306 EAQ - Novice Level

When assessing a patient for malnutrition, the RN would monitor for increase in liver enzymes and a decrease in which water-soluble vitamin? Select all that apply. a. biotin b. niacin c. folic acid d. riboflavin e. vitamin C

a. biotin b. niacin c. folic acid d. riboflavin e. vitamin C

When assessing a client's BP, obtained via the client's unsupported left arm, which reading error would the RN suspect? a. false high reading b. false low reading c. false high systolic reading d. false high diastolic reading

a. false high reading

While assessing a client's vascular system, the nurse finds a diminished and barely palpable pulse strength. Which documentation would the RN utilize in this situation?

1+

In which sequence of techniques would the nurse assess a client's abdomen?

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

which documentation would the RN utilize to report that a client's degree of edema has a depth of 8mm?

4+

when conducting a client interview, which nurse's response is an example of back channeling? a. "all right, go on..." b. "what else is bothering you?" c. "tell me what brought you here." d. "how would you rate your pain on a scale of 0 to 10?"

a. "all right, go on..."

When gathering data for a client's health history, which intellectual factor would the RN consider as a dimension? a. attention span b. primary language c. coping mechanisms d. activity & coordination

a. attention span

Which physical change would the RN observe in a client with malnutrition? Select all that apply. a. hypotension b. dry, dull hair c. abdominal edema d. delayed wound healing e. depletion of muscle mass

a. hypotension b. dry, dull hair c. abdominal edema d. delayed wound healing e. depletion of muscle mass

Which term would the nurse use to document a client with drooping of the eyelid over the pupil? a. ptosis b. ectropion c. entropion d. nystagmus

a. ptosis

which physiologic symptom would the nurse associate with a client's sleep deprivation? Select all that apply. a. ptosis and blurred vision b. agitation and hyperactivity c. confusion and disorientation d. increased sensitivity to pain e. decreased auditory alertness

a. ptosis and blurred vision e. decreased auditory alertness

Which site would be safer and less expensive for the temperature measurement of a human? Select all that apply. a. skin b. oral c. axilla d. rectal e. tympanic membrane

a. skin c. axilla

while assessing a client's pupils, a healthcare professional notices pupillary dilation. which drug would cause this condition? a. heroin b. atropine c. morphine d. pilocarpine

b. atropine

which factor would elevate a client's oxygen saturation? a. nail polishes b. carbon monoxide c. intravascular dyes d. skin pigmentation

b. carbon monoxide

which information obtained during a client's health history, would the RN classify as biographical information? Select all that apply. a. symptoms b. client's age c. family structure d. type of insurance e. occupation status

b. client's age d. type of insurance e. occupation status

Which part of the client's body would the RN assess to confirm a diagnosis of frostbite? Select all that apply. a. axilla b. fingers c. ear lobes d. forehead e. upper thorax

b. fingers c. ear lobes

Which client assessment finding would the nurse document as subjective data? a. BP 120/83 bpm b. pain rating of 5 c. potassium 4.0 mEq d. pulse oximetry reading of 96%

b. pain rating of 5

Which position would the RN utilize to assess the musculoskeletal system, but contraindicated for clients experiencing chronic obstructive respiratory disease? a. left lateral recumbent position b. prone position c. supine position d. knee-chest position

b. prone position

In which situation would the RN consider family members as the primary source of information? Select all that apply. a. the client is an older adult b. the client is an infant or child c. the client is brought in as an emergency d. the client is critically ill and disoriented e. the client visits the outpatient department

b. the client is an infant or child c. the client is brought in as an emergency d. the client is critically ill and disoriented

When examining a client, the nurse finds a 0.6 cm circumscribed elevation of the skin filled with serous fluid on the cheek. Which term would the RN utilize for documentation? a. papule b. vesicle c. nodule d. pustule

b. vesicle

__________ ________________ involves the use of active listening prompts such as "go on...,", "all right,' and "uh-huh" encouraging the client to complete the full story

back channeling

Which example would be a normal blood pressure of a 12 y/o patient? a. 95/65 b. 105/65 c. 110/65 d. 119/75

c. 110/65

planning to provide self-care health information for several clients, which client would the RN anticipate will be most motivated to learn? a. 55 y/o client who had a mastectomy and is very anxious about her body image b. 18 y/o client who smokes cigarettes and is in denial about the dangers of smoking c. 56 y/o client who had a heart attack last week and is requesting information about exercise d. 47 y/o client who has a long-leg cast after sustaining a broken leg and is still experiencing severe pain

c. 56 y/o client who had a heart attack last week and is requesting information about exercise

Which type of breathing pattern would a client experiencing hypercarbia exhibit? a. eupnea b. tachypnea c. hypoventilation d. Kussmaul respiration

c. hypoventilation

When instructing a client to increase his/her potassium intake, which food would the RN recommend? a. onion b. celery c. orange d. cheese

c. orange

When assessing a client who had a thyroidectomy yesterday, which cue would the RN associate with an initial sign of hypocalcemia? a. headache b. pallor c. paresthesias d. blurred vision

c. paresthesias

When developing a nursing diagnosis for a client after surgery, the RN documents the "related to" factor as first-time surgery. Which assessment activity enabled the nurse to draw this conclusion? a. the RN notes nonverbal signs of discomfort b. the RN observed the client's position in bed c. the RN asks the client to explain the surgery d. the RN asks the client to rate the severity of pain

c. the RN asks the client to explain the surgery

Which clinical finding would the RN associate with hypokalemia? a. edema b. muscle spasms c. Kussmaul respirations d. muscle weakness

d. muscle weakness

a client who relocated to a new city for work, is unable to continue the practice of walking for 30 mins/day and exercising for 5 days/week. Which stage of the transtheoretical model of health behavior change is the client experiencing? a. action b. preparation c. maintenance d. precontemplation

d. precontemplation

When interpreting findings from a pain assessment, which factors would the RN consider the most significant influences on a client's perception of pain? a. age and sex b. physical and physiological status c. intelligence and economic status d. previous experience and cultural values

d. previous experience and cultural values