Assessment 3304 FINAL

The nurse is assessing the musculoskeletal system of a teenage boy for participation in athletics. The nurse would expect to find that this client's bones are what as compared to a female of the same age?

Larger and Stronger

Students are practicing documentation of peripheral vascular and lymphatic assessment before going into the clinical setting. A student documents the following: Lower left leg cool to touch with dorsalis pedis, back knee pulse and femoral pulse palpable. How could the following charting be changed to communicate information in appropriate medical terminology?

Left lower extremity cool to touch with femoral, posterior popliteal, and dorsalis pedis pulses palpable

When conducting a generalized assessment of a new client, for what would the nurse inspect the neck?

Limitations in movement

Which of the following would be most important for the nurse to remember when auscultating the thorax?

Listen at each site for at least one complete respiratory cycle

After teaching a group of students about age-related changes in the lungs, the instructor determines that the teaching was successful when the students identify which of the following as an age-related change?

Loss of elasticity

A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 pounds since the last visit. What action by the nurse is best?

Measure for new compression stockings.

What structure in the abdomen provides the blood vessels to the intestinal tract?

Mesentery

The linea alba is located where?

Middle of the ventral abdominal wall

When palpating a client's inguinal lymph nodes, what technique should be used?

Move the finger pads over the area using a gentle circular motion.

The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient:

Moves the head and shoulders against resistance with equal strength.

When assessing the tympanic membrane, where would the nurse expect to visualize the malleus?

Near the center

A modifiable risk factor for breast cancer includes what?

Obesity

An older adult is admitted to the unit with abdominal pain. The nurse doing the admission assessment knows what about pain in older adults?

Older adults may be reluctant to report pain

An older adult client has been admitted to the unit. The client has problems with fine motor movement. What would be important to do for this client?

Open all packages and arrange the meal tray while communicating actions to the client

Which of the following would be best for a nurse to use when assessing for fremitus in a client?

Palmar base (ulnar surface)

A nurse is performing a physical exam on an older client. She reports that her feet feel numb. What assessment should the nurse perform first?

Palpate the dorsalis pedis pulses.

Which of the following tests would be most appropriate for the nurse to use when assessing motor function of the trigeminal nerve?

Palpate the temporal and masseter muscles while the client clenches teeth

While auscultating a client's abdomen, the student notes abnormal bowel sounds. The student's nursing preceptor asks the student to describe the sounds. The student describes them as high-pitched, rushing sounds. The nursing preceptor would know that these sounds indicate what?

Partial intestinal obstruction

A client complains of recurring headaches that are worse when first waking in the morning and with coughing or sneezing. What would be the nurse's most appropriate action?

Perform a focused assessment

When assessing the extremities of a client, the nurse notes muscle atrophy. What does the nurse know may be the cause?

Peripheral artery disease

A pediatric nurse is doing the initial shift assessments on assigned clients. One of the client's is a toddler with pneumonia. How would the nurse assess this client's skin turgor?

Pinch a fold of skin on the client's forearm

When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as:

Positive Romberg test

What pulse is located in the groove between the medial malleolus and the Achilles tendon?

Posterior tibial

A way to use nonverbal communication is through silence. The purposeful use of silence during the interview allows clients to what?

Provide accurate answers

The nurse is in the client's room after she has given birth one day ago and observes a family member offering the baby a bottle after the infant has breastfed. The family member states to the new mother, "This baby is not fat enough and needs to eat double the first few weeks." What is the nurse's best action?

Provide information to the client and family about newborn nutritional needs.

When testing for accommodation, what reaction would you expect to see?

Pupils converge and constrict

A client with an acute appendicitis is ordered a barium enema. What should the nurse do first?

Question the order because you thought a barium enema was contraindicated in cases like this.

In the Hispanic culture, a common rite of passage for a female teenager is called what?

Quinceanera

Clients in health care settings often are anxious. What behaviors would lead a nurse to believe that a client is anxious? (Select all that apply.)

Rapid speech Nail-biting Defensive tone Sweating

Which information in the client's history is a priority safety concern?

Recent immigrant complains of cough

The nursing instructor is discussing the different types of pain with the nursing class. What type of pain would the instructor explain originates from a specific site, yet the client feels the pain at another site?

Referred pain

A trauma client reports pain in the left lower extremity. The nurse notes that the extremity has pallor. Pedal pulses are diminished, and paresthesia is present. What nursing diagnosis might the nurse use?

Risk for peripheral neurovascular dysfunction

An oncology nurse is caring for a client newly diagnosed with an occult nasopharyngeal malignancy. Where would the nurse expect this malignancy to be?

Rosenmuller's fossa

Nursing students are learning about different methods of charting in clinical. What method is the model for improving communication between and among clinicians?

SBAR

A nurse is admitting a new client. The client is lying in bed. Where should the nurse be positioned?

Seated in a chair at eye level with the client

When assessing a client, the nurse asks if the client has ever had varicella. The nurse knows that varicella always precedes what?

Shingles

What type of family violence is among the most common type that children experience?

Sibling Violence

The nurse is assessing the pain of an older adult client who is recovering from a right hip open reduction procedure. What element would the nurse know it is important to review to best understand the patient's pain?

Sleep patterns

When assessing the apices of the lungs, the nurse would locate them at which position?

Slightly above the clavicle

The nurse is caring for a client suffering from a nutritional deficiency. The nurse expects that the client has a dysfunction of which abdominal body part?

Small intestine

A nursing student is helping with a group presentation on social assessment. What would be most important for the student to include in the group presentation?

Social assessment emphasizes the interconnectedness of physical, psychosocial, and spiritual dimensions of health

The nurse is caring for a newly admitted adult client. When performing the general survey of this client, the nurse knows that accurate measurements provide critical information about what?

State of health

What tool does the nurse use to auscultate the client's abdomen?

Stethoscope

When a nurse asks a patient "Do you have any thoughts of wanting to harm or kill yourself?" for what is the nurse assessing?

Suicide ideation

Upon entering an adult client's room to begin a shift assessment, the nurse should call the rapid response team based on which assessment finding?

Systolic pressure 180 mm Hg

A client arrives at the emergency department by ambulance after an accident while playing softball. The client's left leg is swollen and deformed. The client describes the pain as a 9 on a 10-point scale. When the nurse assesses the client's blood pressure, what would the nurse expect to find?

The blood pressure is elevated

The nurse is caring for a client with a nursing diagnosis of impaired skin integrity related to a stage III pressure ulcer. What would be the most important outcome for this client?

The client exhibits no signs or symptoms of infection

A nurse is admitting a client to the hospital. When reviewing the client's medical record, the nurse notes that this client had abnormal findings during the Weber test. What would the nurse know this means?

The client has unilateral hearing loss

A client who only speaks Spanish is admitted to the unit. The client's sister, who speaks English, is in the room when the English-speaking nurse starts the admission assessment. Why would it be inappropriate to use the sister as an interpreter for this client?

The client may not want her sister to know her private information

A nurse conducting a comprehensive nutritional assessment is assisting the client in completing a 24-hour food recall. What does the research show regarding the client's ability to recall intake?

The client often underestimates high intakes

The nurse is performing a generalized assessment of an older adult. The nurse notes that the client's skin is thin and rough with abrasions. The client tells the nurse that it seems to take "forever" for scratches to heal, "a lot longer than when I was younger.". How would the nurse note these findings in the client's medical record?

The client states that wounds are taking longer to heal

Students are learning about the many uses of the medical record. One of these uses is to perform an internal audit. What is the goal of an internal audit?

The evaluation of care for continual improvement

As part of the general survey, the nurse should shake hands with the client when first meeting him/her as long as doing so in culturally appropriate. Why is this action so important?

The handshake portrays caring

What is egocentrism?

The inability to distinguish one's own perspective from another person's

The open space between the eyelids is called what?

The palpebral fissure

A student nurse is taking a nursing test and is asked a question about the columella. What is the best description of the term columella?

The structure that divides the nares

The Joint Commission mandates that nurses assess and reassess a client's pain level. A nurse's healthcare facility mandates pain reassessment at 30 minutes for any drug given intravenously. This mandate is based on what?

The time it takes a pain medication to decrease pain intensity

When the nurse is assessing the client's skin, an ulcer is identified. What would indicate to the nurse that it is a venous ulcer?

The ulcer is superficial and pale.

The nursing students are learning about the abdomen. The nursing instructor would tell the class that the abdominal cavity is bordered on the back by

The vertebral column

To make a legal entry into the medical record, the nurse must document what?

Time of the assessment

The nurse is admitting a new client to the floor and asks if the client has any dizziness. Why does the nurse do this?

To check for possible dehydration

The nursing instructor explains that sometimes a nurse uses a mnemonic, such as OLDCARTS, as the nurse completes the assessment. What is the purpose of the mnemonic?

To remember the elements that are important to assess with a symptom

An nurse practitioner is conducting the physical assessment of a school age child. The child's mother states that it seems like her child always has a strep throat. For what intervention might this indicate a need?

Tonsillectomy

A student is performing a physical assessment on a client. While assessing the abdomen, the student percusses for the spleen. What sound would be normal for the student to hear?

Tympany

A caregiver brings a handicapped client to the ED reporting altered level of consciousness and refusal to eat by the client. The client is found to be severely dehydrated. The nurse suspects neglect and asks the caregiver several questions regarding the client's activities, diet, and care. The caregiver states, "I didn't know it could hurt him if he didn't drink anything." This is an example of what kind of abuse?

Unintentional

The nursing instructor is explaining to students the difference between the language used when a nurse talks to the client and the language used when documenting in the medical record. What would the instructor tell the students about documenting in the medical record?

Use medical terminology when documenting in the medical record

A teenager is brought to the clinic for a sports physical examination. The client states plans to play goalie on the community soccer team. What is the most important teaching opportunity presented for this client?

Use of safety equipment

Parents bring a school age child to the emergency department after a bicycle accident. The father tells the nurse that the child was not wearing a helmet when thrown over the handlebars, striking the child's head on the sidewalk. What would be the most important information for the nurse to include in education for this child and family?

Use of safety equipment

A nurse is teaching a class on diet and nutrition to a group of mothers who are breast-feeding their infants. What would the nurse tell the group is the emphasis of nutritional guidelines?

Variety

A group of students is reviewing the vertical reference lines of the thorax. They demonstrate understanding when they identify which line as a reference line for the posterior thorax?

Vertebral line

A client complains, "I feel like the whole room is spinning around me, and it makes me nauseous sometimes." What term should the nurse use to document the client's symptom?

Vertigo

During the taking of the health history, a patient tells the nurse that "it feels like the room is spinning around me." The nurse would document this finding as:

Vertigo

The nurse is caring for a client with an eye injury. The client asks about the eye, and the nurse explains its structures and functions. What would the nurse tell the client is the largest chamber of the eye?

Vitreous

A newborn is born with cleft lip/palate. As a nursing student, you know that this is:

the most common congenital malformation of the oral cavity

A nurse is performing an admission assessment on a new client to the unit. What would be the best way to phrase a question about the client's marital status?

"Do you live alone or with someone?"

A client reports experiencing leg cramps, usually after walking around the park. Which follow up question by the nurse provides the best information about the client's claudication distance?

"How far do you walk before the leg cramps begin?"

The parents of a newborn appear anxious and express concern upon seeing the pediatrician palpate and gently express a small amount of whitish, milk-like liquid from the baby's nipples. What is the nurse's best response?

"Nothing is wrong with your baby. This liquid will clear up spontaneously."

An older female client states she is upset about her sagging breasts. She states, "I know it's because I haven't been sexually active since my husband died and my hormones are all dried up." What is the nurse's best response?

"What you're experiencing is an expected effect of the aging process."

A nurse is preparing a teaching plan for a client newly diagnosed with peripheral arterial disease. The nurse knows to address in this teaching plan the most modifiable risk factors. What risk factors would the nurse include? (Mark all that apply.)A nurse is preparing a teaching plan for a client newly diagnosed with peripheral arterial disease. The nurse knows to address in this teaching plan the most modifiable risk factors. What risk factors would the nurse include? (Mark all that apply.)

-Activity level -Smoking

What components of sound does the cochlea interpret? (Select all that apply.)

-Amplitude -Frequency

The triage nurse suspects malnutrition in an older adult with altered mental status who has been brought to the emergency department by family members. What visible signs might the nurse have noticed that would lead to the suspicion of malnutrition? (Mark all that apply.)

-Atrophied tongue -Temporal muscle wasting -Generalized muscle weakness -Dry eyes

The nurse is performing visual acuity testing on an older adult who has fallen and fractured their femur. What finding would be considered normal for this client? (Select all that apply.)

-Cataract -Arcus senilis -Decreased tear production

The nursing instructor is discussing with the nursing students different types of health histories. A student asks when it would be appropriate to take a comprehensive health history. What would be the instructor's best answer? (Select all that apply.)

-During a hospital admission -During an annual physical examination -At a screening for sports participation

The lymphatic system functions to? (Mark all that apply.)

-Fight infection -Maintain Fluid Balance -Maintain Protein Balance

A client presents at the emergency room reporting "the worst headache I have ever had." What are critical nursing behaviors for this client? (Select all that apply.)

-Focused history -Physical examination for neurologic changes

What does Healthy People have as its focus areas for the GI tract? (Mark all that apply.)

-Food-borne illness -Colorectal cancer -Hepatitis

When inspecting the hair, what would the nurse note? (Select all that apply.)

-Hair shafts that are shiny - Color -Condition of hair shaft

Which of the following veins drain into the superior vena cava? (Mark all that apply.)

-Head -Upper Extremities -Upper Torso

When assessing a breast, what signs/symptoms might indicate a malignancy? (Mark all that apply.)

-Hyperpigmentation -Peau d 'orange -Unilateral vascular appearance

Which assessment techniques would a nurse use on the external ear? (Select all that apply)

-Inspection -Palpation

A nurse is teaching a client about self breast examination. What would the nurse emphasize? (Mark all that apply.)

-Inspection -Timing -Palpation

An adult comes to the clinic reporting pain in the right lower quadrant. When assessing the client's pain, what elements would the nurse include? (Mark all that apply.)

-Intensity -Quality -Functional goal

The student nurse would learn that there are what types of family violence? (Mark all that apply.)

-Intimate partner violence -Child maltreatment -Elder abuse

Cues for hearing loss include which of the following? (Select all that apply.)

-Leaning forward to hear -Concentrating on lip movement -Asking to repeat questions -Using a loud and monotonous voice

What is the purpose of the tongue? (Select all that apply.)

-Manipulates solids and liquids when eating and drinking -Helps with the identification of sweet, sour, salty, and bitter tastes -Assists in speech production

What is considered true for varicose veins? (Mark all that apply.)

-May be familial -More common in women -Seen more often in people older than 50 years

What does examination of the skin involve? (Select all that apply)

-Palpation -Inspection

When assessing for acute arterial occlusion, what would the nurse include? (Mark all that apply.)

-Paresthesia -Pallor -Paralysis -Pain

A client is thought to have a balance problem. What would be an advanced method of assessing balance in this client? (Mark all that apply.)

-Romberg's test -Standing -Hopping on one foot

Nursing students are learning about assessment of the head and neck. What cultural considerations would the students learn to assess in relation to this area? (Select all that apply.)

-Shape of the lips -Shape of the nose -Shape of the eyes

An older adult client is admitted to the hospital with pneumonia. While performing the admission assessment, the nurse finds a reddened area on the client's coccyx. What would the nurse include about this finding in notes? (Mark all that apply.)

-Size -Texture -Location -Depth

Included in the subjective assessment of the breast are the client's statements about what? (Mark all that apply.)

-Surgeries -Nipple Discharge -Personal History

The nurse is presenting an educational event for a local civic group about the risk factors for neck cancer. What would the nurse list? (Select all that apply.)

-Tobacco use -Age older than 50 years -Male gender

A nursing instructor is discussing areas of health promotion related to the nose, sinuses, mouth, and throat. What topics would the instructor be most likely to cite? (Select all that apply.)

-Tobacco use -Obstructive sleep apnea -Oral health

Normal movement of the eye involves what cranial nerves? (Mark all that apply.)

-VI -IV -III

The autonomic nervous system innervates the salivary glands along with which cranial nerves? (Select all that apply.)

-VII -IX -XII

During the assessment of deep tendon reflexes, the nurse finds that a patient's responses are bilaterally normal. What number is used to indicate normal deep tendon reflexes when the documenting this finding? ____+

2

Which of the following scores for distance vision indicates the patient with the poorest vision?

20/200

Research has found that there is a dramatic increase in the incidence of peripheral arterial disease during what time period in a person's life?

7th and 8th decades

The nurse is assessing balance. Which test would the nurse plan on omitting from the exam?

Achilles reflexes

The nurse can best practice effective care by exhibiting which behavior during a cultural assessment?

Acknowledge own prejudicies that might create barriers to care.

A group of students is giving a presentation about the spleen. What is one of the functions of the spleen?

Activates B and T Lymphocytes

A client diagnosed with rheumatoid arthritis exhibits edema, redness, and tenderness of the fingers. What is the nurse's priority action?

Administer prescribed anti-inflammatory.

In what life stage, defined by Erikson, is group identity important?

Adolescence

When doing a shift assessment on a newly admitted client, the nurse notes lack of hair on the right lower extremity; thickened nails on the right lower digits; dry, flaky skin on the right lower extremity; and diminished tibial pulses bilaterally and absent pedal pulses. What nursing diagnosis should this client receive?

Altered tissue perfusion, arterial related to reduced blood flow

An older adult has been admitted to the emergency department. The client reports pain in his back and abdomen and shortness of breath. What might the nurse suspect is wrong?

Aortic aneurysm

A client presents complaining of nausea, vomiting, and acute abdominal pain. What is the nurse's first action?

Ask the client when the pain began

A nurse in the emergency department is caring for a nonverbal client. What would be the best way for the nurse to assess this client's level of pain?

Ask the family if they have noticed any changes in the client's behavior

The nurse is gathering a complete history of the client's present illness. The nurse knows that the most appropriate way to begin to gather this information is what?

Asking open-ended questions

A client with a cervical spine injury has chronic pain. What would be the most appropriate initial nursing intervention for this client?

Assess characteristics of the pain

The nurse is assessing a client who presents with shoulder pain. No signs of inflammation are present. What is the nurse's priority action?

Assess for shortness of breathe

An Afghani woman is admitted to the obstetric unit. While doing a transcultural assessment, how would the nurse individualize questions for this client?

Assess if the client speaks and understands English

The nursing instructor is discussing the function of sebaceous glands in the body. What would the teacher explain as the purpose of sebum to the students?

Assists in friction protection

A nurse is preparing to assess a client's cerebellar function. Which of the following would the nurse expect to test?

Balance

The nurse is auscultating the abdomen and hears a swooshing sound in the abdominal area. The nurse would document this sound as a what?

Bruit

The nurse practitioner notes that the thyroid gland is enlarged and auscultates both lobes of the thyroid. For what is the nurse practitioner listening?

Bruit

A client tells the nurse that his eyes "are not working right." When the nurse asks what the client means, the client states, "It is like one eye is moving faster than the other." What test would be most appropriate for the nurse to use to assess this client?

Cardinal fields

A client presents to the emergency department after falling off a ladder while doing some outside painting at home. The client's ankle appears swollen, out of alignment, and is painful to touch. What is the nurse's first action?

Check for a pulse, color, temperature, and capillary refill.

Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would most likely suspect which of the following?

Chronic obstructive pulmonary disease

When palpating a client's liver, the nurse feels a firm edge. What would this indicate to the nurse?

Cirrhosis

The nurse is assessing a client and notes dullness to percussion in the lowest point of the abdomen. When rolling the client to the left, the nurse notes that there is now dullness on the left side. This indicates ascites, which can be caused by

Cirrhosis and nephrosis

HIPAA gives clients greater control over their medical records. What else does HIPAA provide?

Client recourse if privacy protections are violated

When using Gordon's framework for a functional health assessment, the nurse asks a client, "Have you made any changes in your environment because of vision, hearing, or memory decrease?" What functional health pattern is the nurse assessing?

Cognition

When assessing a client's strength, it is necessary to

Compare one side to the other

The nursing instructor is explaining SBAR documentation to students before taking them into the clinical area. The instructor explains that SBAR charting is based on?

Complete and accurate assessment findings

A client presents at the urgent care clinic with severe pain and pressure around the eyes. The nurse practitioner suspects a sinus infection. What is considered the gold standard diagnostic technique in evaluating sinus disease?

Computed tomography (CT) scanning

A couple adopts an 8-month-old infant. The clinic nurse writes a care plan that includes the diagnosis of risk for delayed child development related to recent adoption. What would be an appropriate nursing intervention for this infant/family?

Consider visits by a home health nurse to assess the environment for safety and comfort

A mother brings her 2-year-old child to the clinic stating that the child is cross-eyed. What test would the nurse perform to test for strabismus?

Corneal light reflex

A nurse, who suffers from a respiratory infection is preparing to perform a shift assessment on a client when she feels the urge to cough. What is the nurse's best action?

Cough into the inner aspect of the elbow

A client comes to the clinic and reports a sore knee. The nurse notes popping and cracking noises when the client attempts to bend the knee. The client exhibits signs of pain by facial expression. The nurse knows that the popping and cracking noises should be charted as what?

Crepitus

A shared, learned, and symbolic system of values, beliefs, and attitudes that shape and influence how people see and behave in the world is a definition of what?

Culture

Why is the appearance of urine important to evaluate during an abdominal exam?

Dark urine could indicate dehydration

The triage nurse on the adolescent unit knows that puberty can contribute to what?

Depression

A newly admitted client has given their health history and undergone a physical assessment. Laboratory data and diagnostic study results are on the chart. What is the nurse's next step in caring for the client?

Develop a plan of care

How does the nurse use critical thinking when accurately assessing vital signs?

Developing nursing diagnoses

The nurse is caring for an older adult client with a nasogastric feeding tube ordered by the physician. The nurse notes that the client is not a mouth breather and having no difficulty breathing. While inserting the feeding tube, the nurse encounters difficulty getting the tube through the nares. What should the nurse suspect?

Deviated septum

While assessing a new client, the nurse asks about a family history of genetic illnesses. The client states that her mother has diabetes. For which of the following is the patient at increased risk?

Diabetes

The nurse is caring for a client who is vomiting. When inspecting the vomitus, the nurse notes that it appears to contain coffee grounds. This would indicate what to the nurse?

Digested food

A nursing instructor is discussing therapeutic versus nontherapeutic responses with nursing students. Which of the following would the nurse identify as nontherapeutic?

Distraction

What additional health history question related to the abdominal system is appropriate for a client of African American decent?

Do you or your parents have sickle cell disease or carry the trait?

A college age athlete presents to the clinic with pain in the tibiotalar joint. It is a hinge joint limited to flexion and extension. The terms used to describe these movements are what?

Dorsiflexion and plantar flexion

The nurse is performing percussion on a client's abdomen. What would the nurse expect to hear over the liver in the right upper quadrant?

Dullness

A college football player has been hospitalized with a knee injury. When sending his diet orders to the hospital kitchen, the nurse knows what to include?

Extra servings of protein

When percussing the scapula of a client, which of the following would the nurse expect to hear?

Flatness

A middle aged client is admitted to the observation unit with right lower quadrant pain. The client has not kept down any food or drink for 24 hours. The client's temperature is 38.6°C orally (101.5°F). The client describes the pain as "achy with periods of sharp, stabbing sensations." What would be the most appropriate nutritional nursing diagnosis for a client with these assessment data?

Fluid volume less than body requirements related to an inability to tolerate fluids

A clinical instructor is discussing with a clinical group how to take a history of the client's present illness. A student asks how to best guide the interview. What would be the instructor's most appropriate answer?

Follow the cues of the client during the interview

What does the nurse knows about normal blood pressure?

Follows a diurnal rhythm

A nurse asks a client to say "ninety-nine" as the nurse palpates the posterior thorax. The nurse is assessing which of the following?

Fremitus

When doing a risk assessment of the nose, sinuses, mouth, and throat, what finding might indicate an allergy?

Frequent childhood infections

The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviors is the __________ lobe.

Frontal

The nursing instructor is teaching about health assessment and explains to students how to assess the roles and relationships of the client. The students knows that this type of information is assessed in what type of assessment?

Functional

What term is this quote describing? "__________ encompasses the evolutionary development which has made man the teaching, instituting, and learning animal."

Generativity

The nurse is conducting a comprehensive health assessment of an adult Hispanic man. Which of the following abnormal findings would be most likely in this client?

Gingivitis

When assessing risk factors for eye and vision problems, the nurse knows that genetics can play a role. What major eye problem are clients most likely at increased risk for if a first-degree relative has it?

Glaucoma

A client is given a nursing diagnosis of activity intolerance related to pain and claudication with ambulation. What would be an appropriate intervention for this client?

Gradually increase activity

A mother of three young children is newly diagnosed with breast cancer. The client tells the nurse that she is so sad and cannot stop crying. She adds that she feels like she is less of a woman and is having trouble sleeping. When initiating the plan of care, what would be the most appropriate nursing diagnosis?

Grieving

When caring for clients in any health care environment, what is the most important technique for preventing infection?

Hand Hygiene

Adventitious sounds are heard when auscultating a client's lungs. Which of the following would the nurse do first?

Have the client cough and then listen again

The eustachian tube is a passage between the middle ear and the nasopharynx. What is the function of the eustachian tube?

Helps to regulate pressure in the middle ear

Student nurses are spending time in the laboratory learning the proper use of an otoscope. What technique would these students learn for best visualization of the tympanic membrane in an adolescent?

Hold the ear at the helix and lift up and back

Nursing students are learning how to identify different areas of the abdomen. What is the lower middle area called?

Hypogastric

The nursing instructor is discussing the collection of subjective information when assessing a client with arterial, venous, and lymphatic disorders. What would the instructor tell the students to include in the subjective portion of the health assessment?

Identification of cardiovascular risk factors

The nurse is developing a plan of care for a client found to have a strength problem. What would be an appropriate nursing diagnosis for this client?

Impaired physical mobility

A nurse caring for a client admitted 2 days ago following a cerebral vascular accident. The nurse notes that the client is frequently coughing, has food falling from the mouth while eating, and frequently chokes. What would be the most pertinent nursing diagnosis for this client?

Impaired swallowing

When assessing cranial nerves IX and X, which of the following would the nurse consider as an abnormal finding?

Impaired swallowing

A school age child is brought to the pediatric clinic by her mother, who tells the nurse that the child has a sore on her leg that "just keeps getting bigger." On examination, the nurse practitioner notes an area of vesicles and bulla, some of which have ruptured and are oozing serous fluid. A honey-colored crust covers the area. What would the nurse suspect the lesion is?

Impetigo

Which of the following assessment findings would lead the nurse to suspect that a client has Bell's palsy?

Inability to wrinkle the forehead

The nurse is caring for an adult client who presents at the clinic with reports of general malaise and fatigue. Physical assessment reveals that the client's lips are dry and cracked. What might this indicate?

Inadequate hydration

A normal assessment of the neck would include palpation of the thyroid isthmus. Where would the nurse find the isthmus?

Just below the cricoid cartilage

A nurse is providing client teaching to the parents of a preschooler who experiences chronic epistaxis. What would the nurse identify as the area where most nosebleeds originate?

Kiesselbach's plexus