EXAM 1 PRACTICE Qs

A

A client comes to the ED with lower abdominal pain. She is extremely emotional and moving wildly on the gurney. A nurse says to another nurse that the client is "way overdoing it." What action should the nurse take to best provide care for this client? A. Conduct a cultural assessment to better understand the client's perception of pain and illness. B. Tell the physician the client is not hurting as much as she lets on C. Move the client so she will not bother other clients in the department D. Talk to the client's family to find out if this is the normal behavior for this client

C.

A client opens the eyes and answers questions however falls back asleep within seconds. How should the nurse document this assessment finding? a. Coma b. Stupor c. Lethargy d. Obtunded

A

A new nurse is being trained on the different temperature taking techniques. She know that different temperature sites have different normals but is unsure of the normal ranges. After providing education, the new nurse is praised if she says which of the following? A. Tympanic temperature is slightly higher than oral temperature. B. Tympanic temperature is only used if all other methods are unavailable. C. Tympanic temperature varies more widely than oral, rectal, and axillary temperatures. D. In adults, tympanic temperature is equal to axillary temperature.

D. Lifestyle and health practices profile

A nurse assesses a client with regard to nutritional habits, use of substances, education, and work and stress levels. The nurse recognizes this as what type of information? A. Family health history B. Personal health history C. History of present health concern D. Lifestyle and health practices profile

A

A nurse is admitting a client who is from another culture. Prior to caring for a client from another culture, the nurse should place primary importance on which action? A) Examining personal biases and prejudices B) Researching characteristics of the specific culture C) Asking colleagues about ways to approach the client D) Developing awareness of the culture's health practices

C. "What other symptoms occurred during the spell?"

A nurse is collecting data on a client's chief complaint, which is a spell of numbness and tingling on her left side. Which of the following questions would be best for eliciting information related to associated factors? A. "How bad was the tingling and numbness?" B. "Where did the numbness and tingling occur?" C. "What other symptoms occurred during the spell?" D. "How long did the spell last?"

B. Physical assessment data C. Information provided by the client E. Nursing history

A nurse is currently in the assessment phase of the nursing process with a client. Which pieces of information should the nurse document during this phase? Select all that apply. A. Presumptions from objective data B. Physical assessment data C. Information provided by the client D. Interpretation of subjective data E. Nursing history

D. Portraying a neutral and friendly expression

A nurse is interviewing a client who seems anxious. Which nonverbal communication by the nurse helps to facilitate a relaxed environment for the client during the interview process? A. Wearing casual, neat, and comfortable clothes B. Sitting back with crossed arms during the interview C. Ensuring that there are no periods of silence D. Portraying a neutral and friendly expression

B. The client's radial pulse occluded with moderate pressure.

A nurse is reviewing a colleague's documentation of a client assessment. The nurse reads that the client's radial pulse was 2+. How should the nurse interpret this assessment finding? A. The client's radial pulse occluded easily. B. The client's radial pulse occluded with moderate pressure. C. The client's radial pulse occluded with very firm pressure. D. The client's radial pulse could not be manually occluded.

A

A patient is admitted to the postsurgical unit following a total knee replacement. Which of the following would the nurse use as the primary assessment for the client's pain? A. The patient's report of the pain B. Assume she does not have any due to the anesthesia C. What the physician tells you her pain should be at D. The patient's spouse report of the pain

B

How can a nurse best assess a client's dietary habits? A. Assess for the presence of any chronic disease processes B. Obtain a 24 hour dietary recall of all foods and fluids consumed C. Obtain a height and weight and calculate a body mass index (BMI) D. Request the patient's food diary

A

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

B

Mid-arm circumference is a part of the anthropometric assessment that measures___. The patient's measurement is at 77%, which is classified as____. A. Subcutaneous fat; severely malnourished B. Skeletal muscle mass; moderately malnourished C. Subcutaneous fat; moderately malnourished D. Skeletal muscle mass; severely malnourished

C.

The nurse is admitting a client to the unit for surgery the next morning. The nurse notes that the client speaks at an accelerated pace and jumps from topic to topic, none of which progresses to sensible conversation. What would the nurse document about this client? a. Patient demonstrates confabulation b. Patient is delirious c. Patient demonstrates flight of ideas d. Patient demonstrates loose association

D

The nurse is admitting a new patient for a heart bypass surgery. Upon initial assessment, the patient identifies as a Jehovah's witness. Which of the following will the nurse need to clarify while reviewing the patient's plan of care? A. Ensure accurate medical and family history B. Consult chaplain prior to surgery C. Witness and obtain informed consent for the procedure D. Review advance directive regarding blood product administration

B

The nurse is assessing an Asian client and notices that when being asked questions, the client is looking down on the floor and does not make eye contact. The nurse should include what in the plan of care? A. Suspect history of abuse B. Maintain minimal eye contacts C. Kindly ask the patient what makes them uncomfortable D. Suspect depression and conduct screening

C. Heart rate of 110 beats per minute

The nurse is performing an examination on a patient and finds a temperature of102.6°F. Which of the following would the nurse also expect to find during the exam? A. A heart rate of 50 beats per min B. A respiratory rate of 18 breaths per min C. A heart rate of 110 beats per min D. A weak, thready pulse and cold extremities

A, B, D

The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply A. Set the room temperature at a comfortable level. B. Remove distracting objects from the interviewing area. C. Place a chair for the client across from the nurse's desk. D. Ensure comfortable seating at eye level for the client and nurse. E. Provide seating for the client so that the client faces a strong light. F. Ensure that the distance between the client and nurse is at least 7 feet (2.1 meters).

C. Client reports difficulty sleeping at night

The nurse performs a physical assessment on a client and gathers both subjective and objective data. Which would the nurse document as subjective data? A. Pedal pulses are present. B. Temperature is 99.6° F (37.6° C). C. Client reports difficulty sleeping at night. D. Client has an apical pulse rate of 56 beats/min.

B

The nurse spends a day off in a part of a non-English speaking community in order to learn more about the culture to improve interactions when providing client care. What cultural competence component is this nurse demonstrating? A. skill B. desire C. awareness D. competence

A

The nurse suspects that a client is experiencing alcohol abuse. When completing the CAGE questionnaire, the nurse can confirm the client is having guilty feelings when she makes which statement? A. "My family doesn't deserve my bad behavior." B. "In the past I've considered drinking a little less." C. "My husband should stop nagging me about my drinking." D. "I was worried about myself when I needed a glass of wine at 9 o'clock in the morning"

B

Truong is assessing a patient in the outpatient clinic who is suspected to have alcohol abuse. What question would be appropriate for Truong to ask? A. Have you ever blacked out after drinking? B. Have you ever felt guilty about your alcohol abuse? C. Have you ever been treated for alcohol abuse? D. How many drinks did you have?

C

What is the Erikson's Stages of Development for older adult? A. Trust vs. Mistrust B. Intimacy vs. isolation C. Ego integrity vs. despair D. Generativity vs. Stagnation

C

When a nurse asks a client "Do you have any thoughts of wanting to harm or kill yourself?" for what is the nurse assessing? A. Suicide attempts B. Suicide means C. Suicide risk D. Suicide plan

D

When middle adult is unable to give back to the future generations and has not completed the previous developmental task, the individual is at risk for? A. Isolation B. Ego integrity C. Despair D. Stagnation

A

Which Glasgow Coma Score indicates the client is in a deep coma? A. 3 B. 8 C. 14 D. 15

B. Maintain a professional distance during assessment

Which action should a nurse implement when assessing a nonnative client to facilitate collection of subjective data? A. Avoid any eye contact with the client. B. Maintain a professional distance during assessment. C. Speak to the client using local slang. D. Ask one of the client's children to interpret.

C, D, F ,G

Which of the following will the nurse expects to find in a patient diagnosed with kwashiorkor? (SATA) A. Malnutrition of carbohydrates and protein B. Thin appearance due to muscle mass wasting C. Deficient protein intake D. Edematous abdomen appearance E. "Sunken face" appearance with hollow eyes and depressed cheeks F. Lack of muscle mass G. Pruritus manifested by skin lesions H. Hair is thin and brittle

C

While examining a patient's pulse, you find that the pulse rate is 78 beats per minute but that the rhythm is irregular. What should the nurse do next? A. Palpate the patient's ulnar pulse B. Palpate the patient's carotid pulse C. Auscultate the patient's apical pulse D. Document the finding E. Notify the physician

C

You are assessing a patient in the emergency department that is complaining of abdominal pain. Using the COLDSPA mnemonic, with what question would the pain assessment begin? A. How would you rate your pain on a scale of 1 - 10? B. Have you had this pain for more than 6 months? C. Can you describe how the pain feels? D. Do you have any associated symptoms such as nausea or vomiting?

0

what is the normal value for breath alcohol analysis test?

Transduction

which phase of nociceptive pain response involves the release of bradykinin and prostaglandins