes. B. who is six feet tall. C. with osteoarthritis. D. who is a bodybuilder.

D. who is a bodybuilder.

minority

a group with less power or prestige within a society

Risk nursing diagnosis

a nursing diagnosis that indicates the client does not currently have a problem but is at high risk for developing it

ethnocentrism

a shared set of values, beliefs, and learned pattern of behavior

race

a socially constructed concept that has meaning for a larger group

When formulation a nursing diagnosis, the format that is most useful to clearly document the client's problem is a. NANDA label + related to + etiology + aMB + defining characteristics b. NANDA label + defining charcteristics + AMB c. NANDA label + definition + defining characteristics + AMB d. NANDA label + definition + etiology + AMB + defining characteristics

a. NANDA label + related to + etiology + aMB + defining characteristics

which of the following statements is true of sickle cell disease and other hemoglobinopathies a. are associated with adapting to high malaria environments b. ar found only in persons of black african origin c. are associated with ashkenazi jewish genes d. are associated with the far east

a. are associated with adapting to high malaria environments

Before beginning a client interview to assess for the presence of violence, necessary preparations include all except which of the following a. assure confidentiality of all information revealed b. choose an environment where the conversation will not be overheard by others c. discuss legal mandatory reporting requirements d. provide an appropriate interpreter if the client does not speak english

a. assure confidentiality of all information revealed

which of the following statements is true about biologic variation a. both genetics and environment produce biologic variation b. cultural practices produce biologic variation c. race is based on physical variations d. drug metabolism differences are not culture based

a. both genetics and environment produce biologic variation

an elderly client is seen by the nurse in the neighborhood clinic. the nurse observes that the client is dressed in several layers of clothing,, although the temperature is warm outside. the nurse suspects that the clients cold intolerance is a result of a. decreased body metabolism b. neurologic deficits c. recent surgery d. pancreatic disease

a. decreased body metabolism

The nurse assesses a client using the Glasgow Coma Scale. Which of the following indicators will be used to determine the score a. eye opening, and appropriateness of verbal and motor responses b. ability to recall recent and remote memories and used to abstract reasoning c. assessment of the 12 cranial nerves d. naming of objects, recall of three words and ability to redraw a design

a. eye opening, and appropriateness of verbal and motor responses

During a comprehensive assessment of the lungs of an adult client with a diagnosis of emphysema, the nurse anticipates that during percussion the client will exhibit a. hyperresonance b. tympany c. dullness d. flatness

a. hyperresonance

When interviewing a client for the first time, the nurse is using a standardized nursing history form. The nurse should a. maintain eye contact while axing the questions form the form b. read the questions verbatim from the form c. ask the client to complete the form d. leading questions throughout the interview

a. maintain eye contact while axing the questions form the form

Risk factors for mental disorders a. may be specific to an ethnic group b. are the same for all ethic groups c. do not affect treatment plans d. are the same as risks for brain injury

a. may be specific to an ethnic group

While caring for an 80 year old client in his home, the nurse determines that the clients oral temperature is 96.5. the nurse determines that the client is most likely exhibiting a. normal changes that occur with the aging process b. hypothermia that occurs before an infectious process c. a metabolic disorder resulting in circulatory changes d. an immune disorder resulting in low platelet count

a. normal changes that occur with the aging process

When assessing the clients pulse, the nurse should be alert to which of the following characteristics a. rate, rhythm, amplitude and contour and elasticity b. rate, rhythm, temperature, rigidity, color, and elasticity c. tenderness, moistness, contour, elasticity, pressure d. apin, temperature, amplitude, contour and elasticity

a. rate, rhythm, amplitude and contour and elasticity

the nurse assesses the clients vital signs as follows: respirations 20, tympanic temperature: 100.9, pulse 88, bp 104/64 a. record the vital signs b. instruct eh patient to drink more fluids c. refer the client to a primary care provider d. administer tylenol

a. record the vital signs

Shared practices and rituals used to express ones faith can be called a. religion b. spirituality c. denomination d. philosophy

a. religion

A client has an oral temperature of 37.2 degrees C (99 degrees F). The nurse interviews the client. Which of the following pieces of interview data could be an influence on this high body temperature a. the client has just run 4.82 km (3 miles) before coming in b. client drinks 8 glasses of water a day c. client has a history of hypothyroidism d. the client reports having a toe infection treated with antibiotics 3 months ago

a. the client has just run 4.82 km (3 miles) before coming in

which of the following is suggested for family abuse screening a. universal creeping for family and intimate partner violence is recommended b. if there are no obvious signs of abuse, there is no need to screen clients c. only childbearing aged and pregnant women should be routinely screened for sexual abuse d. assess for physical abuse only at the beginning of a couples new relationship

a. universal creeping for family and intimate partner violence is recommended

During a comprehensive assessment of an adult client, the nurse can best hear high-pitched sounds by using a stethoscope with a a. 1-inch bell b. 1 1/2 inch diaphragm c. 15-inch flexible tubing d. 1-inch diaphragm

b. 1 1/2 inch diaphragm

Skin color is a. darker in person with tightly curled hair b. a genetic variation associated with distance form the equator c. a valid predictor of intelligence d. valid characteristic that differentiates racial groups

b. a genetic variation associated with distance form the equator

which of the following is true of psychological abuse a. psychological abuse is easy to define and diagnose b. an abuser may use psychological behaviors such as belittling, exploiting, denigrating, or remaining emotionally unresponsive c. the majority of children experiencing psychological abuse do not use effective coping mechanisms d. psychological abuse of children does not affect long term development

b. an abuser may use psychological behaviors such as belittling, exploiting, denigrating, or remaining emotionally unresponsive

The CAGE assessment is used by the nurse to determine if further assessment is needed. the nurse may assess that it is highly likely the client has a problem and would seek additional assessments if the client a. answered "yes" to one of the four questions b. answered "yes" to three of the four questions c. answered "no" to all four questions d. answered "no" to three of the four questions

b. answered "yes" to three of the four questions

While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's a. lungs b. bone c. liver d. abdomen

b. bone

elder abuse can include a. nursing home admission b. economic exploitation c. using an elder day care sitter d. uncontested divorce

b. economic exploitation

To alleviate a client's anxiety during a comprehensive assessment, the nurse should a. begin with intrusive procedure first to get them completed quickly b. explain each procedure being performed and the reason for the procedure c. remain in the examination room while the client changes into a gown d. ask the client to sign a consent for the physical examination

b. explain each procedure being performed and the reason for the procedure

a culture bound syndrome seen in the african american community is a. empacho b. falling out c. susto d. sickle cell disease

b. falling out

The nurse is interviewing Mr. Jenkins and due particularly to his nervous affect and his reaction when his son is mentioned, suspects potential elder abuse. in assessing Mr. Jenkins, the nurse should a. focus exclusively on the physical examination, as elder abuse is primarily physical in nature b. make sure that the assessment includes questions to ensure that Mr. Jenkins has access to food and needed medication c. ask to speak to Mr. Jenkins son directly, to ask him candidly about the potential abuse d. keep in mind that elder abuse is usually reported, indicating that Mr. Jenkins is not likely a victim

b. make sure that the assessment includes questions to ensure that Mr. Jenkins has access to food and needed medication

The nurse and Hispanic client are developing a transcultural nursing care plan related to hypertension. the nurse will include int he plan a. educational material given to all clients with hypertension b. nutritional information specifically for a hispanic client c. contact number for the cardiac rehabilitation program at the medical center d. referral to a cardiac specialist

b. nutritional information specifically for a hispanic client

The nurse is preparing to assess the respiration of an alert adult client. the nurse should a. explain to the client that he or she will be counting the clients respirations b. observe for equal bilateral chest expansion c. count for 15 seconds and multiply the number by 4 d. ask the client to lie in a supine position which makes counting respirations easier

b. observe for equal bilateral chest expansion

As part of assessing the client's level of consciousness, the nurse asks questions related to person, place, and time. Which of these statements is true a. orientation to person is usually lost first and time lost last b. orientation to time is lost first and person lost last c. orientation to person is lost first and place is lost last d. orientation to time is lost first and place is lost last

b. orientation to time is lost first and person lost last

The nurse documents findings from the client's responses to the SLUMS test. The following information will be documented as a result of this test a. mood, feelings, expressions and perceptions b. orientation, memory, speech and cognitive function c. energy level, satisfaction, and social participation d. appropriateness of dress, grooming, and eye contact

b. orientation, memory, speech and cognitive function

When interviewing a pediatric client and attempting to determine the presence of abuse, the nurse should a. confine the interview to yes/no questions to keep the interview simple b. remain calm and accepting in response to any information the client discloses c. ask leading questions to convince the child to offer information d. offer a reward to the child for answering difficult questions

b. remain calm and accepting in response to any information the client discloses

to give spiritual care to a client, it is not necessary for the nurse to a. recognize that depression may result form unmet religious group expectations b. share the same religious beliefs as the client to provide effective spiritual care c. be aware of personal religious beliefs and biases in order to provide effective spiritual care d. prepare to help clients seek a source of strength and hope form their own clients religion and spiritual beliefs

b. share the same religious beliefs as the client to provide effective spiritual care

when would a nurse obtain a mid arm circumference measurement a. to confirm an abnormal albumin level b. to provide percentage of body fat and muscle tissue c. to screen for nutritional excess or deficits d. to assist in determining body mass index

b. to provide percentage of body fat and muscle tissue

Which of the following is true about violence against women a. verbal attacks by a husband are not considered violence against a wife b. wife abuse is an accepted behavior in some societies c. between married couples, there is no behavior that meets the criteria for rape d. violence against women is recent development in the united states

b. wife abuse is an accepted behavior in some societies

Supine position

back lying position

After using the SLUMS tool to test a client's mental status, the nurse calculates a score of 12. The nurse should make a. the nursing diagnosis: disturbed though process related to substance abuse b. the nursing diagnosis: ineffective decision making related to loss of memory c. a referral to the primary health care provided for further evaluation d. a referral for the family and client to seek mental health counseling

c. a referral to the primary health care provided for further evaluation

The nurse is caring for a client who is having nothing by mouth on the first postoperative day. the clients blood pressure was 120/80 mm Hg approximately 4 hours ago, but it is now 140/88 mm Hg. the nurse hold ask the client which of the following questions a. are you taking any medications for hypertension b. do you have enough blankets to stay warm c. are you having pain form your surgery d. what is your typical blood pressure reading

c. are you having pain form your surgery

while providing spiritual care to clients, nurses must avoid a. assessing spiritual needs of clients b. praying with clients as requested c. attempting to convert clients to your own beliefs d. helping clients determine spiritual aspects of responses to illness

c. attempting to convert clients to your own beliefs

Of the following measurements, which one helps to determine if a client is underweight, normal weight or obese a. mid arm circumference b. triceps skinfold c. body mass index d. waist hip ration

c. body mass index

During palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing a. light palpation b. moderate palpation c. deep palpation d. bimanual palpation

c. deep palpation

The client's daughter asks the nurse why the nurse is asking her mother depression-related questions. The nurse explains that even though the client has symptoms of dementia, the Geriatric Depression Scale is being used because a. depression and dementia are one in the same disorder b. finding out why she is depressed and will help determine the cause of her dementia c. depression often mimics signs and symptoms of dementia d. it is the most accurate tool to determine the stage of dementia

c. depression often mimics signs and symptoms of dementia

While examining a client, the nurse plans to palpate temperature of the skin by using the a. fingertips of the hand b. ulnar surface of the hand c. dorsal surface of the hand d. palmar surface of the hand

c. dorsal surface of the hand

A hispanic mother brings her 2 year old child to the clinic for a well child check up and age appropriate vaccinations. which of the following observations indicate potential abuse at home a. bruising across the lower back and upper buttocks bilaterally b. symmetrical nickel-sized circular bruising across upper back c. hand or finger patterned bruising around upper arm and leg d. scraped and bruised knee

c. hand or finger patterned bruising around upper arm and leg

The most commonly used method of percussion is a. direct percussion b. mild percussion c. indirect percussion d. blunt percussion

c. indirect percussion

Jonny is a 5 year old boy who comes to the clinic for his scheduled injections. Which physical indications would lead you to suspect child abuse a. bruising on the upper portion of his buttocks b. regular pattern of circular, coin sized reddened areas on his back c. irregular pattern of small, circular reddened areas with healing blisters on various parts of his body d. crying when he sees the needle for the injection

c. irregular pattern of small, circular reddened areas with healing blisters on various parts of his body

which of the following is not a true statement about intimate partner violence a. one in every three women worldwide is a victim of intimate partner violence at some point in her life b. intimate partner violence is based on the abusers red to maintain power and control over the victim c. it is related to the female refusing sex from the male

c. it is related to the female refusing sex from the male

The nurse is preparing to assess an adult client in the clinic. the nurse observes that the client is wearing lightweight clothing that is worn and soiled, although the temperature is below freezing outside. the nurse anticipates that the client may be a. abusing drugs b. a victim of abuse c. lacking adequate finances. d. anxious

c. lacking adequate finances.

Sickle cell disease and other hemoglobinopathies such as thalassemia are often found in persons origination from which geographical regions a. south america b. south africa c. mediterranean d. australia

c. mediterranean

the nurse notes which of the following vital sign findings as an abnormal finding inane 88 year old client a. 55 mm Hg pulse pressure b. respiratory rate of 22 bpm c. oral temperature of 37.7 degrees C (100 degrees F) d. blood pressure of 140/90 mm Hg

c. oral temperature of 37.7 degrees C (100 degrees F)

Select the following nursing diagnosis that is correctly stated a. risk for impaired skin integrity related to immobility, bed rest, pain in legs, and the client states "I will not go to physical therapy" b. risk of impaired skin integrity related to immobility as manifested by constant bed rest and the inability to ambulate the client twice a day c. risk for impaired skin integrity related to immobility secondary to right sided paralysis, dehydration, and reluctance to participate in physical therapy as manifested by reddened coccyx and very dry skin

c. risk for impaired skin integrity related to immobility secondary to right sided paralysis, dehydration, and reluctance to participate in physical therapy as manifested by reddened coccyx and very dry skin

The nurse is assessing an elderly post surgical client in the home. To begin the physical examination, the nurse should firs asses the clients a. hight and weight b. ability to swallow c. vital signs d. gait

c. vital signs

Syndrome nursing diagnosis

clinical judgments that describe a specific cluster of nursing diagnoses that occur together and have similar nursing interventions to resolve the situation

to quickly identify a client who may be at risk for nutritional problems, the nurse can use which of the following assessments a. lab blood work b. a comprehensive nutritional exam c. a physical examination d. a nutritional screening tool

d. a nutritional screening tool

When the nurse asks the client to explain similarities and differences between objects, what cognitive ability is being tested a. judgment b. concentration c. memory to learn new information d. abstract reasoning

d. abstract reasoning

illness can be affected by which of the following spiritual beliefs a. beliefs about cause of illness b. beliefs about meaning of suffering c. beliefs about dietary practices d. all of the above

d. all of the above

An adult client visits a clinic and tells the nurse that she suspects she has a urinary tract infection. To detect tenderness over the client's kidneys, the nurse should instruct the client that he or she will be performing a. moderate palpation b. deep palpation c. indirect percussion d. blunt percussion

d. blunt percussion

When the nurse places one hand flat on the body surface and uses the fist of the other hand to strike the back of the hand flat on the body surface, the nurse is using a. firm percussion b direct percussion c. indirect percussion d. blunt percussion

d. blunt percussion

A clients blood pressure is affected by a. cardiac intake, elasticity of the arteries, blood flow, blood cells, and blood thickness b. cardiac intake, elasticity of the veins, blood flow, blood cells, and blood thickness c. cardiac output, distensibility of the veins, blood volume, blood velocity and viscosity d. cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity

d. cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity

stereotyping is defined as a. the belief that ones cultural values are superior to all others b. a worldview that each of us forms values and beliefs based on our own culture c. a culture bound syndrome found in many cultural groups d. expecting all members of a cultural group to hold the same beliefs and behave in the same way

d. expecting all members of a cultural group to hold the same beliefs and behave in the same way

which of the following is not a true statement about intimate partner violence a. one in every three women worldwide is a victim of intimate partner violence at some point in her life b. intimate partner violence is based on the abusers need to maintain power and control over the victim c. the annual cost in the united states for intimate partner violence exceeds 4 billion for medical and health services and over 1 billion for lost productivity d. intimate partner violence is caused by the victim refusing her husbands desire for sex

d. intimate partner violence is caused by the victim refusing her husbands desire for sex

Osteoporotic thinning and collapse of the vertebrae secondary to bone loss in an elderly client may result in a. lordosis b. scoliosis c. skeletaldosis d. kyphosis

d. kyphosis

Which of the following statements is true of cultural group sod magicoreligious beliefs in their health belief systems a. western majority culture does not have magicoreligious beliefs b. hispanic culture has magic beliefs but not religious beliefs d. no culture is without an element of magicoreligious beliefs

d. no culture is without an element of magicoreligious beliefs

Which of the following statements is true a. second generation US citizens from mexico usually eat a diet primarily based on beans and tortillas b. there is no need to adjust diets according to religious rituals for italians c. fasting for lent or ramadan is not acceptable for health reasons d. pork and wine are forbidden in many ethnic groups for religious reasons

d. pork and wine are forbidden in many ethnic groups for religious reasons

The most effective way for a nurse to learn about an ethnic group within the community in which he/she practices is a. study transcultural nursing texts and articles about the group b. interview the traditional healers within the group c. do a community survey of the areas where the ethnic group lives d. spend times with a variety of individuals for that ethnic group

d. spend times with a variety of individuals for that ethnic group

lowest pressure exerted on artery walls

diastolic pressure

An approximate reading go fore body temperature can be taken at various anatomic sites. Which is not a correct place to take a core body temp a. under tongue b. forehead and temporalarter c. opening of ear d. rectum e. groin

e. groin

body mass index

estimate total body fat

visceral fat

excess fat within the abdominal cavity

ethnicity

exists when socially, politically or culturally constructed group holds a common set of characteristics not shared by others

Personality and spirituality

factors affecting mental health

Sedentary lifestyle, substance abuse, exposure to violence

factors affecting mental health

pain

fifth vital sign

Diaphragm of stethoscope

larger end of stethosccope used to detect breath sounds, normal heart sounds and bowel sounds

cachexia

malnutrition sometimes seen in clients with cancer

Mental health

necessary for total health

less than 80 mm Hg

normal diastolic blood pressure range

96-99.9

normal oral temperature

60-100 BPM

normal pulse

12-20

normal respiratory rate

less than 120 mm Hg

normal systolic blood pressure range

Lethargy

opens eyes and answers questions but falls back asleep

more accurate than oral temperature

temporal artery temperature

Critical thinking

the way in which one processes information

normally about 1.4 degrees F higher than the normal oral temperature

tympanic temperature

Mental disorder

underlying psychobiologic dysfunction

Coma

unresponsive to all stimuli

mid arm circumference

used to assess skeletal muscle mass

triceps skinfold

used to evaluate subcutaneous fat stores

Finger pads

used to feel for fine discriminations, pulses, texture, size, consistency, shape and cerpitus

Unlar surface or pam of hand

used to feel for vibration, thrills or fremitus