NUR 210 Exam 1 Prep U

The nurse is reviewing a client's health history and the results of the most recent physical examination. Which of the following data would the nurse identify as being subjective? Select all that apply. "I feel so tired sometimes." "My father died of a heart attack." Weight: 145 lbs Lungs clear to auscultation Client complains of a headache Pupils equal, round, and reactive to light

"I feel so tired sometimes." Client complains of a headache "My father died of a heart attack."

The nurse is integrating health promotion education into the assessment of a client's heart and neck vessels. What teaching point addresses the most significant risk factor for coronary artery disease? "Your risk for heart disease will drop greatly if you're able to stop smoking." "If you can eliminate red meat from your diet, your risk of heart disease will drop significantly." "Try to ensure that you're screened for heart disease at least once every six months." "Anything that you can do to reduce stress in your life will benefit your heart health."

"Your risk for heart disease will drop greatly if you're able to stop smoking." Explanation: Smoking is among the most significant risk factors for heart disease. Screening does not need to be performed on a twice yearly basis. Stress reduction is beneficial, but smoking is a greater risk factor than stress. Dietary fat is a risk factor, but for most clients there is not a need to wholly eliminate red meat from the diet.

An adult client weighs 175 pounds and is 5 feet 6 inches tall. The nurse determines that the client's body mass index is which of the following? 18 12 25 28

28

The principle of confidentiality is of paramount importance in the nurse-patient relationship. When should you inform the patient of with whom his or her information will be shared? At the end of the interview When the patient asks Whenever it seems appropriate At the beginning of the interview

At the beginning of the interview

A mother brings her baby to the pediatric clinic for a 1-year-old wellness check. At birth the baby measured 22 inches and weighed 8 lbs. The nurse would expect to find which of the following when assessing the baby? Baby measures 28 inches and weighs 20 lbs. Baby measures 33 inches and weighs 24 lbs. Baby measures 28 inches and weighs 18 lbs. Baby measures 28 inches and weighs 16 lbs.

Baby measures 33 inches and weighs 24 lbs. Explanation: When assessing normal growth and development, the pattern expected for the infant to 1 year old is to increase the height by one and one-half times the birth length and to triple the birth weight by age 1 year. Therefore, the nurse would expect this child to be 33 inches and weigh 24 lbs.

The nurse is about to leave the floor for her lunch break. Before leaving she must report using the SBAR model to the nurse who is to care for the patient during her absence. She tells the nurse, "The patient was admitted 8 hours ago after spending the night in the ER with abdominal and back pain. He has had numerous tests; results indicate that he has gallstones. He is scheduled for surgery tomorrow." What part of the SBAR model does this information represent? Recommendation Situation Background Assessment

Background Explanation: The model known as SBAR is for improving communication between and among clinicians. The S stands for situation--why the nurse is communicating; B stands for background--the circumstances leading up to current situation; A is for assessement--objective and subjective data pertinent to the situation; and R is for recommendation--the nurse's suggestions of what needs to be done to manage the problem. In this case, the nurse gave background information when reporting.

The nurse is preparing to palpate the posterior tibial pulse. At which location would the nurse expect to palpate? Behind the ankle In the groin area Just behind the knee At the top of the foot

Behind the ankle

The client comes to the health care provider stating he has a sore throat and believes he needs an antibiotic. This is an example of of what type of model for health? Biomedical Alternative Complementary Spiritual

Biomedical

Which of the following statements relating to assessment of the lungs and thorax is most accurate? Moderate to severe chest pain is associated with a cardiac etiology, while mild to moderate chest pain is most often respiratory in origin. Bronchitis is characterized by excess mucus production and chronic cough. Hemoptysis is more common in children and adolescents than in older clients. Loud and very loud percussion notes denote pathological findings.

Bronchitis is characterized by excess mucus production and chronic cough. Explanation: Bronchitis is marked by a chronic, productive cough that results from excess mucus production. Hemoptysis is uncommon in younger clients. It would be simplistic to differentiate cardiac from respiratory chest pain based on severity alone. Similarly, it is inaccurate to characterize all loud percussion sounds as pathological.

The nurse should perform which priority assessment on a client with a history of a high hydrogenated fat intake? Musculoskeletal Respiratory Skin Cardiac

Cardiac Explanation: The cardiac assessment is of priority concern for this client. Foods made with hydrogenated fats are particularly harmful to the diet because they are the largest contributors of trans fats. Empirical evidence suggests that trans fats are as damaging to the heart and blood vessels as saturated fats (Mente de Koning, Shannon, and Anand, 2009).

A client reports pain as being 7 on a scale from 1 to 10. In which area of the symptom should the nurse document this information? Duration Characteristic Location Onset

Characteristic

A nurse draws a genogram to help organize and illustrate a client's family history. Which shape is a standard format for representing a deceased female relative? Circle with a cross Simple circle Square with a cross Simple squareuare

Circle with a cross Explanation: The standard format for representing a deceased female relative in a genogram is using a circle with a cross. A simple circle indicates a living female relative. A simple square indicates a living male relative. A square with a cross indicates a deceased male relative.

A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use? Coin or key Reflex hammer Tuning fork Tongue depressor

Coin or key Explanation: The nurse needs a coin or a key to test the client for stereognosis, which is the ability to recognize objects by touch. A reflex hammer is used to determine deep tendon reflexes. A tuning fork is used to test for vibratory sensation. A tongue depressor is used to test for the rise of the uvula and gag reflex.

A nurse is working in a health care facility that uses charting by exception. Which of the following would the nurse expect to document? Bowel sounds normoactive Liver palpation normal No tenderness on palpation Decreased range of motion in right shoulder

Decreased range of motion in right shoulder

An elderly patient with terminal cancer is admitted to the medical unit. He has been told that he has only a few weeks left to live. Later that evening, he becomes very agitated and starts cursing at the nurses and visiting family members. He yells, "I am a failure. I never amounted to anything. My life was a waste. Now I have a few more weeks left. I know you all are happy. I am so scared." What stage of Erikson's is this patient demonstrating? Inferiority Despair Role confusion Stagnation

Despair

An older client tells the nurse "My family do not talk to me. I have no point of living." This is an example of what stage of Erikson's development? Stagnation Despair Ego integrity Generativity

Despair

A nurse is preparing to assess an adult client's body temperature. At which time of the day would the nurse expect to obtain the lowest body temperature? Early morning Early afternoon Late evening Late afternoon

Early morning Explanation: The lowest body temperature in an adult is seen in the early morning hours before physical activity begins. Body temperature is highest late in the evening (from about 8 p.m. to midnight).

A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment? Evaluation Diagnosis Implementation Assessment

Evaluation Explanation: The evaluation stage of the nursing process involves assessing whether the outcome criteria have been met and the nursing care plan needs to be revised. The assessment stage involves collecting subjective and objective data. The diagnosis phase involves analyzing subjective and objective data to make a professional nursing judgment. The implementation phase involves carrying out the plan to meet the determined outcome criteria.

A nurse will be performing a complete physical examination of a man who has emphysema with a chronic productive cough, including an assessment of his oral cavity. Which pieces of personal protective equipment should the nurse wear? Gloves, gown Mask, protective eye goggles, gown Mask, protective eye goggles Gloves, mask, protective eye goggles, gown

Gloves, mask, protective eye goggles, gown

When assessing a client for possible varicose veins, which of the following would the nurse do? Obtain the ankle-brachial index Tell the client to raise his or her leg Dorsiflex the client's foot Have the client stand for the exam

Have the client stand for the exam Explanation: When assessing for varicose veins, the nurse should have the client stand because the varicose veins may not be visible when the client is supine and not as pronounced when the client is sitting. Raising the client's leg would be inappropriate because this would promote venous return and emptying of the veins. Dorsiflexing the foot is used to assess the Homans' sign. The ankle-brachial index is used if the client has symptoms of arterial occlusion.

Staff are talking to the hospital educator and ask about "a government project that is meant to improve the health of people in the United States." The educator bases her response on the knowledge of the nursing process the Department of Health and Human Services the three levels of preventative care Healthy People 2020

Healthy People 2020 Explanation: Healthy People 2020 is a government project intended to increase the quality of life for people in the United States.

A nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds? Heart murmur Breath Normal heart Bowel

Heart murmur

A client presents to the health care clinic with a 3-week history of pain and swelling of the right foot. A nurse inspects the foot and observes swelling and a large ulcer on the heel. The client reports the right heel is very painful and he has trouble walking. Which nursing diagnosis should the nurse confirm from these data? Imbalanced Nutrition Impaired Skin Integrity Fear of Loss of Extremity Risk for Skin Breakdown

Impaired Skin Integrity

Upon assessing a patient who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs? Increased pulse rate Decreased temperature Decreased pulse rate Increased temperature

Increased pulse rate Explanation: When the stroke volume decreases, such as when blood volume is decreased because of hemorrhage, the heart rate increases to try to maintain the same cardiac output.

A nursing student is working a 7 a.m. to 3 p.m. shift with a preceptor and is caring for three patients independently. When the preceptor asks if the student has completed charting all her assessments, the student informs the preceptor that she is going to do batch charting. The preceptor informs the student of which of the following about batch charting? It helps you remember important information. It is a useful tool for prioritizing when busy. It is fine unless you chart on the wrong patient. It contributes to many potential errors.

It contributes to many potential errors. Explanation: Batch charting, which is waiting until the end of a shift or until all patients have been assessed to document, is not recommended. It contributes to many potential errors. Waiting to chart may also contribute to forgetting important information or charting assessment data on the wrong patient. Reference:

You are the clinic nurse assessing a new patient that has come in to see a physician. The assessment data that you collect reveals that the patient is a 23 year-old female weighing 175 lb with a height of 5 ft 3 in. Her body mass index is 31. What would she be considered? Overweight Average weight Underweight Obese

Obese Explanation: A body mass index of 31 is considered clinically obese. People who have a BMI lower than 18.5 (or who are 80% or less of their desirable body weight for height) are at increased risk for problems associated with poor nutritional status. Those who have a BMI of 25 to 29 are considered overweight; those with a BMI of 30 to 39, obese; and those with a BMI greater than 40, extremely obese.

A nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing? Emergency Initial comprehensive Focused or problem-oriented Ongoing or partial

Ongoing or partial

The nurse is preparing to assess a client's carotid arteries. Which nursing action would be mostappropriate? Palpate the arteries before auscultating them. Ask the client to breathe in and out deeply. Use the diaphragm of the stethoscope. Palpate each artery individually to compare.

Palpate each artery individually to compare. Explanation: When assessing a client's carotid arteries, the nurse should palpate each artery individually because bilateral palpation could result in reduced cerebral blood flow. Auscultation should be done before palpation because palpation may increase or slow the heart rate, changing the strength of the carotid pulse heard. The nurse should use the bell of the stethoscope to auscultate the arteries and have the client hold the breath for a moment so breath sounds do not conceal any vascular sounds.

A parent tells the nurse she is concerned that her 5 year old has an imaginary friend. The nurse understands that the child is in what stage of Piaget's cognitive development. Concrete Formal operations Sensorimotor Preoperational

Preoperational Explanation: The preoperational stage lasts from ages 2 to 7 years. The child has magical thinking during this time. Sensorimotor occurs at the infant stage. Concrete is from ages 7 to 11 years. Formal operations occurs during adolescence.

What is the best action by a nurse when a client has difficulty describing the chief complaint? Ignore the complaint & return to it at a later time in the interview Restate the question using simple terms Provide the client with a laundry list of words to choose from Wait in silence until the client can find the correct words

Provide the client with a laundry list of words to choose from

A nurse who has been working at the health clinic for 20 years has just taken a client's blood pressure and found it to be 110/70. When consulting the client's record, the nurse sees that he has had persistent hypertension for the past 5 years and has been on antihypertensive medication the whole time. His blood pressure has never been below 150/90 and was 180/95 at his last visit, 1 year ago. The patient's weight has remained the same. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case? Asking the physician to come in and take the client's blood pressure Asking the client whether his exercise habits have changed recently Repeating the measurement with a different sphygmomanometer and stethoscope Asking the client whether his diet has changed in the past year

Repeating the measurement with a different sphygmomanometer and stethoscope Explanation: The most appropriate method of validation in this case would be to simply retake the client's blood pressure with a different sphygmomanometer and stethoscope. Given the nurse's work experience, it is unlikely that the discrepancy is due to improper technique, thus having the physician take the client's blood pressure is not warranted. Given the client's long history of hypertension and that his weight has not changed, it seems unlikely that the discrepancy could be explained by improved diet or exercise.

The nurse is taking routine vital signs toward the end of shift. A client's BP reads 204/148. The client's baseline BP has been in the 130's systolic. What should the nurse do first? Document the findings Notify the physician immediately Retake the blood pressure Give PRN blood pressure medications

Retake the blood pressure Explanation: When encountering an abnormal value, obtain the vital sign(s) again to assess accuracy. It would be inappropriate to notify the physician immediately, give PRN blood pressure medications, or document the findings before rechecking the reading.

An older client has increasing physical challenges and receives care by the spouse. Which nursing diagnosis should the nurse identify for this family? Risk for self-directed violence Risk for hopelessness Risk for powerlessness Risk for caregiver role strain

Risk for caregiver role strain Explanation: Because the client's spouse is the primary caregiver, the nursing diagnosis Risk for caregiver role strain is the most appropriate. There is no evidence that the client is at risk for hopelessness, powerlessness, or self-directed violence.

The nurse is assessing the apices of the client's lungs. The nurse should locate them at which position? Slightly above the clavicle Near the level of the eighth rib At the level of the diaphragm At about the tenth rib

Slightly above the clavicle Explanation: The apex of each lung extends slightly above the clavicle. The base is at the level of the diaphragm. Laterally, lung tissue reaches the level of the eighth rib and posteriorly, the base lies at about the tenth rib.

A 17-year-old high school senior presents to the clinic in acute respiratory distress. Between shallow breaths he states he was at home finishing his homework when he suddenly began having right-sided chest pain and severe shortness of breath. He denies any recent traumas or illnesses. His past medical history is unremarkable. He doesn't smoke, but drinks several beers on the weekend. He has tried marijuana several times but denies any other illegal drugs. He is an honour student and on the basketball team. His parents are both in good health. He denies any recent weight gain, weight loss, fever, or night sweats. Examination shows a tall, thin young man in obvious distress. He is diaphoretic and breathing at a rate of 35 breaths per minute. Auscultation reveals no breath sounds on the right side of his superior chest wall. On percussion he is hyperresonant over the right upper lobe. With palpation he has absent fremitus over the right upper lobe. What disorder of the thorax or lung best describes his symptoms? Chronic obstructive pulmonary disease (COPD) Pneumonia Spontaneous pneumothorax Asthma

Spontaneous pneumothorax

Long-term care facilities in a community would be deemed adequate if which situation exists? Older adults are able to live in their own homes regardless of health status. Sufficiently specialized care is available for local residents who cannot live independently. Residents are admitted to inpatient hospital units during exacerbations of symptoms. Older adults are able to live in structured settings without having to pay.

Sufficiently specialized care is available for local residents who cannot live independently.

As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure? The blood pressure is erratic. The blood pressure does not change. The blood pressure decreases. The blood pressure increases.

The blood pressure increases. Explanation: The elasticity and resistance of the walls of the arterioles help to maintain normal blood pressure. With aging, the walls of arterioles become less elastic, which interferes with their ability to stretch and dilate, contributing to a rising pressure within the vascular system that is reflected in an increased blood pressure.

The nurse is utilizing the Health Belief Model in the care of a client whose type 1 diabetes is inadequately controlled. When implementing this model, the nurse should begin by assessing which of the following? The client's learning style The client's prognosis for recovery The client's motivation for change The client's medical comorbidities

The client's motivation for change Explanation: The Health Belief Model is based on three concepts: the existence of sufficient motivation, the belief that one is susceptible or vulnerable to a serious problem, and the belief that change following a health recommendation would be beneficial to the individual at a level of acceptable cost. As a result, implementation of this model should begin with an appraisal of the client's motivation to change. This consideration would precede the other listed variables, although each may affect care.

A nurse recognizes the need to perform a spiritual assessment of a newly admitted hospital client, but the circumstances surrounding the client's diagnosis and family dynamics make this challenging. What variable is likely to have the greatest impact on enhancing the quality of data from the nurse's spiritual assessment? The nurse's knowledge of major religions The quality of rapport between the nurse and the client The setting in which the assessment is performed The nature of the nurse's spiritual beliefs

The quality of rapport between the nurse and the client

The nurse on the cardiac unit is caring for a patient who thinks he was having amyocardial infarction when he came to the emergency department. When reviewinglaboratory data on this patient, the nurse notes that all tests are within normal limits except for the cholesterol and C-reactive protein, both of which are elevated outside the normal range. The nurse should be aware of what fact relating to elevated cholesterol and C-reactive protein? They more than double the risk of cardiac disease. They are clinical proof that the patient had a coronary event. They have no direct correlation with increased risk of cardiac disease. They are both sensitive and specific to heart failure.

They more than double the risk of cardiac disease. Explanation: The risk of a cardiovascular event more than doubles with an elevated cholesterol and C-reactive protein level.

The nurse is preparing to perform the physical examination of an older adult client who will begin rehabilitation from an ischemic stroke. Which nursing action would be most appropriate? Allow client to remain dressed. Dim the room light. Try to minimize position changes. Omit intrusive parts of the exam.

Try to minimize position changes. Explanation: Some positions may be very difficult or impossible for the older client to assume or maintain because of decreased joint mobility and flexibility. The nurse cannot omit intrusive parts of the exam or allow the client to remain dressed because essential information may be missed. The nurse can approach the client slowly, allow for rest periods, and provide clear explanations to the older adult client to help facilitate the exam and decrease anxiety. Dimming the lights would interfere with the nurse's ability to inspect the client.

Which vitamin is found only in animal foods? Vitamin A Vitamin D Vitamin C Vitamin B12

Vitamin B12 Explanation: Vitamin B12 functions in the formation of mature red blood cells and in synthesis of DNA and RNA. This vitamin is only found in animal foods (meats, fish, poultry, milk, and eggs).

A nurse provides prevention strategies to a group of clients who are identified as at risk for hypertension. Which strategies should the nurse include? Select all that apply. Choose foods like bananas and sweet potatoes. Increase consumption of dairy products. Use a low sodium seasoning to flavor food. Walk briskly 30 minutes per day. Consume two to three glasses of red wine daily.

Walk briskly 30 minutes per day. Use a low sodium seasoning to flavor food. Choose foods like bananas and sweet potatoes.

A Muslim teenager is in the hospital for surgical repair of a severe fracture in the leg during the month of Ramadan, which the client says he would like to observe during his stay. Which of the following interventions should the nurse be prepared for in caring for this client? Serve meals as normal, but do not include pork Withhold all food and drink between sunrise and sunset Do not mix dairy and meats together on the client's tray Serve only kosher meats at all three meals

Withhold all food and drink between sunrise and sunset

It would be a priority for the nurse to provide counseling about nutrition and exercise for weight loss for which client? a client with body mass index of 18.5 and family history of heart disease a client with a body mass index of 25 and normal HDL cholesterol a client with body mass index of 27 and blood pressure of 145/80 mm Hg a client with a body mass index of 23 and high LDL cholesterol

a client with body mass index of 27 and blood pressure of 145/80 mm Hg Explanation: The client with a body mass index (BMI) of 27 is overweight and has hypertension. The nurse should offer strategies for weight loss to prevent the progression of cardiovascular disease. A client with a BMI of 18.5 borders on normal and underweight. Despite having a family history of heart disease, the client should be discouraged from further weight loss. Other risk factors for heart disease should be identified and treated as necessary. The client with a BMI of 23 is in the normal range; therefore, pursuing weight loss is not indicated. Further monitoring of the LDL cholesterol is warranted, however. The client with a BMI of 25 would be considered on the borderline of the overweight category; however, the HDL cholesterol is normal. Cardiovascular risk associated with the BMI is not higher in the absence of other risk factors. Reference:

The apex of each lung is located at the left oblique fissure. level of the diaphragm. area slightly above the clavicle. level of the sixth rib.

area slightly above the clavicle. Explanation: The apex of each lung extends slightly above the clavicle.

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

bone.

A nurse is caring for a patient who has been admitted to the medical-surgical unit. After the original admission assessment is done and charted, the nurse documents only abnormalities found on subsequent assessments. This type of charting is called: pie charting narrative charting batch charting charting by exception

charting by exception

The nurse assesses an adult client and observes that the client's breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a physician for possible renal failure. chronic bronchitis. atelectasis. congestive heart failure.

chronic bronchitis. Explanation: Labored and noisy breathing is often seen with severe asthma or chronic bronchitis.

The nurse assesses a hospitalized adult client and observes that the client's jugular veins are fully extended. The nurse contacts the client's physician because the client's signs are indicative of patent ductus arteriosus. pulmonary emphysema. diastolic murmurs. increased central venous pressure.

increased central venous pressure. Explanation: The level of the jugular venous pressure reflects right atrial (central venous) pressure and, usually, right ventricular diastolic filling pressure. Right-sided heart failure raises pressure and volume, thus raising jugular venous pressure.

Shared practices and rituals used to express one's faith can be called philosophy. religion. spirituality. denomination.

religion.

The nurse conducts a health history with a client who reports having a dull headache over the past month. The client tells the nurse that using aromatherapy scents have helped manage the pain sometimes. This information is belongs to which attribute of a symptom? treatment duration onset associated manifestations

treatment

A client has a brownish discoloration of the skin of both lower legs. What should the nurse suspect is occurring with this client? venous insufficiency arterial insufficiency atherosclerosis deep vein thrombosis

venous insufficiency Explanation: Brownish discoloration just above the malleolus suggests chronic venous insufficiency. There are no specific skin changes associated with atherosclerosis. The lower extremities in the dependent position would be pale in color in arterial insufficiency. The extremity would be warm and edematous with a deep vein thrombosis.