The Point Questions Nursing

The nurse notes thrush on the palate of a client. The most appropriate question the nurse should ask is "Have you traveled out of the country in the last month?" "Have you been tested for HIV?" "Have you been on antibiotics recently?" "Do you smoke?"

"Have you been on antibiotics recently?"

When trying to explore a client's perspective on his or her illness, the question that would best determine the client's thoughts on the cause of the problem would be "How has this been for you?" "Has this affected your ability to work?" "Why do you think you have (name the specific symptom)?" "What can't you do now that you could before?"

"Why do you think you have (name the specific symptom)?"

Identify the location where vesicular, bronchovesicular, bronchial, and tracheal lung sounds are heard (in that order)

1) over most of both lungs 2) between the scapulae 3) over the manubrium 4) over the trachea in the neck

Which ribs are considered "floating ribs"? 10th and 11th 9th and 10th 8th and 9th 11th and 12th

11th and 12th

When assessing the posterior chest, what is a starting point for counting ribs and interspaces? 12th rib 8th rib 10th rib 6th rib

12th rib

It is important to encourage all men to do testicular self-examinations. The nurse would emphasize that the highest incidence of testicular cancer occurs in men aged 50-65 68-82 15-35 38-45

15-35

While discussing family history with a client who is healthy except for a current UTI requiring IV antibiotics, the client tells the nurse that he has three sisters and two brothers. Two of his sisters have died and one brother is in a nursing home after a stroke. The nurse would include the sibling group in a genogram in what manner? 3 circles and 3 squares with lines through 2 squares 3 circles and 3 squares with broken lines connecting 2 of the circles 3 circles and 3 squares with two diagonal slashed lines through lines connecting the 2 deceased siblings 3 circles and 3 squares with lines through 2 circles

3 circles and 3 squares with lines through 2 circles

The nurse examines the pharynx of a client and records that the tonsils are touching the uvula. The nurse would grade the tonsils as 1+ 3+ 4+ 2+

3+

As a nursing student you learn that the normal range for an adult pulse is what? 70-110 bpm 50-90 bpm 80-120 bpm 60-100 bpm

60-100 bpm

A female client has come to the clinic for her yearly check-up. During the history the client tells the nurse that she does not "feel anything" during sex with her husband. The nurse knows that the most common cause of this type of problem is what? A medical factor A situational factor A physical factor A social factor

A situational factor Sexual problems can be the result of physical or psychological issues. More commonly, however, a sexual problem is related to situational or psychosocial factors.

The client has epigastric pain that is poorly localized and radiates to the back. What would be an important diagnosis to assess for? Acute diverticulitis Acute pancreatitis Biliary colic Acute cholecystitis

Acute pancreatitis

What ethnic group has a significantly higher incidence rate of prostate cancer? Asian African American Caucasian Native American

African American

What term is used to describe the degree of vascular resistance to ventricular contraction? Afterload Preload Contractile overload Volume overload

Afterload

What is a long-term complication of peripheral vascular disease? Amputation Diabetes mellitus Metabolic changes Thickened skin

Amputation

While interviewing a new client, you notice that he is mirroring your position. What can this signify? The client does not take you seriously A desire to be on an equal power level A desire for increased rapport An increasing sense of connectedness

An increasing sense of connectedness Matching your position to the client's can signify increased rapport, just as mirroring your position can signify the client's increasing sense of connectedness.

A client presents at the clinic with a chief complaint of "indigestion." The client tells the nurse, "It usually happens after I do things like mowing the lawn or doing other yard work." What should the nurse suspect? Ulcer disease Angina Aortic aneurysm Gallbladder disease

Angina

When a client is obese or has a thick chest wall, what is difficult to palpate? JVP Grade 4 murmur Apical impulse Sternal angle

Apical impulse

What important questions guide the approach to physical assessment of the nervous system? (Select all that apply.) Is the central nervous system intact? Are right-sided and left-sided examination findings symmetric? Is the mental status intact? Where does the lesion lie? Is the peripheral nervous system intact?

Are right-sided and left-sided examination findings symmetric? Is the mental status intact? Where does the lesion lie?

What techniques encourage client disclosures while minimizing the risk for distorting the client's ideas or missing significant details? (Mark all that apply.) Asking a series of questions, one at a time Offering multiple choices for answers Using reflection Encouraging with repetition Asking only open-ended questions

Asking a series of questions, one at a time Offering multiple choices for answers Using reflection Learning the following techniques encourages client disclosures while minimizing the risk for distorting the client's ideas or missing significant details. • Moving from open-ended to focused questions • Using questioning that elicits a graded response • Asking a series of questions, one at a time • Offering multiple choices for answers • Clarifying what the client means • Encouraging with continuers • Using reflection

Ideally, when taking a blood pressure, the client should be instructed to what? Avoid smoking for 30 minutes prior to the assessment Take several deep breaths to help relax prior to the assessment Sit quietly for at least 10 minutes in a chair, rather than on the examining table, with feet flat on the floor and Abstain from drinking caffeine for 45 minutes prior to the assessment

Avoid smoking for 30 minutes prior to the assessment

What general goals do you organize your comprehensive or focused examination around? (Select all that apply.) Avoiding unnecessary changes in position Maximizing the client's comfort Identifying the client's medical diagnosis Ensuring the client's compliance with treatment Enhancing clinical efficiency

Avoiding unnecessary changes in position Maximizing the client's comfort Enhancing clinical efficiency

Bronchovesicular

B=V Inspiratory= expiratory equal in length Between scapulae

What is located at the right and left 2nd intercostal spaces next to the sternum? Apex of the heart Pulmonary vein Aortic valve Base of the heart

Base of the heart

The nurse is assessing the client's coordination and finds that her movements are clumsy, unsteady, and inappropriately varying in their speed, force, and direction. The nurse notes that client has dysmetria. What would the nurse know this client has? Cerebellar disease Basal ganglia disease Cerebral disease Brainstem disease

Cerebellar disease

The nurse is presenting client education on STDs to a high school health class. What infection would the nurse tell the students can be transmitted by oral-penile transmission? Chlamydia Prostatitis Urethritis Cervical cancer

Chlamydia

You are performing a physical examination on a new client. What would you be assessing if you were testing the client's sense of smell? Upper neuron function Cranial nerves Strength of nerve functioning Nose

Cranial nerves

Your client has two affirmative answers to the CAGE Questionnaire. What other questions should you ask? (Mark all that apply.) What OTC medications do you take? Do you have seizures while drinking? Do you have any legal problems? Do you experience blackouts when drinking? How would you describe your level of nutrition?

Do you have seizures while drinking? Do you have any legal problems? Do you experience blackouts when drinking? Two or more affirmative answers to the CAGE Questionnaire suggest alcohol misuse. If you detect misuse, you need to ask about blackouts (loss of memory about events during drinking), seizures, accidents or injuries while drinking, job problems, conflict in personal relationships, or legal problems.

What replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space? Hyperresonance Tympany Dullness Chief complaint

Dullness

The client presents at the clinic with a chief complaint of pain in her upper abdomen. On assessment the nurse notes that the client has recurrent pain, more than two times weekly, in her upper abdomen, and that this recurrent pain started 2 months ago. What term should the nurse use for this type of pain? Odynophagia Dysphagia Dyspepsia Discomfort

Dyspepsia For more chronic symptoms, dyspepsia is defined as chronic or recurrent discomfort or pain centered in the upper abdomen.

The apocrine glands are stimulated by what? Overhydration Physical stress Emotional stress Temperature

Emotional stress

A client with lobar pneumonia would have muffled and indistinct spoken voice sounds.

FALSE

The nurse is performing a physical examination and is using a stethoscope to listen to lung sounds. When using the diaphragm, the nurse would expect to hear lower-pitched sounds. FALSE TRUE

FALSE

When interviewing, the nurse should logically move from specific to open-ended questions. FALSE TRUE

FALSE

What are associated manifestations of a headache caused by a traumatic head injury? (Mark all that apply.) Changes in appetite Apathy Gait changes Attention span deficit Seizures

Gait changes Attention span deficit Seizures

Learning about the effects of the illness does what for the nurse and the client? Gives them the opportunity to create a complete and congruent picture of the problem Gives them the ability to communicate better Gives them the basis to establish a trusting relationship Gives them each a better understanding of the other

Gives them the opportunity to create a complete and congruent picture of the problem

What is the Virchow triad? (Mark all that apply.) Hypercoagulability High fat content in blood Venous stasis Arterial stasis Vessel wall damage

Hypercoagulability Venous stasis Vessel wall damage

A client presents at the clinic for a routine check-up. The nurse notes that she is dressed in warm clothing even though the temperature outside is 73°F (22.8°C). The nurse also notes that the client has gained 10 pounds (4.5 kg) since her last visit 9 months ago. What might the nurse suspect?

Hypothyroidism Intolerance to cold, preference for warm clothing and many blankets, and decreased sweating suggest hypothyroidism; the opposite symptoms, palpitations, and involuntary weight loss suggest hyperthyroidism.

What does the nurse assess the face for? (Select all that apply.) Involuntary movements Edema Asymmetry Affect Hair color

Involuntary movements Edema Asymmetry

Bronchial

LOUD and HIGH pitch Expiratory > Inspiratory Over manubrium

During the physical examination of your client you auscultate the sound of the client's breathing. What area of the client are you assessing? Abdomen Lungs Neck Back

Lungs

Your client describes her stool as soft, light yellow to gray, mushy, greasy, foul-smelling, and usually floats in the toilet. What would you suspect is wrong with your client? Lactose intolerance Ulcerative colitis Malabsorption syndrome Crohn disease

Malabsorption syndrome

When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc? Upward toward the forehead Laterally toward the ear Medially toward the nose Downward toward the chin

Medially toward the nose

What is a lay term for the spontaneous loss of pregnancy? Missed abortion Miscarriage Missed pregnancy Abortion

Miscarriage

You are assessing a client for acute cholecystitis. What sign would you assess for? Murphy sign Obstipation sign Cutaneous hyperesthesia Psoas sign

Murphy sign

The client presents at the clinic with a complaint of weakness that is made worse with repeated effort and improves with rest. The client's complaint is consistent with what health problem? Lyme disease Myasthenia gravis Parkinson disease Ischemic stroke

Myasthenia gravis

The nurse is assessing a client with Raynaud disease. When assessing the wrist pulses, what would the nurse expect to find? Bounding wrist pulses Decreased wrist pulses Absent wrist pulses Normal wrist pulses

Normal wrist pulses In Raynaud disease, wrist pulses are typically normal, but spasm of more distal arteries causes episodes of sharply demarcated pallor of the fingers.

Which cranial nerve controls pupillary constriction? Trigeminal Optic Oculomotor Trochlear

Oculomotor

Which type of incontinence occurs when excessive bladder volume exceeds urethral pressure? Functional incontinence Urge incontinence Overflow incontinence Stress incontinence

Overflow incontinence

Mr. Smith presents to the clinic stating, "My face looks funny." You note that his face is asymmetric. What might you suspect is the client's problem? Muscular dystrophy Myocardial infarction Parafacial macrosomia Palsy

Palsy

The nurse is collecting data for a comprehensive health history on a client new to the clinic. Under what component of the health history would the nurse place data on a chronic childhood illness? Risk factors Past history Health maintenance General information

Past history

Your lab instructor explains that physical examination relies on what cardinal assessment technique? Percussion Organization Communication Assessment

Percussion

What occurs during the termination phase of an interview? Planning for follow-up care Addressing topics that have not yet been addressed Letting the client know you understood all he or she has told you Assessing the client's mental status

Planning for follow-up care

Which of the following are aspects of the comprehensive health history? (Mark all that apply.) Is appropriate for established clients Provides baselines for future assessments Obtains data to evaluate the outcomes of the plan of care Strengthens the nurse-client relationship Creates platform for health promotion through education and counseling

Provides baselines for future assessments Strengthens the nurse-client relationship Creates platform for health promotion through education and counseling The comprehensive health history performs multiple functions. These include strengthening the nurse-client relationship and providing baselines for assessment and health promotion. It is not normally used for specific evaluative purposes or for established clients.

What is a key element of the history of present illness? Self-treatment Initiating a problem list Developing accurate nursing diagnoses Obtaining an accurate history

Self-treatment Key elements of the History of Present Illness: Seven attributes of each principal symptom; self-treatment for the symptom by the client or family; past occurrences of the symptom(s); and pertinent positives and/or negatives from the review of systems.

The client tells the nurse that he has little or no interest in sex. He says he is concerned and he knows his wife is unhappy with his lack of libido. What can the nurse tell the client often causes lack of libido? Mental illness Testosterone hypersecretion Side effects of medications Manic episodes

Side effects of medications

When assessing a client with Graves disease, how would you expect the thyroid gland to be? Soft Tender Nodular Firm

Soft

What information aids the nurse in assessing possible biases in the data collected in the health history? Source of information Gender of client Socioeconomic status of the client Ethnicity of client

Source of information

Where do the cell bodies of the lower motor neurons lie? Anterior roots Motor strip Spinal cord Neuromuscular junction

Spinal cord

What is used to gauge central and peripheral nervous system disorders? Tuning fork Gait Heat and cold Strength of a reflex

Strength of a reflex

A student nurse is conducting her first client interview. The student suddenly draws a blank on what to ask the client next. What is a useful interview technique for the student to use at this point? Summarization Reassurance Transition Termination

Summarization Summarization can be used at different points in the interview to structure the visit, especially at times of transition. This technique also allows the nurse to organize his or her clinical reasoning and to convey it to the client, making the relationship more collaborative. It is also a useful technique for learners when they draw a blank on what to ask the client next.

The nurse is assessing a client with a bladder disorder. Where would the nurse expect the pain to be? Back Perineal Suprapubic Upper abdomen

Suprapubic

When, in the cardiac cycle, does blood pressure peak? Diastole Preload Afterload Systole

Systole

When assessing posteriorly, where would the trachea bifurcate into its mainstem bronchi? Sternal angle Suprasternal notch T4 spinous process Midaxillary line

T4 spinous process

It is recommended that a left-handed examiner adopt a right-sided position. FALSE TRUE

TRUE

The nurse should use the handle of the reflex hammer to detect the plantar reflex. TRUE FALSE

TRUE

When assessing the gastrointestinal system, the nurse correctly asks, "Do you have any trouble swallowing?" FALSE TRUE

TRUE

When inspecting structures such as the jugular venous pulse, what would be the best lighting to use? Tangential lighting Diffuse lighting Direct lighting Back lighting

Tangential lighting

You have finished the physical examination. What do you do immediately after finishing? (Mark all that apply.) Share findings with physician Perform interventions Tell client what to expect next Give your general impressions Identify needed laboratory tests

Tell client what to expect next Give your general impressions When you have completed the examination, tell the client your general impressions and what to expect next.

When assessing the breath sounds of a newly admitted client, the nurse notes increased transmission of voice sounds over the right lung. What would this indicate to the nurse? The lung has an embolus The lung is full of fluid The lung has become airless The lung is overinflated

The lung has become airless Increased transmission of voice sounds suggests that air-filled lung has become airless.

The nurse is testing the valvular competency of the saphenous system. What test is the nurse performing on the client? Allen test Ankle-brachial index test Venous occlusion test Trendelenburg test

Trendelenburg test By the retrograde filling (Trendelenburg) test, you can assess the valvular competency in both the communicating veins and the saphenous system.

The nurse is admitting a client new to the clinic who states, "My face feels funny." When the nurse assesses the client she finds isolated facial sensory loss to pain and no neurologic deficits in his extremities. What diagnosis would the nurse expect for this client? Horner syndrome Stroke Trigeminal neuralgia Bell palsy

Trigeminal neuralgia Ask the client to report whether it is "sharp" or "dull" and to compare sides. Isolated facial sensory loss is seen in peripheral nerve disorders like trigeminal neuralgia.

Vesicular

V= birds ALL OVER LUNGS Soft-low-pitched sounds Heard through inspiration 1/3 of the way through expiration

Tracheal

VERY LOUD, HARSH E=I Over trachea in neck

The nurse plans to test which cranial nerve when testing an elderly client's hearing status? VII VI V VIII

VIII- Acoustic

What are the indications for a pelvic examination during adolescence? (Select all that apply.) Minimal bleeding during menses Vaginal discharge Onset of menarche at age 13 Prescription of contraceptives Dysmenorrhea

Vaginal discharge Prescription of contraceptives Dysmenorrhea

The client is diagnosed with a peripheral neuropathy. The nurse knows that often the first sensation lost in a peripheral neuropathy is what? Pain Vibration Temperature Light touch

Vibration

What associated symptoms might a client with a history of chronic bronchitis have? (Mark all that apply.) Paroxysmal nocturnal dyspnea Wheezing Recurrent respiratory infections Orthopnea Chronic productive cough

Wheezing Recurrent respiratory infections Chronic productive cough

A young toddler is brought to the emergency room by his parents. The mother states that the child was playing on the floor with toys and suddenly began to wheeze. The mother reports no recent illnesses. The nurse suspects that the most likely cause of the wheezing is increased secretions exercise-induced asthma a foreign body obstruction a severe cold

a foreign body obstruction

The nurse is performing a physical examination and notes an enlarged left supraclavicular lymph node. The nurse understands that this could be indicative of nasopharyngitis a goiter tonsillitis a metastasis

a metastasis

A past history is being taken by the nurse for a client with COPD. The nurse includes which elements in this part of the health history? Select all that apply. allergies treatment options childhood illnesses health maintenance

allergies childhood illnesses health maintenance

The nurse documents a 2+ radial pulse. What assessment data indicated this result? bounding pulse absent (unable to palpate) pulse diminished pulse brisk, expected (normal) pulse

brisk, expected (normal) pulse

A client is being admitted to a medical unit with an acute illness. The nurse would plan to gather information using which tool? emergency history follow-up history problem-oriented assessment comprehensive health history

comprehensive health history

While reviewing the medical record before examining a male clinic client, the nurse notes that the urinary meatus is located on the top of the glans of the penis. The nurse understands the correct term for this congenital defect is hydrocele varicocele epispadias hypospadias

epispadias

The nurse hears a quiet murmur immediately after placing the stethoscope on the chest. Documentation of grading for this murmur would include grade 2 grade 1 grade 4 grade 3

grade 2

A client has conjunctivitis. The nurses understand that conjunctivitis differs from conjunctival hemorrhage in that conjunctivitis can result from a cough. has a watery, mucoid discharge. is not painful. usually follows trauma.

has a watery, mucoid discharge.

The nurse is using the ophthalmoscope to examine the client's eyes. The nurse holds the scope in the right hand for both eyes in the right hand for the right eye and in the left hand for the left eye in the left hand for the right eye and in the right hand for the left eye in the left hand for both eyes

in the right hand for the right eye and in the left hand for the left eye

The nurse assesses edema in a newly admitted client. Further evaluation is based on the fact that the nurse knows edema is caused by (Select all that apply.) increased capillary membrane permeability blockage of lymphatic drainage colloid osmotic pressure increased capillary blood pressure low plasma protein levels

increased capillary membrane permeability blockage of lymphatic drainage increased capillary blood pressure low plasma protein levels

Prostate cancer is the leading cancer diagnosed in men in the United States. To increase knowledge of risk factors, the nurse would teach men that (Select all that apply.) symptoms are often undetectable testicular self-examinations can reduce the risk by 50% it occurs earlier and is more advanced in African American men each decade after age 50 increases the risk 15% have an affected first-degree relative

it occurs earlier and is more advanced in African American men each decade after age 50 increases the risk 15% have an affected first-degree relative

A client asks to have her temperature taken because she feels hot and is sweating. The previous oral temperature 3 hours ago was 101.6°F. The nurse would expect the new temperature reading to be within an afebrile range lower than previous higher than previous within a subnormal range

lower than previous

The nurse is doing a neurologic screening examination. The nurse should include some aspect of which areas? Select all that apply. cardiovascular system mental status reflexes cranial nerves sensory system motor system

mental status reflexes cranial nerves sensory system motor system

When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.) notched border pink color asymmetry diameter great than 6 mm

notched border asymmetry diameter great than 6 mm

The nurse is preparing to test the sensory cranial nerves. The nerves being tested include (Select all that apply.) optic hypoglossal acoustic olfactory trochlear

optic acoustic olfactory

The current blood pressure measurement on a 24-hour uncomplicated postoperative client while standing at the bedside is 105/65. The last two readings were 130/75 and 125/70 while resting in bed. The nurse should be alert for signs of: postural hypertension. orthostatic hypotension. supine hypotension. hypertensive crisis.

orthostatic hypotension.

The client with psoriasis is admitted to a medical unit for unrelated reasons. When documenting the type of lesion represented by psoriasis, the nurse should document a pustule wheal papule bulla

papule

A client is in the emergency room with what could be a lumbar injury. Which deep tendon reflex would be most appropriate to test? triceps ankle supinator patellar

patellar

A female client presents with right lower quadrant pain that radiates from the periumbilical area. The abdomen is rigid on palpation. The nurse would prepare for physician follow-up for possible small bowel obstruction pelvic inflammatory disease peptic ulcer disease diverticulitis

pelvic inflammatory disease

After assessing pitting edema below the knee in a client, the nurse would suspect that which artery may be occluded? iliofemoral popliteal communicating saphenous

popliteal

The symptom that would alert the nurse to a problem with cranial nerve III would be vertigo difficulty clenching jaw ptosis absent blinking

ptosis

When evaluating the jugular venous pressure in a client with known coronary artery disease, the nurse explains to the client that the JVP measures the pressure in the right ventricle left ventricle right atrium left atrium

right atrium

When palpating the abdomen, the nurse may be able to feel the lower edge of the liver in which quadrant? left lower right upper left upper right lower

right upper

During an assessment, the client describes vomiting moderate amounts that "smell like poop." The nurse might suspect hypercalcemia small bowel obstruction gastric varices irritable bowel syndrome

small bowel obstruction

The nurse documents vesicular lung sounds upon auscultation. The nurse heard what type of sound? expiratory sounds lasting longer than inspiratory short silence between inspiration and expiration inspiratory and expiratory sounds equal in length sound heard throughout inspiration and two thirds of expiration

sound heard throughout inspiration and two thirds of expiration

A client has had consecutive blood pressure readings in the 140s/90s for the last week of evaluation. The nurse classifies this as stage 2 hypertension normal blood pressure stage 1 hypertension elevated blood pressure

stage 2 hypertension

When examining the eye, the nurse notices difficulty with downward motion. The nurse understands that which cranial nerve is involved? optic abducens facial trochlear

trochlear

sceral pain is associated with a hollow abdominal organ such as the intestine. Visceral pain is right or left sided also called referred pain more severe than parietal pain usually difficult to localize

usually difficult to localize

A client appears in the clinic with a cough that began 24 hours prior to coming to this visit. The nurse evaluates the client based on the most common cause of an acute cough, which is asthma pneumonia chronic bronchitis viral respiratory infection

viral respiratory infection

The nurse notes that the ophthalmologist suspects death of the optic nerve. When looking into the eye, the nurse would expect to see what color if the disc is dead? red white black yellow

white

The client is noted to have a pathologic change in ventricular compliance. What information from the cardiac assessment would indicate this? A weak S4 An S3 gallop A split S2 A delayed S3

An S3 gallop

While assessing the legs of the client, the nurse notes that the legs and feet are cool to the touch. What would the nurse know is most often the cause of bilateral coolness? DVT Embolism Anxiety Inadequate arterial circulation

Anxiety

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

At the beginning of the interview

The client asks the nurse what the small P wave on her ECG indicates. What would the nurse answer? Ventricular depolarization Ventricular repolarization Atrial repolarization Atrial depolarization

Atrial depolarization

When assessing for appendicitis, what signs might the nurse look for? (Select all that apply.) Obfuscator sign Psoas sign Rovsing sign Cutaneous hyperesthesia Murphy sign

Psoas sign Rovsing sign Cutaneous hyperesthesia

The client states that she does not enjoy sex because she does not attain adequate vaginal lubrication. The nurse should be aware of what potential causes of sexual dysfunction? (Select all that apply.) Amenorrhea Excessive testosterone Psychiatric conditions Lack of estrogen Medical illness

Psychiatric conditions Lack of estrogen Medical illness

Which of the following are part of the preinterview of the nurse-client interview? Select all that apply. identifying client's emotional clues establishing the agenda taking time for reflection generating diagnostic hypotheses setting goals for the interview taking notes

1. taking time for reflection 2. setting goals for the interview 3. taking notes

A client is trying to explain how he feels about his eye problem. He pauses often during the conversation and often repeats himself when expressing his concern about his problem. After listening, the best response by the nurse would be "I can understand why you feel the way you do." "Wow, I don't know how you do it!" "It sounds like you've been dealt a bad hand in life." "Tell me more about how you feel."

"I can understand why you feel the way you do." Pausing and repeating are part of emotional cues when a client is describing how an illness impacts his life. The response reflects understanding and is part of the mnemonic NURS, which helps respond to emotional cues.

A nurse knocks and enters a client room, makes introductions to the client and visitors, and explains to the client that she would like to conduct an interview so a plan of care can be completed. Which statement by the nurse would be most appropriate? "I see you have visitors. I need to ask that they step out to the lobby for about 30 minutes so I can ask you some questions in private." "Barbara, I am going to conduct an interview so I would like to ask your visitors to leave so we can have some privacy." "Mrs. Smith, I would like to conduct an interview with you but I see you have visitors. I will come back in about 30 minutes so you can visit before you and I sit privately to talk." "Mrs. Smith, I need to ask your visitors to leave so you and I can talk for about 30 minutes."

"Mrs. Smith, I would like to conduct an interview with you but I see you have visitors. I will come back in about 30 minutes so you can visit before you and I sit privately to talk." Recognizing visitors but setting a time for returning to discuss privately gives everyone time to talk and visit but does not cause a long delay for the important interview.

The new grad asks the preceptor to explain why the order of the examination is different for the abdomen. The best response by the preceptor would include "It is easiest to hear bowel sounds using this technique." "Bowel motility is best heard before percussion." "It is important to auscultate the bowel sounds heard with percussion." "Palpation will increase bowel motility and alter the sounds heard on auscultation."

"Palpation will increase bowel motility and alter the sounds heard on auscultation."

Dyspnea, an uncomfortable awareness of breathing that is inappropriate to the level of exertion, is what? Air hunger Audible breathing Prolonged inspiration Painful breathing

Air hunger

The new RN is now performing the examination of the abdomen. What order of examination techniques would be correct?

1) inspection 2) auscultation 3) percussion 4) palpation

A new RN is being observed by the preceptor when doing a client examination. The preceptor notes the appropriate order of examination techniques on the lungs. The preceptor observed what order of the lung examination techniques?

1) inspection 2) palpation 3) percussion 4) auscultation

A client with acute onset of shoulder pain is answering questions during a health history. The nurse is utilizing a mnemonic specific to the attributes of a symptom. The nurse first asks about the onset of symptoms followed by

1) location 2) duration 3) characteristic symptoms 4) associated manifestations 5) relieving/exacerbating factors 6) treatment Rationale: This is an example of using the "OLDCARTS" mnemonic to understand a symptom.

A rape victim is being examined in the emergency department. A special rape kit must be used to ensure what? Diagnostic imaging is performed A chain of custody for evidence Only licensed personnel do the examination Anonymity of care

A chain of custody for evidence

"How many steps can you climb before you get short of breath?" is an example of what kind of question? A question that is qualitative in focus A question that demands an imprecise response A question that elicits a graded response A question that offers multiple choices for answers

A question that elicits a graded response The nurse should ask questions that require a graded response rather than a single answer. "How many steps can you climb before you get short of breath?" is better than "Do you get short of breath climbing stairs?" This question is neither qualitative nor imprecise.

When assessing the client, the nurse notes bradykinesia. The nurse would know that this abnormality is caused by damage to what? Basal ganglia system Brainstem Cerebellar system Medulla

Basal ganglia system

An alternate pathway that bypasses the external and middle ear is called what? Bone conduction Sensory conduction Air conduction Neuro conduction

Bone conduction

A client states that the reason he has come into the clinic is for a routine annual physical. In what section of the health history would you document this information? Chief complaint History of present illness Initial information Health maintenance

Chief complaint Chief Complaint(s)-Sometimes clients have no specific complaints. Report their goals instead. For example, "I have come for my regular check-up" or "I've been admitted for a thorough evaluation of my heart."

While gathering data for the family history portion of the health history, what would you ask about? Low bone density Coronary artery disease Liver disease Injuries

Coronary artery disease Review each of the following conditions and record whether they are present or absent in the family: hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, substance abuse, and allergies, as well as symptoms reported by the client.

The nurse is taking a sexual history on a new client. What action is considered appropriate at this time? (Select all that apply.) Explain why you are taking the sexual history Relate that you gather this history on only high-risk clients Affirm that your conversation is confidential Explain to the client what is considered to be normal sexual behavior Note that you realize this information is highly perso

Explain why you are taking the sexual history Affirm that your conversation is confidential Note that you realize this information is highly perso

When interacting with a client, what conveys the extent of interest, attention, acceptance, and understanding of the nurse? (Select all that apply.) Cultural reassurance Eye contact Gestures Tone of voice Posture

Eye contact Gestures Tone of voice Posture

When interviewing a client with a language barrier, it is best to use a family member to help interpret so the client has a level of comfort with the process. FALSE TRUE

FALSE Recruiting family members or friends to serve as interpreters can be hazardous—confidentiality and cultural norms may be violated, meanings may be distorted, and transmitted information may be incomplete. Untrained interpreters may try to speed up the interview by telescoping lengthy replies into a few words, losing much of what may be significant detail.

How would the nursing instructor explain the goal of guided questioning to his or her students? Creating an opportunity for the early generation of a plan Providing the most plausible answer to the client Facilitating the client's fullest communication Developing a basis for accurate health promotion activities

Facilitating the client's fullest communication

When assessing your new client, you note that he has no hair on his legs. What might this indicate about the client? He has peripheral artery disease He has a hormonal imbalance He has hyperthyroidism He has hypothyroidism

He has peripheral artery disease

A nurse at the local free clinic is collecting data on a 16-year-old boy who has come to the clinic. Under what component of the health history would the nurse place data on whether the teen routinely uses seat belts when in a vehicle? Risk factors General information Initial information Health maintenance

Health maintenance Health Maintenance—Safety measures: seat belts in cars, smoke/carbon monoxide detectors, sports helmets or padding, etc.

To adhere to standard precautions, the nurse should remember to do which? Select all that apply. When a gown is required, reuse gown when reinitiating contact with the same client. Perform hand hygiene before and after direct client contact. Wear gloves for each client contact. Remove any personal protective equipment (PPE) before leaving client's room.

Perform hand hygiene before and after direct client contact. Remove any personal protective equipment (PPE) before leaving client's room.

A client is brought to the emergency department by ambulance after being involved in a motor vehicle accident. The nurse finds that he has decreased breath sounds over the left lung fields. What might the nurse suspect is the cause? Atelectasis Pneumothorax Asthma Muscular weakness

Pneumothorax

As a nursing student you learn that mastering all the components of the comprehensive history provides what? Proficiency Empathy Authority Advocacy

Proficiency

The nurse is caring for a client who is 48 hours post op from the repair of a fractured hip. She has a sudden onset of dyspnea without pain. What disease process would the nurse suspect? Asthma Chronic lung disease Pulmonary embolism Left ventricular failure

Pulmonary embolism Risk factors for pulmonary embolism include postpartum or postoperative periods, prolonged bed rest, congestive heart failure, chronic lung disease, fractures of hip or leg, and deep venous thrombosis (often not clinically apparent).

A client has had consecutive blood pressure readings in the 130s/80s for the last week of evaluation. This would be classified as Stage 2 hypertension Stage 1 hypertension Elevated blood pressure Normal blood pressure

Stage 1 hypertension

What is the best guide to make vertical locations on the chest? Angle of Henri 5th intercostal space Sternal angle Midclavicular line

Sternal angle

"Tell me about your pain" is an example of an open-ended question. FALSE TRUE

TRUE If the client has not mentioned his or her perspective on illness during the open-ended portion of the interview, explore this perspective prior to the directive. Probe the personal context of the illness by asking, "How has this affected you?"

The nurse notes guarding while palpating the abdomen of a newly admitted client despite asking the client to try to relax. The nurse should (Select all that apply.) assess relaxation of abdominal muscle after the client exhales have the client mouth breathe with the jaw dropped open have the client stand during the examination tell the client to take a deep breath and hold it distract the client with conversation

assess relaxation of abdominal muscle after the client exhales have the client mouth breathe with the jaw dropped open distract the client with conversa

The nurse percusses the lungs of a client with pneumonia. What percussion note would the nurse expect to document? hyperresonance flatness dullness tympany

dullness

The nurse palpates slightly enlarged epitrochlear nodes. The nurse should evaluate more closely which part of the body? axillae neck mouth fingers

fingers

A nurse is performing a client assessment in an urgent care clinic. The most likely tool being used is the follow-up history emergency history comprehensive health history focused assessment

focused assessment

The nurse hears a murmur in a client with a known mitral valve prolapse. The murmur most likely occurs in mid-diastole late systole mid-systole early diastole

late systole

A client has COPD. On examination, the nurse would expect the liver span to be decreased difficulty in percussing liver dullness the liver to be enlarged liver dullness to be displaced downward

liver dullness to be displaced downward

What are the components of S1? (Mark all that apply.) A later pulmonic sound An earlier aortic sound An earlier mitral sound An earlier tricuspid sound A later tricuspid sound

An earlier mitral sound A later tricuspid sound

When collecting data on the history of the present illness, it is appropriate to include what? Chronic childhood illnesses Reliability of information source Treatment recommendations Current medications

Current medications

Which of the following is a component of the general survey? Patient's breath sounds Patient's oral temperature Patient's state of hygiene Patient's blood pressure

Patient's state of hygiene

Your new client becomes visibly anxious during the nursing interview. You respond by telling her, "Don't worry, everything will be okay." What might this premature reassurance cause? The nurse to shorten the interview process A noticeable lessening of the client's anxiety A feeling of closeness between the client and the nurse The blockage of further disclosures by the client

The blockage of further disclosures by the client Premature reassurance may block further disclosures, especially if the client feels that the clinician is uncomfortable with the anxiety or has not appreciated the extent of the client's distress.

During one of your clinical placements you encounter a client who becomes silent during the nursing interview. What would be appropriate for you to do? (Mark all that apply.) Watch the client closely for nonverbal cues Appear attentive Change the subject you are asking about Ask your question again Give brief encouragement to the client

Watch the client closely for nonverbal cues Appear attentive Give brief encouragement to the client The period of silence usually feels much longer to the nurse than it does to the client. The nurse should appear attentive and give brief encouragement to continue when appropriate. During periods of silence, watch the client closely for nonverbal cues, such as difficulty controlling emotions. Repetition may make the client more uncomfortable and further hinder communication. The nurse should implement the other listed techniques before changing the subject.