Foundations Hesi

While caring for a client with heat stroke, the nurse measured the temperature and noted it as 39ºC. What is this temperature in Fahrenheit?

Ans: 102.2F Rationale Fahrenheit is converted by multiply C by 1.8 and adding 32. C is converted by subtracting by 32 and dividing by 1.8

Which factor can elevate the oxygen saturation during an assessment? Nail polishes Carbon monoxide Intravascular dyes Skin pigmentation

Ans: B Rationale Carbon monoxide artificially elevates the oxygen saturation during assessment. Nail polishes interfere with the ability of the oximeter. Intravascular dyes will artificially lower the oxygen saturation. Skin pigmentation will overestimate the saturation.

The nurse assesses an elderly client with a diagnosis of dehydration and recognizes which finding as an early sign of dehydration? Sunken eyes Dry, flaky skin Change in mental status Decreased bowel sounds

Ans: C Rationale Older adults are sensitive to changes in fluid and electrolyte levels, especially sodium, potassium, and chloride. These changes will manifest as a change in mental status and confusion. It is difficult to assess dehydration in older adults based on sunken eyes, dry skin, and decreased bowel sounds because these can be prominent as general normal findings in the elderly client.

A nurse is assessing several clients. Which client will require parenteral nutrition? A client with brain neoplasm A client with anorexia nervosa A client with inflammatory bowel disease A client with severe malabsorption disorder

Ans: D Rationale A client with severe malabsorption disorder requires parenteral nutrition. Clients with a brain neoplasm, anorexia nervosa, or inflammatory bowel disease will require enteral nutrition.

A client is admitted to the hospital after an accident. The nurse uses the Glasgow Coma Scale (GCS) with the client. The client is alert and opens his or her eyes when there is a sound or when someone talks. When questions are asked, the client answers in a confused manner. The client obeys commands, such as being asked to move a leg. What would be the client's total score?

Ans: 13 Rationale The Glasgow Coma Scale (GCS) is used to measure the level of a client's consciousness and assigns a numerical score for each area of neurological status. The score for opening eyes on sound or speech is a 3. The score assigned for confused verbal responses is a 4. A score of 6 is assigned to the motor response of obeying commands. Therefore, the total score of the client is 13.

A client weighs 150 lb and is 5 feet 7 inches tall. What is this client's body mass index (BMI)?

Ans: 23.53 Rationale Body mass index (BMI) can be calculated by dividing the client's weight in kilograms by the height in meters squared. Therefore, a client who weighs 150 lb (68 kg) and stands 5 feet 7 inches (1.7 m) tall will have a BMI of 23.53: 68/1.7 2 = 23.53.

While caring for a client with heat stroke, the nurse measured the temperature and noted it as 109o F.

Ans: 42.8

A 16-year-old client has a blood pressure reading of 119/75. What is the approximate pulse pressure?

Ans: 44 Rationale The difference between the systolic and diastolic pressure is called the pulse pressure. The given blood pressure is 119/75. The difference between 119 and 75 is 44.

A client has a heart rate of 72 beats/min and stroke volume of 70 mL. What is the client's cardiac output?

Ans: 5040 Rationale The volume of blood pumped by the heart in 1 minute is the cardiac output. Cardiac output is the product of the heart rate and the stroke volume of the ventricle. Therefore cardiac output in the client with a heart rate of 72 beats/min and stroke volume of 70 mL is 5040 mL/min: 72 × 70 = 5040.

A nursing student under the supervision of a registered nurse is performing a pulse assessment. While preparing to assess the client, the registered nurse asks the nursing student to check the apical pulse after assessing the radial pulse. What could be the reason behind for this change? The client may have a dysrhythmia The client may have physiologic shock The client underwent surgery earlier in the day The cient may have peripheral artery disease

Ans: A Rationale A client with dysrhythmia may have an intermittent or abnormal radial pulse. For this condition, the registered nurse should advise the nursing student to assess the apical pulse because it will be more accurate. If the client is in shock, then assessing the carotid or femoral pulse would be appropriate. The femoral pulse is preferred to assess a client with peripheral artery disease.

A registered nurse is teaching a nursing student about when a client with high blood pressure should follow up with the primary healthcare provider. Which statement made by the nursing student indicates effective learning? "I will advise a client with a blood pressure of 130/80 mm Hg to follow up in a year." "I will advise a client with a blood pressure of 110/70 mm Hg to follow up in a year." "I will advise a client with a blood pressure of 150/90 mm Hg to follow up in a month." "I will advise a client with a blood pressure of 185/115 mm Hg to follow up in a month."

Ans: A Rationale A client with prehypertension tends to have a blood pressure (BP) between 120/80 and 139/89 mm Hg. These clients should be rechecked in a year. Clients with BP less than 120/80 mm Hg are considered normal. These clients should be rechecked in two years. Clients with stage 1 hypertension have a BP between 140/90 and 159/99 mm Hg. These clients should be rechecked in two months to confirm stage 1 hypertension. Clients with stage 2 hypertension have a BP greater than 160/100 mm Hg. These clients should be rechecked in one month. If a client's BP is greater than 180/110 mm Hg, then he or she should be treated immediately or within 1 week.

The nurse is caring for an elderly client with dementia. Which client need should the nurse prioritize while providing care? Safety Self-esteem Self-actualization Love and belonging

Ans: A Rationale An elderly client with dementia has impaired cognition. Therefore the nurse should make arrangements such as applying bed side rails to ensure that the client's safety needs are met first. At this stage, self-esteem or factors that enhance confidence and self-worth are not as important as safety. Self-actualization is the ability to solve problems and being able to cope realistically, which is beyond the capacity of the client with dementia. All clients need to feel love and belonging; however, safety is the first priority for this client.

An older client with shortness of breath is admitted to the hospital. The medical history reveals hypertension in the last year and a diagnosis of pneumonia three days ago. Which vital sign assessment would be seen as a sign that the client needs immediate medical attention? Oxygen Saturation: 89% Body temperature: 101°F Blood Pressure: 130/80 mmHg Respiratory rate: 26 beats/minute

Ans: A Rationale An oxygen saturation less than 90% observed in a client with pneumonia indicates that the client is at risk of respiratory depression. Oxygen saturation would take priority in initiating the care. The client's body temperature indicates fever due to pneumonia, which should be considered secondary to the oxygen saturation problem. The blood pressure reading is normal. The increased respiratory rate may be due to fever, which would be considered secondary to the oxygen saturation problem.

While assessing a client with dehydration, the nurse notices diminished skin elasticity. Which portion of the hand is used to perform this assessment? Fingertips Pads of fingertips Ulnar surface of hand Palmer surface of finger pads

Ans: A Rationale The fingertips are used to palpate the skin for elasticity. The pads of the fingertips are used to palpate pulse amplitude. The ulnar surface of the hand is used to detect fremitus. The palmer surface of the fingertips is used to examine the thorax.

A client presents with bilateral leg pain and cramping in the lower extremities. The client has a history of cardiovascular disease, diabetes, and varicose veins. To guide the assessment of the pain and cramping, the nurse should include which question when completing the initial assessment? "Does walking for long periods of time increase your pain?" "Does standing without moving decrease your pain?" "Have you had your potassium level checked recently?" "Have you had any broken bones in your lower extremities?"

Ans: A Rationale Clients with a medical history of heart disease, hypertension, phlebitis, diabetes, or varicose veins often develop vascular-related complications. The nurse should recognize that the relationship of symptoms to exercise will clarify whether the presenting problem is vascular or musculoskeletal. Pain caused by a vascular condition tends to increase with activity. Musculoskeletal pain is not usually relieved when exercise ends. Low potassium levels can cause cramping in the lower extremities; however, given the client's health history, vascular insufficiency should be suspected. Previously healed broken bones do not cause cramping and pain.

A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful? Clear breath sounds Positive pedal pulses Normal potassium level Decreased urine specific gravity

Ans: A Rationale Excess fluid can move into the lungs, causing crackles; clear breath sounds support that treatment was effective. Although it may make palpation more difficult, excess fluid will not diminish pedal pulses. A normal potassium level can be maintained independently of fluid excess correction. As the client excretes excess fluid, the urine specific gravity will increase, not decrease.

Which error will result in false high diastolic readings while measuring a client's blood pressure during a physical examination? Inflating the cuff too slowly Wrapping the cuff too loosely Applying the stethoscope too firmly Repeating the assessment too quickly

Ans: A Rationale Inflating or deflating the cuff too slowly will yield false high diastolic readings. Wrapping the cuff too loosely will result in false high systolic and diastolic values. Applying the stethoscope too firmly will result in false low diastolic readings. Repeating the assessment too quickly will result in false high systolic readings.

After performing an optical assessment on a client, a primary healthcare provider notices impaired near vision. Which other finding in this client confirms the diagnosis as presbyopia? Loss of elasticity of the lens Increased opacity of the lens Elevated intraocular pressure Noninflammatory changes in eyes

Ans: A Rationale Presbyopia is defined as impaired near vision caused by a loss of elasticity of the lens. This condition is reported in middle-aged and older adults. Increased opacity of the lens is seen in cataracts. Elevated intraocular pressure is associated with glaucoma. Retinopathy causes noninflammatory eye changes.

What type of interview is most appropriate when a nurse admits a client to a clinic? Directive Exploratory Problem solving Information giving

Ans: A Rationale The first step in the problem-solving process is data collection so that client needs can be identified. During the initial interview a direct approach obtains specific information, such as allergies, current medications, and health history. The exploratory approach is too broad, because in a nondirective interview the client controls the subject matter. Problem solving and information giving are premature at the initial visit.

The nurse is caring for a client whose forehead feels warm to the touch. The nurse uses a thermometer and obtains the client's temperature. What is the nurse doing? Validation Assessment Interpretation Documentation

Ans: A Rationale The nurse is validating the presence of fever in the client. Validation is the process of gathering more assessment data. It involves clarifying vague or unclear data. Assessment is the first step of the nursing process. It involves collecting information from the client and secondary sources. During interpretation, the nurse recognizes that further observations are needed to clarify information. Data documentation is the last part of a complete assessment. The nurse must document facts in a timely, thorough, and accurate manner to prevent information from getting lost.

A nurse is teaching a client about measures to promote health. Which statements made by the client indicate effective learning? Select all that apply. "I will assess my own pulse rate after exercising." "I will follow my hypertension treatment plan consistently." "I will recalibrate my aneroid sphygmomanometer once a year." "I will perform a self-assessment of my heart rate using the carotid pulse." "I will ask my caretaker to check my blood pressure at a different time every day."

Ans: A, B, D Rationale Assessing the pulse rate after exercising is helpful in knowing the impact of exercise on the pulse rate. Following the hypertension treatment plan consistently will help the client stay healthy. Performing a heart rate self-assessment using the carotid pulse is also effective in promoting health. This action will also help the client to know if there are any abnormalities related to the pulse rate. An aneroid sphygmomanometer is a sophisticated device that requires recalibration more than once a year. Blood pressure should be measured at the same time every day for accurate results.

Which questions should the nurse ask the client when obtaining the health history? Select all that apply. "Tell me about your food habits." "Do you use alcohol or tobacco?" "Have you sustained any personal loss recently?" "Have you ever experienced any allergic reactions?" "Does any family member have a long-term illness?"

Ans: A,B, D Rationale The health history of a client includes the client's food habits so that the nurse can obtain an assessment of the client's nutrition status. The nurse also assesses the client's habits and lifestyle patterns. The use of alcohol and tobacco helps to determine the client's risk for diseases involving the liver or lungs. The health history includes descriptions of allergies and reactions to food, latex, drugs, or contact agents such as soap. While assessing the family history, the nurse assesses the client for stress-related problems by asking about recent personal losses. The family history provides information about family members to determine the risk for illnesses of a genetic or familial nature.

A nurse is obtaining a health history from the newly-admitted client who has chronic pain in the right knee. What should the nurse include in the pain assessment? Select all that apply. Pain history, including location, intensity, and quality of pain Client's purposeful body movement in arranging the papers on the bedside table Pain pattern, including precipitating and alleviating factors Vital signs, such as increased blood pressure and heart rate The client's family statement about increases in pain with ambulation

Ans: A, C Rationale The initial pain assessment should include information about the location, quality, intensity, onset, duration and frequency of pain, as well as factors that relieve or exacerbate the pain. Vital signs are a secondary assessment related to the initial pain assessment. Accurate pain assessment includes pain history with the client's identification of pain location, intensity, and quality and helps the nurse identify what pain means to the client. The pattern of pain includes time of onset, duration, and recurrence of pain, and its assessment helps the nurse anticipate and meet the needs of the client. Purposeless movements such as tossing and turning or involuntary movements such as a reflexive jerking may indicate pain. Assessment of the precipitating factors helps the nurse prevent the pain and determine its cause. Elevated blood pressure and heart rate are physiological responses to pain and not a direct evaluation of pain. Pain is a subjective experience, and therefore the nurse has to ask the client directly instead of accepting the statement of the family members.

Which sites would be safe and inexpensive for temperature measurement? Select all that apply. Skin Oral Axilla Rectal Tympanic membrane

Ans: A, C Rationale The skin and axilla are safe and inexpensive sites of the body for temperature measurement. The oral route is an easily accessible site for temperature measurement but it may not be the safest route because of the exposure to body fluids. The rectal route may not be easily accessible and safe because a measurement via this route may increase the risk of body fluid exposure. The tympanic membrane is an easily accessible site for temperature measurement but care should be taken when used in neonates, infants, and children.

While assessing a client's hair, a nurse notices that the client has head lice. The nurse teaches the client about hair hygiene and lice control. Which statements made by the client indicates an understanding of the teaching? Select all that apply. "I will clean my comb in ammonia water." "I should use lindane-containing shampoo." "I should shampoo my hair in a tub or shower." "I should use a dilute vinegar solution to loosen the nits." "I should use a shampoo treatment once every 24 hours."

Ans: A, D,E Rationale Lindane may be used to treat lice and scabies, but it may cause serious side effects. Clients with lice are instructed not to wash their hair in a tub or shower because this action may cause the lice to migrate to other sites. Ammonia water should be used to clean combs and other hair accessories to enhance lice control. Nits are loosened by the use of dilute vinegar solution. Shampooing should be continued once every 24 to 48 hours.

An older adult client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which nursing actions have specific gerontologic implications the nurse must consider? Select all that apply. Assessment of skin turgor Documentation of vital signs Assessment of intake and output Administration of antiemetic drugs Replacement of fluid and electrolytes

Ans: A, D,E Rationale When skin turgor is assessed, the presence of tenting may be related to loss of subcutaneous tissue associated with aging rather than to dehydration; skin over the sternum should be used instead of skin on the arm for checking turgor. Older adults are susceptible to central nervous system side effects, such as confusion, associated with antiemetic drugs; dosages must be reduced, and responses must be evaluated closely. Because many older adults have delicate fluid balance and may have cardiac and renal disease, replacement of fluid and electrolytes may result in adverse consequences, such as hypervolemia, pulmonary edema, and electrolyte imbalance. Vital signs can be obtained as with any other adult. Intake and output can be measured accurately in older adults.

A registered nurse is teaching a nursing student about precautions to be taken for physical examination of a client. Which statements made by the nursing student indicate effective learning? Select all that apply. "I should examine the client in noise-free areas." "I should use latex gloves during the physical examination." "I should perform a physical examination in a cool room." "I should leave a combative client alone during a physical examination." "I should wear eye shields while examining a client with excessive drainage."

Ans: A, E Rationale Clients should be examined in noise-free areas to prevent interruptions. Wearing eye shields while examining a client with excessive drainage helps to reduce contamination. Latex gloves should be used with caution because they may cause allergy in clients who are allergic to latex. A physical examination should be performed in a warm room to minimize discomfort. Combative clients should never be left alone during physical examinations.

Which client is suspected to have an increased risk of hyperlipidemia? Select all that apply. Client with corneal arcus Client with periorbital edema Client with decreased skin turgor Client with paleness of conjunctivae Client with yellow lipid lesions on eyelids

Ans: A, E Rationale The presence of corneal arcus, which is the whitish opaque ring around the junction of the cornea and sclera, indicates that the client has hyperlipidemia. Yellow lipid lesions on the eyelids refer to xanthelasma, which indicates a client has hyperlipidemia. The presence of periorbital edema indicates the client may have kidney disease. Decreased skin turgor may be due to dehydration. Paleness of the conjunctivae indicates anemia.

While assessing a client's skin, a nurse notices that the skin is dry. What is the probable etiology of the condition? Select all that apply. Use of hard soap Frequent bathing Use of tanning pills Presence of an allergy Use of petroleum products

Ans: A,B Rationale The use of hard soap and frequent bathing may result in dry skin. A skin allergy may result in skin rashes, but not dry skin. Using tanning pills and petroleum products may result in skin cancer.

A client with a history of cardiac dysrhythmias is admitted to the hospital due to a fluid volume deficit caused by a pulmonary infection. The registered nurse is assessing the vital signs recorded by the student nurse. Which vital sign assessments require reassessment based on the data given by the student nurse? Select all that apply. Respiratory rate of 14 breaths/minute Blood pressure of 120/80 mmHg Oxygen saturation of 95% Temporal temperature of 37.4 °C Radial pulse rate of 72 and irregular

Ans: A,B,C Rationale In pulmonary infections, the respiratory rate may increase and oxygen saturation may decrease. In fluid volume deficit, the blood pressure may be decreased. A respiratory rate of 14 breaths/minute, a blood pressure of 120/80 mmHg, and an oxygen saturation of 95% are normal readings. Therefore, the registered nurse should reassess these vital signs. The normal temperature range is 36 to 38 0C; this range is unaffected by a pulmonary infection. Therefore, the nurse does not need to reassess the temperature. Cardiac dysrhythmias are associated with a pulse deficit in which the radial pulse would be irregular. Therefore reassessment would not be required.

The nurse is performing a skin assessment of a client. Which findings in the client may indicate a risk of skin cancer? Select all that apply. Lesion Lumps Rashes Bruising Dryness

Ans: A,B,C Rationale Lesions on the skin that take a long time to heal may indicate skin cancer. Lumps and rashes on the skin are characteristics of skin cancer. Bruising may indicate a bleeding disorder or injury. Dryness of the skin may be due to excessive bathing and use of harsh soaps.

A nurse is assessing a client with a history of marijuana use. Which long-term effects are associated with marijuana? Select all that apply. Lung cancer Emphysema Heart disease Laryngeal disorder Stroke Chronic nasal irritation

Ans: A,B,C Rationale Lung cancer, emphysema, and heart disease are outcomes that may occur due to marijuana use. Laryngeal disorders, stroke, and chronic nasal irritation are associated with the abuse of cocaine but are not associated with marijuana use.

The registered nurse is teaching a nursing student about ways to minimize heat radiation. Which statements made by the nursing student indicate effective learning? Select all that apply. "I will apply an ice pack to the client." "I will cover the client with dark clothes." "I will instruct the client to remove extra clothes." "I will instruct the client to lie in the fetal position." "I will advise the client to wear sparsely woven clothes."

Ans: A,B,D Rationale Applying an ice pack will increase conductive heat loss, which results in minimizing heat radiation. Wearing dark clothes and lying in the fetal position will minimize heat radiation. Removing extra clothes will increase heat radiation. Wearing sparsely woven clothes will enhance heat radiation.

A nurse assesses the vital signs of a 50-year-old female client and documents the results. Which of the following are considered within normal range for this client? Select all that apply. Oral temperature of 98.2° F (36.8° C) Apical pulse of 88 beats per minute and regular Respiratory rate of 30 per minute Blood pressure of 116/78 mm Hg while in a sitting position Oxygen saturation of 92%

Ans: A,B,D Rationale The client's temperature, pulse, and blood pressure are within normal ranges for a 50-year-old female. The client's respirations are mildly elevated, and the oxygen saturation level is below normal. A normal respiratory rate for a female client in this age group would be 12 to 20 per minute, and oxygen saturation level should be 95%.

Which actions by the nurse help set the stage for a client-centered interview during the first visit after admission to the healthcare facility? Select all that apply. Close the door after entering the room. Greet the client using his or her last name. Open the curtains to allow plenty of light in the room. Introduce oneself with a smile and explain the reason for the visit. Obtain an authorization from the client after the interview.

Ans: A,B,D Rationale The nurse should maintain the client's privacy by closing the door after entering the room. The nurse should maintain the dignity of the client by greeting the client using his or her last name. Smiling is a positive sign of warmth and immediacy when first establishing the nurse-client relationship. The nurse should explain his or her role in the providing care for the client. The nurse should ensure the room is adequately lit, comfortable, and soothing for the client. The nurse need not open the curtains to allow plenty of light in the room. The Health Insurance Portability and Accountability Act (HIPAA) requires the nurse to obtain an authorization from the client before collecting personal health data.

Which clients should be considered for assessing the carotid pulse? Select all that apply. Client with cardiac arrest Client indicated for Allen test Client under physiologic shock Client with impaired circulation to foot Client with impaired circulation to hand

Ans: A,C Rationale Carotid pulse is indicated in clients with physiologic shock or cardiac arrest when other sites are not palpable in the client. Assessment of the ulnar pulse is indicated in clients requiring an Allen test. Assessment of posterior tibial pulse and dorsalis pedis pulse is indicated in clients with impaired circulation to the feet. Assessment of the radial and ulnar pulse is indicated in clients with impaired circulation to the hands.

What are the benefits of using standard formal nursing diagnostic statements? Select all that apply. Fosters development of nursing knowledge Allows nurses to communicate with the client Provides precise definition of the client's problem Distinguishes the nurse's role from that of other care providers Enables the primary healthcare provider to deliver effective health care

Ans: A,C,D Rationale The use of standard formal nursing diagnostic statements fosters the development of nursing knowledge, which is important to be able to assess a client's specific risk for problems, identify them early, and take preventive action. Nursing diagnostic statements provide precise definitions of the client's problem. They give the nurses and other members of the healthcare team a common language for understanding the client's needs. Nursing is emphasized as an independent practice when the nurse formulates nursing diagnoses and individualized nursing care plans. This distinguishes the nurse's role from that of other care providers. Nursing diagnostic statements allow nurses to communicate what they do among themselves with other healthcare professionals and the public. A nursing diagnosis helps the nurse focus on the scope of nursing practice and to deliver effective healthcare.

When should the nurse observe the client to assess his or her level of functioning? Select all that apply. During meal time When talking about pain When preparing medication During the assessment interview When administering insulin injections

Ans: A,C,E Rationale An observation of the functional level of the client often occurs during a return demonstration. The nurse may also observe the client while eating to determine if the client is able to eat without assistance. The nurse teaches the client how to prepare medications and asks for a return demonstration to assess the client's understanding. The nurse also observes the client administering insulin injections to ensure that the client is able to perform it properly. Observation of functional level differs from the observation during a physical examination. The nurse closely observes the client during the physical assessment when the client talks about pain. During the assessment interview, the nurse observes the client's facial expressions and eye contact to form accurate conclusions about the client's condition. The nurse does not assess the client's functional abilities during the subjective assessment.

A client suffers hypoxia and a resultant increase in deoxygenated hemoglobin in the blood. What are the best sites to assess this condition? Select all that apply. Lips Sclera Mouth Sacrum Nail beds Shoulders

Ans: A,C,E Rationale Prolonged hypoxia resulting in increased amounts of deoxygenated blood causes cyanosis, which can be best evaluated in lips, mouth, nail beds, and skin (in extreme conditions). Sclera is the site of assessment for jaundice, while shoulders are assessed to confirm the condition of erythema.

Which features distinguish nursing diagnoses from medical diagnoses? Select all that apply. Nursing diagnoses involve the client when possible. Nursing diagnoses are based on results of diagnostic tests and procedures. Nursing diagnoses are the identification of a disease condition in the client. Nursing diagnoses involve the sorting of health problems within the nursing domain. Nursing diagnoses involve clinical judgment about the client's response to health problems.

Ans: A,D,E Rationale Establishing a nursing diagnosis is the second step in the nursing process. It is unique and involves the client's participation in the process. Nursing diagnoses classify health problems to be treated primarily by nurses. The nurse reviews the client assessment, sees cues and patterns in the data, and identifies the client's specific health care problems. The nursing diagnosis is a clinical judgment about the client's actual or potential health problems that the nurse is licensed to treat. A medical diagnosis is based on results of diagnostic tests and procedures, whereas a nursing diagnosis is based on the results of the nursing assessment. A medical diagnosis identifies a disease condition in the client.

A nurse is assessing an older adult male client. Which clinical findings are expected responses to the aging process? Select all that apply. Slowed neurologic responses Lowered intelligence quotient Long-term memory impairment Forgetfulness about recent events Reduced ability to maintain an erection

Ans: A,D,E Rationale Slowing of neurologic responses is part of the aging process. Memory for short-term situations and events is reduced. The ability of the male to attain and sustain an erection is reduced. There should not be a loss of intellectual ability. Memory of long-term experiences and events should not be impaired

While assessing a client, the nurse finds inflammation of the skin at the bases of the client's nails. What might be the reason behind this condition? Trauma Trichinosis Pulmonary disease Iron-deficiency anemia

Ans: ARationale Paronychia is an abnormality of the nail bed. The condition is marked by inflammation of the skin at the base of the nail; this condition may be caused by trauma or a local infection. Trichinosis is associated with red or brown linear streaks in the nail bed. Pulmonary diseases can cause changes in the angle between nail and nail base, which is a phenomenon known as clubbing. Koilonychia, a concave curvature of the nails, may occur as a result of iron-deficiency anemia.

The nurse is assessing a client who arrived at the healthcare facility for an appointment. Which action by the nurse will be beneficial during the interview? Asking about the client's current concerns Ensuring the interview follows a strict agenda Asking questions that promote short responses by the client Telling the client what he or she should expect from the visit

Ans: ARationale The nurse should begin the interview by gathering information about the client's current concerns to encourage the client to express his or her chief problems. The nurse then sets an agenda for the interview. However, the nurse must remember that the best interview focuses on the client and not the nurse's agenda. The nurse must ask open-ended questions that allow the client to describe his or her concerns more clearly. The nurse should ask the client to describe his or her healthcare expectations to help the client understand that the nurse is genuinely interested in the client's health.

While conducting an assessment, the nurse finds that the client shivers uncontrollably and experiences memory loss, depression, and poor judgment. What might the client's body temperature be? 29° C 33° C 36° C 38° C

Ans: B Rationale A body temperature in the range of 36° to 38 ° C is normal. When skin temperature drops below 35° C, the client may exhibit uncontrolled shivering, loss of memory, depression, and poor judgment as a result of hypothermia. A body temperature lower than 30° C represents severe hyperthermia. In this condition, the client will demonstrate a lack of response to stimuli and extremely slow respiration and pulse. Based on the signs given, the client's temperature is most likely 33° C.

The student nurse prepares a concept map while caring for a client recovering from surgery. What is the first step that the student nurse should take when preparing the concept map? Assess the client and gather information. Arrange cues into clusters that form patterns. Identify patterns reflecting the client's problem. Identify specific nursing diagnoses for the client.

Ans: B Rationale A concept map is a visual representation of the connection between the client's many health problems. The first step is to arrange all the cues into clusters that form patterns. This helps the nurse identify specific nursing diagnoses for the client. During the assessment stage, the nurse assesses the client and gathers information. This step is performed before preparing the concept map. After placing all cues into clusters, the nurse begins to identify patterns reflecting the client's problem. The concept map helps the nurse obtain a holistic view of the client's needs. The next step is to identify specific diagnoses so that appropriate nursing interventions can be provided.

The nurse asks the client to shrug the shoulders and to turn the head against passive resistance. Which cranial nerve is involved in this action? Cranial nerve II Cranial nerve XI Cranial nerve VI Cranial nerve VII

Ans: B Rationale Cranial nerve XI (the spinal accessory nerve) is the motor nerve that coordinates the movement of head and shoulders. Cranial nerve II (optic nerve) is a sensory nerve for visual acuity. Cranial nerve VI (abducens nerve) is a motor nerve that coordinates the lateral movement of eyeballs. Cranial nerve VII or (auditory nerve) is a sensory nerve which coordinates the hearing sense.

A client arrives at a health clinic stating, "I am here to have my tuberculin skin test read." The nurse notes that there is a 7-mm indurated area at the injection site. Which statement made by the nurse correctly describes this result? "The result indicates that you have active tuberculosis." "The result indicates that you are infected with the tuberculosis organism." "The result indicates that there are no tuberculin antibodies in your system." "The result indicates that you have a secondary infection related to the tuberculin organism."

Ans: B Rationale An indurated area 5 mm or larger noted 48 to 72 hours after the tuberculin test indicates that the person is infected with the tuberculin organism. A positive tuberculin skin test accompanied by fever, coughing, weakness, and positive chest x-ray are manifestations of active tuberculosis. The other choices are incorrect.

A registered nurse is supervising a student nurse while assessing a 70-year-old client who is receiving aminoglycoside therapy. Which statement about the client's condition requires correction? "The client may have deterioration of the cochlea." "The client may have thinning of the tympanic membrane." "The client may have an inability to hear high-frequency sounds." "The client may have an inability to differentiate between consonants."

Ans: B Rationale An older adult who is on aminoglycoside antibiotic therapy is at a high risk of developing ototoxicity. The client with ototoxicity may have thickening of the tympanic membrane, but not thinning of the tympanic membrane. Deterioration of the cochlea may cause older adults to gradually lose hearing. They may experience an inability to hear high-frequency sounds and differentiate between consonants.

The nurse is preparing to teach a client about self-injection of insulin. Which action by the nurse will increase the effectiveness of the teaching session? Wait until a family member is also present. Assess the client's barriers to learning self-injection techniques. Begin with simple written instructions describing the technique. Wait until the client has accepted the new diagnosis of type 1 diabetes mellitus.

Ans: B Rationale Before a teaching plan can be developed, the factors that interfere with learning must be identified. Although family members can be helpful, client involvement in care is most important for promoting independence and self-esteem. Assessment comes before intervention; written instructions may not be the most appropriate teaching modality. The client may never accept the change but must learn to manage care; this may be an unrealistic expectation.

A client complains of sudden muscle weakness during times of anger or laughter that may occur at any time during the day. Which condition should be suspected in this client? Insomnia Cataplexy Narcolepsy Sleep apnea

Ans: B Rationale Cataplexy is a condition in which muscle weakness occurs suddenly during times of intense emotion, such as anger, sadness, or laughter. A cataplexic attack may occur at any time during the day. Insomnia is a condition in which a person has chronic difficulty falling asleep. A person with narcolepsy also experiences frequent awakenings from sleep, short periods of sleep or nonrestorative sleep, or some combination thereof. Narcolepsy is a dysfunction of the mechanisms that regulate sleeping and waking states. Sleep apnea is a disorder characterized by a lack of airflow through the nose and mouth for periods of 10 seconds or longer during sleep.

A nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremities, the nurse notes that the client has thin, shiny skin; decreased hair growth; and thickened toenails. What might this indicate? Venous insufficiency Arterial insufficiency Phlebitis Lymphedema

Ans: B Rationale Clients experiencing arterial insufficiency present with extremities that become pale when elevated and dusky red when lowered. Lower extremities may also be cool to touch, pulses may be absent or mild, and skin may be shiny and thin with decreased hair growth and thickened nails. Clients with venous insufficiency often have normal-colored extremities, normal temperature, normal pulses, marked edema, and brown pigmentation around the ankles. Phlebitis is an inflammation of a vein that occurs most often after trauma to the vessel wall, infection, and immobilization. Lymphedema is swelling in one or more extremities that is a direct result of impaired flow of the lymphatic system.

The nurse tells a client undergoing diuretic therapy to avoid working in the garden on hot summer days. What condition is the nurse trying to prevent in this client? Frostbite Heatstroke Hypothermia Hyperthermia

Ans: B Rationale Clients undergoing diuretic therapy are at risk of heatstroke when exposed to temperatures higher than 40° C. Frostbite occurs when the body is exposed to ice-cold temperatures. Hypothermia is a condition in which the skin temperature drops below 36° C. Hyperthermia occurs when the body is exposed to temperatures higher than 38.5° C.

An older adult is found to have a thin white ring around the margin of the iris. What condition does this denote? Cataract Arcus senilis Conjunctivitis Macular degeneration

Ans: B Rationale In older adults, the iris becomes faded and a thin white ring (known as arcus senilis) appears around the margin of the iris. A cataract is a condition involving increased opacity of the lens that blocks light rays from entering the eye. The presence of redness indicates allergic or infectious conjunctivitis. Macular degeneration is marked by a blurring of central vision caused by progressive degeneration of the center of the retina.

A nurse is assessing an 89-year-old client with a history of severe congenital spinal deformity. Which condition would most likely describe the nurse's finding? Lordosis Kyphosis Presbycusis Osteoporosis

Ans: B Rationale Kyphosis is an increase in the curvature of the thoracic spine and may result from a congenital abnormality. Lordosis, also known as swayback, is an increased lumbar curvature and may not be a congenital abnormality. Presbycusis is the loss of acuity for high-frequency tones and is not related to the spine. Osteoporosis is a condition in which the bones become brittle and fragile from the loss of tissue and bone mass.

While assessing the nails of a client with diabetes, the nurse finds that the skin on the client's hands and feet are dry due to infection. What could be the reason for this dryness? Applying moisturizing lotion between toes Cutting nails after soaking them for 10 minutes in warm water Cutting nails straight across and even with the tops of the fingers or toes Using sharp objects to poke or dig under the toenail or around the cuticle

Ans: B Rationale Normally, nails should be cut after soaking them in warm water for 10 minutes. This action should not be performed for diabetic patients because soaking the nails will dry out the hands and feet, which may lead to infection. Applying moisturizing lotion between the toes will promote microorganism growth; it will not dry the skin. Cutting nails straight across and even with the tops of the fingers or toes is the proper way to maintain nail hygiene. Diabetic clients are advised not to use sharp objects to poke or dig under the toenails or around the cuticles to avoid injury to the skin.

What is a nurse's most appropriate response, based on current research, when asked about spanking as a disciplinary technique? "Effectiveness depends on the child's age." "Spanking is strongly suggestive of negative role behavior." "Spanking may be the only option when no other technique works." "Research studies have shown it to be an effective disciplinary technique."

Ans: B Rationale Research suggests that children who are spanked tend to use aggressive behavior; as they grow older they learn their own behavior through their parents' behavior. Age is not significant in terms of the effectiveness of spanking. Research studies contradict the assertion that spanking is an effective disciplinary technique.

Three days after bariatric surgery, the client puts the call light on and states, "I felt a 'pop' in my belly after I had a coughing spell." The nurse assesses the client's incision site for signs of dehiscence. Which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence? Loosening of the sutures Sharp increase in serosanguineous drainage Purplish color of the incision Protrusion of organs through an open incision

Ans: B Rationale Serosanguineous drainage from the wound or on the dressing forewarns separation of the wound edges (dehiscence); dehiscence may progress to movement of abdominal organs outside of the abdominal cavity (evisceration). Loosening of sutures may occur after the initial wound edema subsides, but is not a sign of failure of the suture line. A purplish incision is the expected coloration of a healing wound.

A nurse is caring for a client with diarrhea. The nurse anticipates a decrease in which clinical indicator? Pulse rate Tissue turgor Specific gravity Body temperature

Ans: B Rationale Skin elasticity will decrease because of a decrease in interstitial fluid. The pulse rate will increase to oxygenate the body's cells. Specific gravity will increase because of the greater concentration of waste particles in the decreased amount of urine. The temperature will increase, not decrease.

During an assessment, the client complains of tenderness when the nurse palpates the calf muscle. What would be the nurse's next assessment? To evaluate for any reduced hair growth To evaluate for swelling, warmth and muscle firmness To assess for any history of ulcer formation around the calf muscle To evaluate for venous distension in the posterolateral part of ankle

Ans: B Rationale Tenderness at the site of calf muscle may indicate phlebitis. Other symptoms of phlebitis include swelling, warmth, and muscle firmness at the site. Reduced hair growth or a history of recurring ulcers may indicate circulatory insufficiency. Venous distension in the anterior or medial part of the thigh indicates varicosities.

A client was admitted to a surgical unit in an unconscious state due to head trauma. Which site would be most appropriate to obtain the client's temperature? Oral Axilla Temporal artery Tympanic membrane

Ans: B Rationale The axilla would be the most appropriate site to obtain a temperature measurement in a client who is unconscious due to head trauma. The oral route is not accessible when the client is unconscious. Because the client is in a surgical unit, his or her head may be covered. Therefore, obtaining a temperature measurement through the temporal artery or tympanic membrane may not be possible.

A registered nurse (RN) is instructed to assess the body temperature of a neonate. Which site for placing the thermometer is contraindicated in these clients? Axilla Oral cavity Temporal artery Tympanic membrane

Ans: B Rationale The oral cavity is the preferred site for temperature measurement in adult clients. This site is contraindicated for neonates and unconscious or uncooperative clients. The axilla is a safe site for placing a thermometer in neonates. The temporal artery is indicated for rapid temperature measurement. This site is indicated for premature infants, newborns, and children. The tympanic membrane is indicated in newborns to reduce infant handling and heat loss.

Which related factor is appropriate for a nursing diagnosis? Prostectomy Trauma of incision Acute renal failure Knee replacement surgery

Ans: B Rationale The related factor or etiology of a nursing diagnosis is always within the nursing domain. The nurse must ensure that the related factor is a condition that responds to nursing interventions. Trauma of incision is an appropriate related factor for a nursing diagnosis. A prostectomy is a medical condition that cannot be influenced by nursing actions. Similarly, acute renal failure is also a medical condition. Nursing interventions should be directed towards behaviors or conditions that can be managed or treated by the nurse. Knee replacement surgery is a medical condition that cannot be managed by nursing interventions.

A registered nurse is teaching a nursing student about the third heart sound (S 3). Which statement given by the nursing student indicates a need for further education? "S 3 is heard in clients with heart failure." "S 3 is normal in pregnant women." "S 3 is abnormal in adults over 31 years of age." "S 3 is normal in children and young adults."

Ans: B Rationale The third heart sound (S 3) can be heard when the heart attempts to fill an already distended ventricle. This sound may be common and normal in the last stages of pregnancy, but not in all stages. This sound may be heard in heart failure clients. The S 3 sound is abnormal in adults over the age of 31. This sound is normally heard in children and young adults.

A client reports to the nurse sleeping until noon every day and taking frequent naps during the rest of the day. What should the nurse do initially? Encourage the client to exercise during the day. Arrange a referral for a thorough medical evaluation. Explain that this behavior is an attempt to avoid facing daily responsibilities. Identify that the client is describing clinical findings associated with narcolepsy.

Ans: B Rationale This behavior is a sign of hypersomnia, and the client needs a medical assessment; it is commonly caused by central nervous system damage or certain kidney, liver, or metabolic disorders. Exercise is appropriate for a client experiencing insomnia, not hypersomnia. This behavior is a sign of hypersomnia, and medical causes should be ruled out before attributing it to a psychogenic cause. Narcolepsy consists of recurrent sudden waves of overwhelming sleepiness that occur during the day, even during activities such as eating or conversing.

The nurse performs a respiratory assessment and auscultates breath sounds that are high pitched, creaking, and accentuated on expiration. Which term best describes the findings? Rhonchi Wheezes Pleural friction rub Bronchovesicular

Ans: B Rationale Wheezes are one of the most common breath sounds assessed and auscultated in clients with asthma and chronic obstructive pulmonary disease (COPD). Wheezes are produced as air flows through narrowed passageways. Rhonchi are coarse, rattling sounds similar to snoring and are usually caused by secretions in the bronchial airways. A pleural friction rub is an abrasive sound made by two acutely inflamed serous surfaces rubbing together during the respiratory cycle. Bronchovesicular sounds are intermediate between bronchial (upper) and vesicular (lower) breath sounds; they are normal when heard between the first and second intercostal spaces anteriorly and posteriorly between scapulae.

An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult, the nurse recalls what expected sensory losses associated with aging? Select all that apply. Difficulty in swallowing Diminished sensation of pain Heightened response to stimuli Impaired hearing of high frequency sounds Increased ability to tolerate environmental heat

Ans: B, D Rationale Because of aging of the nervous system, an older adult has a diminished sensation of pain and may be unaware of a serious illness, thermal extremes, or excessive pressure. As people age they experience atrophy of the organ of Corti and cochlear neurons, loss of the sensory hair cells, and degeneration of the stria vascularis, which affects an older person's ability to perceive high frequency sounds. An interference with swallowing is a motor loss, not a sensory loss, and it is not an expected response to aging. There is a decreased, not heightened, response to stimuli in older adults. There is a decreased, not increased, ability to physiologically adjust to extremes in environmental temperature.

A client with severe bleeding due to a motor vehicle accident was admitted to the emergency department. The nurse assessed that the client was unconscious and the healthcare provider diagnosed the client with a hand fracture. The client is receiving oxygen therapy as well as intravenous fluids through the antecubital fossa. Which sites should be used to obtain the client's pulse rate? Select all that apply. Apical Carotid Brachial Femoral Popliteal

Ans: B, D Rationale Clients with severe bleeding may develop hypovolemic shock. The carotid and femoral pulses are easily accessible sites to measure pulses in clients with hypovolemic shock. The apical pulse may not be palpable in a client with hypovolemic shock. Because the client is diagnosed with a hand fracture and is receiving intravenous fluids through the antecubital fossa, the brachial artery cannot be accessed to measure the pulse rate. The popliteal site is used to assess the status of the circulation in the lower leg.

While assessing a pediatric client, an ophthalmologist notices that the child is unable to focus on an object with both eyes simultaneously. Which other findings in the client confirms the diagnosis as strabismus? Select all that apply. Impaired near vision Crossed appearance of eyes Elevated intraocular pressure Impaired extraocular muscles Degeneration of central retina

Ans: B, D Rationale Strabismus is a congenital condition in which both eyes do not focus on an object simultaneously, resulting in a crossed appearance of the eyes. This condition is caused by impaired extraocular muscles. Impaired near vision is associated with hyperopia or presbyopia. Elevated intraocular pressure results in glaucoma. Macular degeneration is caused by degeneration of the central retina.

A nurse teaches an obese client measures to calculate the body mass index. Which of these statements by the client indicate effective learning? Select all that apply. "I should include sugared beverages in my diet." "I should lose at least half a pound to a pound each week." "My daily nutritional fat intake should be more than 30%." "I'll make sure to eat foods that meet my daily nutritional requirement." "I should stay away from unhealthy foods between meals and after dinner."

Ans: B, D,E Rationale A client's body mass index (BMI) height-weight range is appropriate when it is within 10% of the ideal body weight. To achieve this, the client should lose at least 0.5 to 1 lb (0.2 to 0.45 kg) per week. The client's daily nutritional intake should meet the minimal dietary reference index. Refraining from eating unhealthy foods between meals and after dinner will help the client achieve an appropriate BMI. The client should avoid sugared beverages to achieve the appropriate BMI. Another effective way to achieve this is a daily fat intake less than 30% of total consumption.

Which parts of the body should be assessed for temperature in clients who abuse sedatives or hypnotics? Select all that apply. Axillae Thorax Forehead Oral cavity Rectal area

Ans: B,C Rationale Diaphoresis (excessive perspiration) is an abnormal condition noticed in clients as a result of the substance abuse of sedatives and hypnotics. For this case, the temperature should be primarily assessed in the forehead or upper thorax. The axillae, oral cavity, and rectal area are the regularly preferred site for assessing body temperature in those that do not abuse sedatives or hypnotics.

The community nurse is assessing an elderly client who lives alone at home. The nurse finds that the client refrains from physical activity for fear of falling when walking. Which interventions by the nurse are most beneficial to promote a healthy lifestyle? Select all that apply. Instruct the client to apply bed side rails. Encourage the client to wear nonskid shoes. Suggest that the client use an assistive device. Ask the client to install hand rails in the bathroom. Help the client rearrange furniture in the house.

Ans: B,C,E

How does the nurse identify an illness as chronic? Select all that apply. The illness is reversible and often severe. The illness persists for longer than six months. The client may develop life threatening relapse. The symptoms are intense and appear abruptly. The illness affects the functioning of one or more systems.

Ans: B,C,E Rationale A chronic illness usually lasts longer than six months. The client with chronic illness often fluctuates between maximal functioning and serious health relapses that may be life threatening. The illness affects the functioning of one or more systems. A chronic illness is irreversible, whereas an acute illness is reversible and often much more severe than a chronic illness. The client with acute illness develops intense symptoms that appear abruptly and often subside after a relatively short period.

The nurse is performing a breast assessment. Which statement made by the client indicates the risk of breast cancer? Select all that apply. "I had a late onset of menarche." "My first child was born when I was 32." "I noticed a slight discharge from a nipple." "I perform breast self-examinations frequently." "I consume two to four glasses of alcohol a day."

Ans: B,C,E Rationale Clients who gave birth to a first child after the age of 30 are at a risk of breast cancer. Discharge from the nipple may indicate an early symptom of breast cancer. Consuming two to four glasses of alcohol daily may also increase the risk of breast cancer. An early onset of menarche is a risk factor for breast cancer. Performing breast self-examinations frequently may help to identify the early stages of breast cancer.

During a physical assessment, a client was diagnosed with increased temperature due to an increased basal metabolic rate (BMR). Which hormonal imbalances may the client have? Select all that apply. Cortisol Thyroid Estrogen Testosterone Progesterone

Ans: B,D Rationale Body temperature is assessed during physical assessment. An increased basal metabolism rate increases the body temperature. Hormonal imbalances may alter the basal metabolic rate (BMR). Testosterone regulates the BMR in males. Thyroid hormone regulates the BMR of the body. Increases in the levels of these hormones may increase the BMR, which may in turn raise body temperature. Cortisol regulates blood glucose levels. Estrogen and progesterone are female hormones that do not regulate the BMR.

Which statements related to initial assessment of hypertension by the nurse requires correction? Select all that apply. "Deflating the cuff too slowly will show false-high diastolic readings." "The stethoscope applied too firmly against the antecubital fossa will show a low systolic reading." "If the blood pressure in the left arm is 110/80 mm Hg and in the right arm it is 130/80 mm Hg, it is reportable." "Having the client's arm unsupported while assessing blood pressure will result in a false low reading of blood pressure." "It is normal to have blood pressure of 110/80 mm Hg in the left arm and blood pressure of 120/80 mm Hg in the right arm."

Ans: B,D Rationale False low diastolic readings are obtained in clients if the stethoscope is held too firmly against the antecubital fossa. Keeping the arm unsupported while assessing blood pressure results in false high blood pressure values. False high diastolic readings are obtained when the cuff is deflated too slowly. Pressure differences greater than 10 mm Hg between the two arms should be reported because it indicates vascular problems. Normally there is a difference of 5 to 10 mm Hg of blood pressure between the arms.

The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply. Dyspnea Flushed face Precordial pain Increased pulse rate Increased blood pressure

Ans: B,D Rationale Increased body heat dilates blood vessels, causing a flushed face. The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may not cause difficult breathing. Pain is not related to fever. Blood pressure is not expected to increase with fever.

While assessing a client, a nurse finds that the ratio of the anteroposterior diameter and transverse diameter of the chest is 1:1. What is indicated by this finding? Select all that apply. Client has lordosis. Client is an older adult. Client has osteoporosis. Client has a history of smoking. Client has chronic lung disease.

Ans: B,D,E Rationale The 1:1 ratio of the anteroposterior diameter and transverse diameter of the chest indicates a barrel-shaped chest. This is a characteristic feature in an older adult who smokes and has chronic lung disease. In lordosis, there is an increase in lumbar curvature. Osteoporosis is a systemic skeletal condition in which there is a decreased bone mass and deterioration of bone tissue.

The nurse recognizes that which are important components of a neurovascular assessment? Select all that apply. Orientation Capillary refill Pupillary response Respiratory rate Pulse and skin temperature Movement and sensation

Ans: B,E,F Rationale A neurovascular assessment involves evaluation of nerve and blood supply to an extremity involved in an injury. The area involved may include an orthopedic or soft tissue injury. A correct neurovascular assessment should include evaluation of capillary refill, pulses, warmth and paresthesias, and movement and sensation. Orientation, pupillary response, and respiratory rate are components of a neurologic assessment.

The nurse recognizes that a common conflict experienced by older adults is the conflict between what? Youth and old age Retirement and work Independence and dependence Wishing to die and wishing to live

Ans: C Rationale A common conflict confronting older adults is between the desire to be taken care of by others and the desire to be in charge of their own destiny. The conflict between the young and old age may occur but is not common. The conflict between the retirement and working may occur but is not common. The conflict between wishing to die and wishing to live may occur but is not common.

The nurse is providing postoperative care to a client who had a submucosal resection (SMR) for a deviated septum. The nurse should monitor for what complication associated with this type of surgery? Occipital headache Periorbital crepitus Expectoration of blood Changes in vocalization

Ans: C Rationale After an SMR, hemorrhage from the area should be suspected if the client is swallowing frequently or expelling blood with saliva. A headache in the back of the head is not a complication of a submucosal resection. Crepitus is caused by leakage of air into tissue spaces; it is not an expected complication of SMR. The nerves and structures involved with speech are not within the operative area. However, the sound of the voice is altered temporarily by the presence of nasal packing and edema.

A client develops an allergic reaction when a student nurse is performing a physical assessment. Which statement made by the student nurse in response to this incident indicates the need for further teaching? "Type I immune response to latex has an immediate onset." "Type I immune reaction to latex leads to release of IgE antibodies." "The client's first exposure to latex will cause a type IV allergic reaction." "Type IV immune response to latex occurs after 12 to 48 hours after exposure."

Ans: C Rationale Both type I and type IV hypersensitive reactions require prior exposure to cause an immune response in a subsequent exposure. The most immediate immune response is a type I reaction, in which the body produces IgE antibodies against the allergen. A type IV immune response occurs 12 to 48 hours after the exposure to the allergen and is referred to as a delayed hypersensitivity response.

What should the nurse assess to determine whether a 75-year-old individual is meeting the developmental tasks associated with aging? Achievement of a personal philosophy Adaptation to the children leaving home Attainment of a sense of worth as a person Adjustment to life in an assisted-living facility

Ans: C Rationale Developing and participating in meaningful activities and satisfaction with past accomplishments increase feelings of self-worth. Achievement of a personal philosophy is a task of early adulthood. Adaptation to the children leaving home is a task of middle adulthood. Adjustment to life in an assisted-living facility is not a developmental task of older adults; not all older adults live in assisted-living facilities.

While performing a physical assessment of a female client, a nurse notices hair on the client's upper lip, chin, and cheeks. Which condition may result in this condition? Aging Poor nutrition Endocrine disease Arterial insufficiency

Ans: C Rationale Endocrine diseases such as hirsutism will result in excessive hair growth on the upper lip, chin, and cheeks. Aging and poor nutrition will result in decreased hair growth. Arterial insufficiency will result in decreased hair growth due to compromised blood supply.

Which finding is inferred from a grade 4 intensity of heart murmurs? Thrill is easily palpable Quiet and clearly audible thrill Loud murmur associated with thrill Moderately loud murmur without thrill

Ans: C Rationale Grade 4 indicates loud murmurs with an associated thrill. A thrill is a fine vibration that is felt by palpation. A grade 5 intensity is characterized by an easily palpable thrill. A grade 2 intensity is characterized by quiet and clearly audible murmurs. A moderately loud murmur without a thrill is noted as grade 3.

Which clinical condition will result in changes in the integrity of the arterial walls and small blood vessels? Contusion Thrombosis Atherosclerosis Tourniquet effect

Ans: C Rationale In atherosclerosis, there may be changes in the integrity of the walls of the arteries and smaller blood vessels. Direct manipulation of vessels or localized edema that impairs blood flow will lead to a contusion. Blood clotting that causes mechanical obstruction to blood flow indicates thrombosis. The tourniquet effect may be caused by the application of constricting devices, which may lead to impaired blood flow to areas below the site of constriction.

While assessing the eyes of a client, a healthcare provider notices there is an obstruction to the outflow of aqueous humor. Which additional finding might be noted to support a diagnosis of glaucoma? Blurred central vision Increased opacity of the lens Elevated intraocular pressure Changes in retinal blood vessels

Ans: C Rationale In glaucoma, there is an obstruction of the outflow of aqueous humor due to an intraocular structural damage, which may result from elevated intraocular pressure. Blurred central vision is seen in macular degeneration. Increased opacity of the lens may be seen in cataracts. Retinopathy may result from the changes in retinal blood vessels.

A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes? Skeletal and nervous Circulatory and urinary Respiratory and urinary Muscular and endocrine

Ans: C Rationale Increased respirations blow off carbon dioxide (CO 2), which decreases the hydrogen ion concentration and the pH increases (less acidity). Decreased respirations result in CO 2 buildup, which increases hydrogen ion concentration and the pH falls (more acidity). The kidneys either conserve or excrete bicarbonate and hydrogen ions, which helps to adjust the body's pH. The buffering capacity of the renal system is greater than that of the pulmonary system, but the pulmonary system is quicker to respond. Skeletal and nervous systems do not maintain the pH, nor do muscular and endocrine systems. Although the circulatory system carries fluids and electrolytes to the kidneys, it does not interact with the urinary system to regulate plasma pH.

A senior high school student, whose immunization status is current, asks the school nurse which immunizations will be included in the precollege physical. Which vaccine should the nurse tell the student to expect to receive? Hepatitis C (HepC) Influenza type B (HIB) Measles, mumps, rubella (MMR) Diphtheria, tetanus, pertussis (DTaP)

Ans: C Rationale Individuals born after 1956 should receive one additional dose of MMR vaccine if they are students in postsecondary educational institutions. Currently there is no vaccine for hepatitis C. The HIB immunization is unnecessary. If the student received an additional DTaP at age 12, it is not necessary. A booster dose of tetanus toxoid (Td) should be received every 10 years.

A client shows an increase in rate respirations that are abnormally deep and regular. What condition would the nurse expect? Hypoventilation Biot's respiration Kussmaul's respiration Cheyne-Stokes respiration

Ans: C Rationale Kussmaul's respiration is an alteration in the breathing process that is characterized by an increased and abnormal deep and regular rate of respiration. A client suffering from hypoventilation would have an abnormally low respiratory rate and the depth of ventilation is depressed. In Biot's respiration, respirations are abnormally shallow for two to three breaths, followed by irregular periods of apnea. An irregular respiratory rate and depth characterized by alternating periods of apnea and hyperventilation would be observed in a client with Cheyne-Stokes respiration.

A client complains of rapid, involuntary movement of the eyes after a minor eye injury. A nurse assesses the client and finds that it is a disorder of the cranial nerves. Which condition does the nurse suspect? Cataract Glaucoma Nystagmus Strabismus

Ans: C Rationale Nystagmus is a condition defined by rapid, involuntary, rhythmical oscillation of the eyes. This condition is caused by local injury to the eye muscles and supporting structures. A cataract is a condition in which the opacity of the lens will be increased; this disorder is commonly related to age. Glaucoma is intraocular structural damage resulting from elevated intraocular pressure. Strabismus is a congenital condition in which both eyes do not focus on an object simultaneously. In this condition, the eyes appear crossed.

A mother is worried about the sudden behavioral changes in her child. The child has suddenly developed a fear of certain people and places. The child's school performance is declining rapidly, and the child has developed poor relationships with his or her peers. After assessing the physical findings of the child, the nurse suspects child abuse. Which physical findings might have led the nurse to this suspicion? Sunken eyes and loss of weight Uncommunicative and uninteractive with others Foreign bodies in the rectum, urethra, or vagina Strangulation marks on neck from rope burns or bruises

Ans: C Rationale One of the physical findings that may be required to confirm child abuse is the presence of foreign bodies in the rectum, urethra, or vagina. Weight loss and sunken eyes may be a physical finding for older adult abuse. When the abuse is related to an intimate partner, the nurse may observe strangulation marks on the neck from rope burns or bruises. Staying isolated and not communicating with others are behavioral findings that may be related to older adult abuse.

The nurse discovers several palpable elevated masses on a client's arms. Which term most accurately describes the assessment findings? Erosions Macules Papules Vesicles

Ans: C Rationale Papules are superficial and elevated up to 0.5 cm. Nodules and tumors are masses similar to papules, but are elevated more than 0.5 cm and may infiltrate deeper into tissues. Erosions are characterized as loss of the epidermis layer; macules are nonpalpable, flat changes in skin color less than 1 cm in diameter; and vesicles are usually transparent, filled with serous fluid, and are a blisterlike elevation.

Which assessment should the nurse exclude when dealing with a client with receptive and expressive aphasia? Ask the client to read simple sentences aloud Point to a familiar object and ask the client to name it Test the mental status by asking for feedback from the client Ask the client to respond to simple verbal commands such as "Stand up"

Ans: C Rationale Receptive and expressive aphasia are the two types of aphasia. A client with receptive is unable to understand written or verbal speech. A client with expressive aphasia understands written and verbal speech but cannot write or speak appropriately. A client with aphasia may not have the mental ability to give feedback; asking for feedback is ineffective. Asking the client to read simple sentences aloud is an effective way of dealing with this client. Pointing to a familiar object and asking the client to name it is also effective. A client with aphasia can understand simple verbal commands.

While performing a physical assessment in a client, the registered nurse (RN) notices reddish linear streaks in the nail bed. Which systemic condition can the registered nurse (RN) suspect in the client based on these assessment findings? Syphilis Iron deficiency anemia Subacute bacterial endocarditis Chronic obstructive pulmonary disease

Ans: C Rationale Red or brown linear streaks in the nail bed are caused by minor trauma to nails, subacute bacterial endocarditis, or trichinosis and are called splinter hemorrhages. Conditions such as syphilis and iron deficiency anemia cause concavely curved nails, called koilonychia. Heart and lung abnormalities such as chronic obstructive pulmonary disease cause clubbing of the nail beds.

While assessing a client who experienced an accident, the nurse found that the client is unable to move eyeballs laterally. Which nerve damage led to this condition in the client? Optic nerve Facial nerve Abducens nerve Oculomotor nerve

Ans: C Rationale The abducens nerve is the VI cranial nerve, which helps in lateral movement of the eyeballs. Damage to this nerve limits lateral movement of the eyeball. Injury to the optic nerve causes changes in visual acuity. Injury to the facial nerve results in loss of facial expressions and loss of taste perception from the anterior one third of the tongue. Injury to the oculomotor nerve limits the extraocular movements and pupillary responses.

The nurse is caring for a client with a family history of diabetes mellitus. The client has been following a diet regimen recommended by the dietician and walking for 45 minutes daily for the past eight months. How should the nurse document the client's stage based on the transtheoretical model of health behavior change? Action Preparation Maintenance Contemplation

Ans: C Rationale The client is in the maintenance stage of human behavior change. During this stage, the client has managed to incorporate the changes in to the lifestyle. This stage begins six months after the action has started and continues indefinitely. The action stage lasts for six months from the time the client has incorporated the changes in to the lifestyle. During the preparation stage, the client begins to realize that the advantages of the change outweigh the disadvantages. The client starts making small changes in preparation for major changes the following month. During the contemplation stage, the client is still considering whether to incorporate changes in the next six months.

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency? Select all that apply. Diplopia Skin rash Leg cramps Tachycardia Muscle weakness

Ans: C, E Rationale Leg cramps occur with hypokalemia because of potassium deficit. Muscle weakness occurs with hypokalemia because of the alteration in the sodium potassium pump mechanism. Diplopia does not indicate an electrolyte deficit. A skin rash does not indicate an electrolyte deficit. Tachycardia is not associated with hypokalemia; bradycardia is.

A nurse is caring for a client who underwent cardiac catheterization. The client's skin was found to be blanched, and there was formation of edema of 15.2 cm (1-6 inches) at the site of catheterization. Upon further assessment, the skin was found to be cool, and the client complains of tenderness. Which condition does the nurse expect? Phlebitis Infection Infiltration Circulatory overload

Ans: C Rationale The client with blanched skin, edema of 15.2 cm, cool temperature, and pain at the site of catheterization has symptoms of grade 2 infiltration. Phlebitis is an inflammation of the inner layer of the vein. The findings for this include redness, tenderness, pain, and warmth along the course of the vein starting at the access site. If there is infection, there will be findings that include redness, heat, swelling at catheter-skin entry point, and possible purulent drainage. Circulatory overload can occur if intravenous solutions are infused too rapidly or in great amounts.

Which Korotkoff sound represents the diastolic pressure in children? First Second Fourth Fifth

Ans: C Rationale The fourth Korotkoff sound represents the diastolic pressure in children. The first Korotkoff sound represents the systolic pressure. The fifth Korotkoff sound represents the diastolic pressure in adults and adolescents. A blowing or swishing sound occurs in the second Korotkoff sound.

After recovery from a modified neck dissection for oropharyngeal cancer, the client receives external radiation to the operative site. For which most critical reaction to the radiation should the nurse assess the client? Dry mouth Skin reactions Mucosal edema Bone marrow suppression

Ans: C Rationale The mucosal lining of the oral cavity, oropharynx, and esophagus is sensitive to the effects of radiation therapy; the inflammatory response causes mucosal edema that may progress to an airway obstruction. A decrease in salivary secretions resulting in dry mouth may interfere with nutritional intake, but it is not life threatening. Erythema of the skin may cause dry or wet desquamation, but it is not life threatening. Radiation to the neck area should not produce as significant bone marrow suppression as radiation to the other sites.

The nurse documents the data gathered during the assessment in a client's medical record. What should the nurse do to ensure that the data is meaningful to other healthcare providers? Record subjective information in own words. Form judgments through written communication. Record objective information using accurate terminology. Compare data from the physical examination with client behavior.

Ans: C Rationale The nurse should document all objective information using accurate terminology. The nurse should pay attention to the facts and report findings exactly as seen, felt, or smelled. If the information is not specific, another healthcare provider reading the data gets only general impressions. The nurse should record subjective information in quotations, exactly as described by the client. The nurse should refrain from generalizing or forming judgments during documentation. This information is used to form nursing diagnoses, which must be factual and accurate. During validation, the nurse compares data from the physical examination with client behavior.

The nurse has just arrived in the unit for her shift at the healthcare facility. There are two new clients admitted to the unit. What should the nurse do first to collect the first set of information about the clients assigned to his or her care? Meet the clients' family. Read the clients' medical reports. Participate in the bedside rounds. Visit the clients and introduce self.

Ans: C Rationale The nurse should participate in bedside rounds with the healthcare team from the previous shift. The nurse who is completing care for one shift prepares the change-of-shift report to communicate client details to the nurse in the next shift. These bedside rounds provide patient-centered care as the nurse shares information about the client's condition, status of problems, and treatment plan for the next shift. The nurse can meet the client's family after obtaining firsthand information from the nurse completing the shift. The nurses review the client's medical reports and discuss treatment plans for the next shift after completing the bedside rounds. The nurse may meet the client during bedside rounds or after obtaining the handover report.

A registered nurse (RN) must assess the body temperature of a client with a history of epilepsy. Which site for measuring temperature is contraindicated in this client? Skin Axilla Oral cavity Temporal artery

Ans: C Rationale The oral cavity is not a preferred site to measure the body temperature of a client with epilepsy, oral surgery, trauma, or shaking chills. Epileptic clients become rigid during seizures and any sudden seizure attack during temperature measurement poses the risk of breaking the thermometer in the mouth, lacerations, accidental mercury ingestion, and possibly aspirating the broken pieces. The skin, axilla, and temporal artery are sites that can be safely used to measure topical body temperature in an epileptic client.

When assessing a client, the nurse auscultates a murmur at the second left intercostal space (ICS) along the sternal border. This reflects sound from which valve? Aortic Mitral Pulmonic Tricuspid

Ans: C Rationale The second left intercostal space (ICS) along the sternal border reflects sounds from the pulmonic valve. The correct landmark for auscultating the aortic valve is at the right second ICS at the sternal border; for the mitral valve (apical pulse) at the left fifth ICS in the midclavicular line; and for the tricuspid valve at the left fifth ICS at the sternal border.

The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this pulse can be characterized as what? Diminished Normal Full Bounding

Ans: C Rationale The strength of a pulse is a measurement of the force at which blood is ejected against the arterial wall. A 3+ rating indicates a full increased pulse. A zero rating indicates an absent pulse. A rating of a 1+ indicates a diminished pulse that is barely palpable. A 2+ rating is an expected or normal pulse, and a 4+ rating is a bounding pulse.

The nurse suspects that an intraoperative client has a distended bladder. Which method is correct to assess for this condition? Inspect and palpate in the epigastric region. Auscultate and percuss in the inguinal areas. Percuss and palpate in the hypogastric region. Percuss and palpate bilaterally in the lumbar areas.

Ans: C Rationale To detect a distended bladder, percussion and palpation should be performed over the hypogastric region of the abdomen. Percussion of a distended bladder would produce a dull sound and feel firm on palpation. Inspecting and palpating in the epigastric region, auscultating and percussing in the inguinal areas, or percussing and palpating bilaterally in the lumbar areas are all inaccurate procedures to assess for a distended bladder.

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply. Tetany Seizures Confusion Weakness Dysrhythmias

Ans: C, D, E Rationale Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are associated with low calcium or sodium levels. Because of potassium's role in the sodium/potassium pump, hyperkalemia will cause confusion, weakness, and cardiac dysrhythmias.

Which client body temperatures are indicative of moderate hypothermia? Select all that apply. 80° F (26.7° C) 84° F (28.9° C) 88° F (31.1° C) 92° F (33.3° C) 96° F (35.6° C)

Ans: C,D Rationale Moderate hypothermia is a body temperature between 86°F and 93.2°F (30° C to 34° C). Therefore clients with body temperatures between 88°F and 92°F (31.1° C to 33.3° C) have moderate hypothermia. Mild hypothermia is a body temperature between 93.2°F and 96.8°F (34° C to 36° C). Therefore clients with body temperatures of 96°F (35.6° C) have mild hypothermia. Body temperature below 86°F (30° C) indicates severe hypothermia.

Which age-related change should the nurse consider when formulating a plan of care for an older adult? Select all that apply. Difficulty in swallowing Increased sensitivity to heat Increased sensitivity to glare Diminished sensation of pain Heightened response to stimuli

Ans: C,D Rationale Changes in the ciliary muscles, decrease in pupil size, and a more rigid pupil sphincter contribute to an increased sensitivity to glare. Diminished sensation of pain may make an older adultunaware of a serious illness, thermal extremes, or excessive pressure. There should be no interference with swallowing in older adults. Older adults tend to feel the cold and rarely complain of the heat. There is a decreased response to stimuli in older adults.

A nurse is performing an eye assessment in an older adult. The older adult is unable to see near objects. Which conditions may be suspected in the older adult? Select all that apply. Cataract Glaucoma Hyperopia Presbyopia Macular degeneration

Ans: C,D Rationale In hyperopia, the client has farsightedness. In this condition, the client is unable to see near objects. Presbyopia is an impaired near vision that may occur with aging. Therefore, the nurse can suspect either of the conditions. In cataracts, there is an increased opacity of the lens that blocks light rays from entering the eye, leading to impaired vision. Glaucoma is a condition in which there is intraocular structural damage resulting from elevated intraocular pressure. Macular degeneration is caused due to blurred central vision that often occurs suddenly. This is caused by a progressive degeneration of the center of the retina.

While assessing an older adult during a regular health checkup, a nurse finds signs of elder abuse. Which physical findings would further confirm the nurse's suspicion? Select all that apply. Presence of hyoid bone damage Presence of cognitive impairment Presence of burns from cigarettes Presence of bed sores. Presence of unexplained bruises on the wrist(s)

Ans: C,D,E Rationale A physical finding of abuse in older adults can be the presence of burns from cigarettes. The physical presence of bed sores also indicates client abuse. Unexplained bruises on the wrist(s) may also be an indication of abuse in older adults. The presence of hyoid bone damage is an indication of intimate partner violence. The presence of cognitive impairment is a behavioral finding in older adult abuse.

While assessing a 7-month-old infant, the nurse advises the mother to avoid regular cow's milk. Which of these are valid reasons for the suggestion? Select all that apply. Cow's milk is not tolerated by infants. Cow's milk is a potential source of botulism toxin. Cow's milk increases the risk of milk product allergies. Cow's milk is a poor source of iron and vitamins C and E. Cow's milk is too concentrated for an infant's kidneys to manage.

Ans: C,D,E Rationale Regular cow's milk is avoided in infants during the first year of life because it is too concentrated for an infant's kidneys to manage. It also increases the risk of milk product allergies and is also a poor source of iron and vitamins C and E. Honey and corn syrup are potential sources of botulism toxin. Most infants are not allergic to or intolerant of cow's milk.

What should the nurse do when the defining characteristics of assessment data for a client can apply to more than one diagnosis? Select all that apply. Reassess the client. Reject all diagnoses. Gather more information. Identify related factors. Review all defining characteristics.

Ans: C,D,E Rationale The nurse must gather more information to clarify interpretations of assessment data. Correct interpretation of information allows the nurse to select the right diagnosis that applies to the client. A related factor is a condition or etiology that gives a context for the defining characteristics. The nurse should identify related factors to individualize a nursing diagnosis for the client. The nurse should review all the defining characteristics, eliminate irrelevant ones, and confirm the relevant ones. The nurse must interpret the data to form data clusters only after reassessing and validating it. At this stage, the nurse should have only validated assessment data in the database. The nurse need not reject all diagnoses. The nurse should review all the defining characteristics to support or eliminate the irrelevant ones.

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer? Stage I Stage II Stage III Unstageable

Ans: D Rationale A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage III pressure ulcer involves full-thickness tissue loss with visible subcutaneous fat. Bone, tendon, and muscle are not exposed.

A nurse is teaching a male client about measures to maintain sexual health and prevent transmission of sexually transmitted infections (STI). Which statement of the client indicates effective learning? "I will use condoms when having sex with an infected partner." "I will perform a genital self-examination every month before bathing." "I will refrain from getting the human papilloma virus vaccine (HPV) before the age of 27 years." "I will consult with my primary healthcare provider when there is a rash or ulcer on my genitalia."

Ans: D Rationale The client should consult a primary healthcare provider when there is a rash or ulcer on genitalia because these are the warning signs of a sexually transmitted infection (STI). Having sex with an infected partner with or without using condoms may increase the risk of contracting an STI. A male client should perform a genital self-examination every month after taking a bath, when the scrotal skin is less thick. The human papilloma virus vaccine (HPV) vaccine should be taken between 9 and 26 years of age.

A client has a history of a persistent cough, hemoptysis, unexplained weight loss, fatigue, night sweats, and fever. Which risk should be assessed? Lung cancer Cerebrovascular disease Cardiopulmonary alterations Human immunodeficiency virus (HIV) infection

Ans: D Rationale A client with a history of persistent cough, hemoptysis, unexplained weight loss, fatigue, night sweats, or fever may have a human immunodeficiency virus (HIV) infection or tuberculosis. Lung cancer and cerebrovascular disease are risks to be assessed in the client with a history of tobacco or marijuana use. Cardiopulmonary alterations may be present in a client with a persistent cough (productive or nonproductive), sputum streaked with blood, or voice changes.

A client who has been admitted to the hospital with chest pain complains of shortness of breath, weakness, and vomiting. The nurse suspects cardiac arrest. Which site is the most appropriate place to check the client's pulse rate? Ulnar Radial Brachial Femoral

Ans: D Rationale A client with chest pain, shortness of breath, weakness, and vomiting may be experiencing cardiac arrest. In a client with cardiac arrest, the most appropriate place to check the pulse rate is the femoral site, because other pulses may not be palpable at this time. The ulnar site is used to assess the status of circulation to the hand and also used to perform the Allen test. The radial site is commonly used to assess the character of the pulse peripherally and to assess the status of the circulation to the hand. The brachial site is used to assess the status of the circulation to the client's lower arm or the blood pressure is being auscultated.

A client who does not understand English requires an interpreter. Which nursing student action may exacerbate health disparities? The student expects the interpreter to act as the client's advocate. The student expects the interpreter to have a health care background. The student maintains steady eye contact with the client. The student talks only to the interpreter about the client.

Ans: D Rationale A nurse should follow certain strategies while working with an interpreter for a client who does not understand English. The nurse should talk to the client about the client's condition and care and not to the interpreter. The interpreter may act as a client advocate and represent the client's needs to the nurse. The nurse should use a trained medical interpreter who has a health care background. The nurse should maintain eye contact with the client and obtain feedback to be certain that the client understands.

The nurse cares for an unconscious client who underwent head surgery. Which site would be best used to monitor body temperature? Skin Oral Axilla Rectal

Ans: D Rationale Although the oral route is the most common route for monitoring body temperature, clients who are unconscious should have their temperatures monitored rectally. Skin temperature may be impaired due to diaphoresis; this measurement may not reliable. The axilla temperature may underestimate the core temperature.

The nurse is caring for an African American client with renal failure. The client states that the illness is a punishment for sins. Which cultural health belief does the client communicate? Yin/Yang balance Biomedical belief Determinism belief Magicoreligious belief

Ans: D Rationale An African American client may have magicoreligious beliefs, which focuses on hexes or supernatural forces that cause illness. Such clients may believe that illness is a punishment for sins. The yin/yang belief system does not consider illness as a punishment. The biomedical belief system maintains that health and illness are related to physical and biochemical processes with disease being a breakdown of the processes. The belief of determinism focuses on outcomes that are externally preordained and cannot be changed.

A client has a fever spike that is combined with normal temperature levels. The client's body temperature returns to a normal body temperature at least once a day. Which type of fever can be assessed in the client? Sustained Relapsing Remittent Intermittent

Ans: D Rationale An intermittent fever is characterized by fever spikes interspersed with normal temperatures. In this type of fever, the body temperature returns to normal at least once in 24 hours. In the case of sustained fever, there is a constant body temperature greater than 38ºC. In relapsing fever, there is an occurrence of periods of febrile episodes with acceptable temperature values. In remittent fever, the body temperature increases and decreases without returning to normal body temperature levels.

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client? Skin turgor Intake and output results Client's report about fluid intake Blood lab results

Ans: D Rationale Blood lab results provide objective data about fluid and electrolyte status, as well as about hemoglobin and hematocrit. Skin turgor is not a reliable indicator of hydration status for the elderly client because it is generally decreased with age. Intake and output results provide data only about fluid balance, but do not present a comprehensive picture of the client's fluid and electrolyte status; therefore this is not the best answer. The client's report about fluid intake is subjective data in general and not reliable because this client has dementia and therefore has memory problems .

A client reports to the hospital with skin lesions. Upon physical examination, the nurse notices circumscribed elevations of the skin, measuring about 0.5 × 0.5 cm. The lesions are filled with serous fluid. What is the suspected cause of these skin lesions? Venous stasis ulcer Arterial insufficiency Staphylococcal infection Herpes simplex infection

Ans: D Rationale Circumscribed elevated skin lesions filled with serous fluid smaller than 1 cm are called vesicles. Vesicles are found in conditions such as herpes simplex infection and chicken pox. Venous stasis ulcers are characterized by deep loss of skin surface that extends to the dermis and is associated with frequent bleeding. The appearance of shiny and translucent skin with loss of normal furrow indicates arterial insufficiency. In a staphylococcal infection, the skin lesion is similar to that of vesicle, but is filled with pus instead of serous fluid.

A client who sustained head injuries is admitted to the hospital. During assessment of cranial nerves, the nurse notices that the client lost the perception of taste, especially in the anterior portion of the tongue. Which cranial nerve might have been injured in this client? Cranial nerve X Cranial nerve IX Cranial nerve XII Cranial nerve VII

Ans: D Rationale Cranial nerve VII is the facial nerve. Injury to the facial nerve limits the sensory impulses from the anterior two-thirds of the tongue, along with altered facial expressions. Cranial nerve X is the vagus nerve, injury to which causes limitation of palatal movements. Cranial nerve IX is the glossopharyngeal nerve. Injury to this nerve results in loss of taste impulses from the posterior one-third of the tongue. Cranial nerve XII is the hypoglossal nerve, damage of which results in improper movements of the tongue.

A registered nurse notices that a student nurse who is assessing the blood pressure in a client is deflating the cuff too rapidly. What is the probable reading of blood pressure that the student nurse could have obtained if the actual blood pressure of the client is 140/90 mm Hg? 130/80 mm Hg 150/100 mm Hg 140/100 mm Hg 130/100 mm Hg

Ans: D Rationale Deflating the cuff too quickly will result in false low systolic and false high diastolic readings. Therefore the client's systolic readings decreased to 130 mm Hg while the diastolic readings increased to 100 mm Hg. If the bladder or cuff is too wide, it results in false low readings in the client, as in the blood pressure of 130/80 mm Hg. If the bladder or cuff is too narrow or too short or if the cuff is wrapped too loosely or unevenly, the result is a false high, as in the blood pressure of 150/100 mm Hg. Deflating the cuff too slowly results in false high diastolic readings, such as the blood pressure of 140/100 mm Hg.

While assessing the client's skin, a nurse notices a skin condition, the pathophysiology of which involves increased visibility of oxyhemoglobin caused by an increased blood flow due to capillary dilation. Which condition is associated with this client? Pallor Vitiligo Cyanosis Erythema

Ans: D Rationale Erythema occurs due to an increased visibility of oxyhemoglobin, which is caused by increased blood flow. Pallor is caused by a reduced amount of oxyhemoglobin or a reduced visibility of oxyhemoglobin. Vitiligo is a pigmentation disorder caused by autoimmune diseases. Cyanosis is a bluish discoloration of the skin around the lips; this occurs due to an increased amount of deoxygenated hemoglobin in the blood.

A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Before responding, what should the nurse consider about how gamma globulin provides passive immunity? It increases production of short-lived antibodies. It accelerates antigen-antibody union at the hepatic sites. The lymphatic system is stimulated to produce antibodies. The antigen is neutralized by the antibodies that it supplies.

Ans: D Rationale Gamma globulin, which is an immune globulin, contains most of the antibodies circulating in the blood. When injected into an individual, it prevents a specific antigen from entering a host cell. Gamma globulin does not stimulate antibody production. It does not affect antigen-antibody function.

While assessing an immobilized client, the nurse notes that the client has shortened muscles over a joint, preventing full extension. What is this condition known as? Osteoarthritis Osteoporosis Muscle atrophy Contracture

Ans: D Rationale Immobilized clients are at high risk for the development of contractures. Contractures are characterized by permanent shortening of the muscle covering a joint. Osteoarthritis is a disease process of the weight-bearing joints caused by wear and tear. Osteoporosis is a metabolic disease process in which the bones lose calcium. Muscle atrophy is a wasting and/or decrease in the strength and size of muscles because of a lack of physical activity or a neurologic or musculoskeletal disorder.

A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock? Respirations of 10 Urine output of 30 mL/hour Lethargy Restlessness

Ans: D Rationale In the early stage of shock, the client has increased epinephrine secretion. This, in turn, causes the client to become restless, anxious, nervous, and irritable. Decreased respiratory rate is a late sign of shock. A urine output of 30 mL/hour is within normal limits. Lethargy is not a sign of shock.

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? Rapid, thready pulse Distended jugular veins Elevated hematocrit level Increased serum sodium level

Ans:B Rationale Because of fluid overload in the intravascular space, the neck veins become visibly distended. Rapid, thready pulse and elevated hematocrit level occur with a fluid deficit. If sodium causes fluid retention, its concentration is unchanged; if fluid is retained independently of sodium, its concentration is decreased.

A nurse is discussing weight loss with an obese individual with Ménière disease. Which suggestion by the nurse is most important? Limit intake to 900 calories per day. Enroll in an exercise class. Get involved in diversionary activities when there is an urge to eat. Keep a diary of all foods eaten each day.

Ans: D Rationale Keeping a record of what one eats helps to limit nonconscious and nervous eating by making the individual aware of intake. Limiting calories to 900 per day is a severe restriction that requires a primary healthcare provider's prescription. Exercise causes rapid head movements, which may precipitate a Ménière attack. Although diversionary activities are a therapeutic intervention, the nurse first should make suggestions that help increase the client's awareness of personal eating habits.

A client who is suspected of having tetanus asks a nurse about immunizations against tetanus. Before responding, what should the nurse consider about the benefits of tetanus antitoxin? It stimulates plasma cells directly. A delayed titer of antibodies is generated. It provides immediate active immunity. A passive immunity is produced.

Ans: D Rationale Tetanus antitoxin stimulates the body to create protective antibodies to the tetanus toxin. It helps provide these antibodies, which confer immediate passive immunity that lasts about seven to 14 days. Passive immunization is the administration of immunoglobulin prepared from individuals known to have high levels of antibodies to the infectious agent in question. Antitoxin does not stimulate production of antibodies. It provides passive, not active, immunity.

The nurse administers a pneumococcal vaccine to a 70-year-old client. The client asks "Will I have to get this every year like I do with the flu shot?" How should the nurse respond? "You need to receive the pneumococcal vaccine every other year." "The pneumococcal vaccine should be received in early autumn every year." "You should get the flu and pneumococcal vaccines at your annual physical examination." "It is unnecessary to have any follow-up injections of the pneumococcal vaccine after this dose."

Ans: D Rationale The Centers for Disease Control and Prevention recommend that adults be immunized with pneumococcal vaccine at age 65 years or older with a single dose of the vaccine; if the pneumococcal vaccine was received before 65 years of age or if there is the highest risk of fatal pneumococcal infection, revaccination should occur 5 years after the initial vaccination. The pneumococcal vaccine should not be administered every 2 years. The pneumococcal vaccine should not be administered annually.

An elderly client is admitted to the healthcare facility following a stroke. What should the nurse do when the client's relative who arrived much later asks to see the client's health record? Confirm the client's relationship first. Ask the client's primary healthcare provider. Inform the nurse manager and show the records. Explain that medical health records are confidential.

Ans: D Rationale The Health Insurance Portability and Accountability Act (HIPAA) sets the standards for the protection of the client's health information. The nurse must explain that medical health records are confidential. The healthcare team must be aware of the organization's policies for reviewing a client's medical record for assessment. The nurse need not confirm the client's relationship because the client's medical records are confidential and cannot be shared with anyone unless authorized by the client. The primary healthcare provider cannot authorize the nurse to show the medical records. The nurse cannot inform the nurse manager and show the medical record to persons not involved in direct client care. Healthcare providers share information with reasonable safeguards within the healthcare team for the purpose of providing client care.

A registered nurse is teaching a nursing student about skin assessment. Which statement made by the nursing student indicates the need for further teaching? "Skin assessments are best performed in daylight." "Skin assessments performed at cool room temperatures can result in cyanosis." "Skin assessment performed at warm room temperatures can result in vasodilatation." "In the absence of sunlight, skin assessments are performed best with other sources of light instead of fluorescent light."

Ans: D Rationale Though skin assessments are best conducted in daylight, in the absence of sunlight, they are best performed in fluorescent lighting. Skin exposure during skin assessments in cool room temperature can result in cyanosis. Skin exposure during skin assessments made in warm room temperature can result in vasodilatation.

The nurse is caring for a client who has lost an arm in a motor vehicle accident. Which reaction made by the client leads the nurse to realize that the client is in the withdrawal phase of adjusting to the change in body image? The client is going through a grieving period. The client talks as if another person is affected. The client is willing to learn techniques to adapt. The client recognizes the reality and becomes anxious.

Ans: D Rationale The client with a change in body image following an injury recognizes the reality of the change, becomes anxious, and refuses to discuss it. This client uses withdrawal as an adaptive coping mechanism. During the acknowledgement phase, the client and family go through a grieving period as they acknowledge the change in physical appearance. At the end of the acknowledgement phase, they learn to accept the loss. Initially, the client is in a state of shock and depersonalizes the change. The client talks as if another person is affected by the change. The client in the rehabilitation stage is ready to learn how to adapt to the change in body image through use of prosthesis or changing lifestyles and goals.

A registered nurse is teaching a nursing student how to assess for edema. Which statement made by the student indicates the need for further education? "Edema results in the separation of skin from pigmented and vascular tissue." "Pitting edema leaves an indentation on the site of application of pressure." "Trauma or impaired venous return should be suspected in clients with edema." "If the pressure on an edematous site leaves an indentation of 2 mm, a score of 2+ is given."

Ans: D Rationale The depth of indentation left after applying pressure to an edematous site determines the degree of edema. A 1+ score is given if the depth of indentation is 2 mm. A 2+ is the score given if the depth of edema indentation is 4 mm. An accumulation of edematous fluid will result in the separation of skin and underlying vasculature. Edema is classified as pitting if the application of pressure on the edematous site will leave an indentation for some time. Edema results from a direct trauma to the tissue or by impaired venous return.

A client with a head injury underwent a physical examination. The nurse observes that the client's temperature assessments do not correspond with the client's condition. An injury to which part of the brain may be the reason for this condition? Pons Medulla Thalamus Hypothalamus

Ans: D Rationale The hypothalamus controls the body temperature. Damage to the hypothalamus may cause abnormalities in the body temperature values during a physical assessment. The pons is responsible for maintaining level of consciousness. The medulla controls heart rate and breathing. The thalamus performs motor and sensory functions.

The nurse is preparing to assess the four abdominal quadrants of a client who complains of stomach pain. When determining the order of the assessment, the nurse recognizes that it is important to assess the symptomatic quadrant when? First Second Third Last

Ans: D Rationale The nurse should systematically assess the abdomen concluding with the symptomatic area. Pain may be elicited in the symptomatic area if assessed first, second, or third, causing the muscles in other abdominal areas to tighten. This would interfere with the assessment.

An adolescent is taken to the emergency department of the local hospital after stepping on a nail. The puncture wound is cleansed and a sterile dressing applied. The nurse asks if the client has had a tetanus immunization. The adolescent responds that all immunizations are up to date. Penicillin is administered, and the client is sent home with instructions to return if there is any change in the wound area. A few days later, the client is admitted to the hospital with a diagnosis of tetanus. Legally, what is the nurse's responsibility in this situation? The nurse's judgment was adequate and the client was treated accordingly. The possibility of tetanus was not foreseen because the client was immunized. Nurses should routinely administer immunization against tetanus after such an injury. Assessment by the nurse was incomplete and, as a result, the treatment was insufficient.

Ans: D Rationale The nurse's data collection was not adequate because the nurse did not ask about the date of the previous tetanus inoculation. The nurse failed to support the life and well-being of a client. The nurse's assessment was not thorough in regard to determining the date of immunization. It was essential to determine when the client was last immunized; for a "tetanus-prone" wound, like a puncture from a rusty nail, some form of tetanus immunization usually is given. Administering immunization against tetanus is not an independent function of the nurse.

While assessing a client who sustained a road traffic accident, a nurse notices that the client is unable to clench his teeth. Which cranial nerve might have been affected? Facial nerve Trochlear nerve Abducens nerve Trigeminal nerve

Ans: D Rationale The trigeminal nerve provides sensory innervation to the facial skin and motor innervation to the muscles of the jaw. A client with a damaged trigeminal nerve will be unable to clench his teeth. The facial nerve provides sensory and motor innervations for facial expressions. The trochlear nerve is involved in downward and inward eye movements. The abducens nerve helps in the eyeball's lateral movement.

Which sites would the nurse prefer while assessing for turgor in an older adult? Select all that apply. Back of the neck Back of the hand Palm of the hand On the sternal area Back of the fore arm

Ans: D,E Rationale Turgor indicates the elasticity of the skin. The ideal site to assess the skin for turgor in an older adult is back of the forearm or the sternal area. The back of the neck contains redundant skin and may not be reliable. The skin on the back of the hand is normally loose and thin; turgor assessed at that site may not be reliable. The palm of the hand is not an ideal site for the assessment of turgor.

A student nurse is assessing the blood pressure of a client with the client's arm unsupported. What are the expected errors in the obtained readings? False high reading False low diastolic reading False high systolic reading False high diastolic reading

Ans:A Rationale If the client's arm is unsupported, or if the arm is below the heart level, the resulting outcome is a false high reading. Application of the stethoscope too firmly against antecubital fossa will result in a false low diastolic reading. Repeated assessments of blood pressure too often result in a false high systolic reading. Deflating the cuff too slowly results in a false high diastolic reading.

A nurse is teaching a client about different prevention and detection practices to ensure breast health. Which statement made by the client indicates the need for further teaching? "I will increase my meat consumption." "I will perform a self-breast examination every week." "I will schedule routine mammograms." "I will reduce my caffeine and theophylline intake."

Ans:A Rationale Meat consumption should be reduced to prevent breast cancer; a high meat consumption may lead to obesity, which is a risk factor for breast cancer. Performing self-breast examinations is an effective way to feel changes or any abnormal growth in the breast. The client should undergo mammograms regularly to check for early signs and abnormalities of the breast. Although the approach of reduced intake of caffeine and theophylline is controversial, these actions may reduce the symptoms of benign breast disease.

A nurse is caring for an older adult with a hearing loss secondary to aging. What can the nurse expect to identify when assessing this client? Select all that apply. Dry cerumen Tears in the tympanic membrane Difficulty hearing high pitched voices Decrease of hair in the auditory canal Overgrowth of the epithelial auditory lining

Ans:A, C Rationale Cerumen (ear wax) becomes drier and harder as a person ages. Generally, female voices have a higher pitch than male voices; older adults with presbycusis (hearing loss caused by the aging process) have more difficulty hearing higher pitched sounds. There is no greater incidence of tympanic tears caused by the aging process. The hair in the auditory canal increases, not decreases. The epithelium of the lining of the ear becomes thinner and drier.

A registered nurse is teaching a student nurse about various sites for assessing body temperature. Which statements made by the student nurse indicates the need for further teaching? Select all that apply. "The axilla is not recommended to measure body temperature in unconscious clients." "The oral cavity is not suitable for clients with epilepsy to measure body temperature." "The tympanic membrane is not a preferred site of measuring body temperature in infants." "The rectum is not a preferred site of measuring body temperature in clients who underwent rectal surgeries." "The temporal artery is not a preferred site of thermometer placement to measure rapid changes in core temperature."

Ans:A,C,E Rationale The axilla is the preferred site for measuring body temperature in unconscious clients. The tympanic membrane is the preferred site for measuring body temperature in newborns to reduce infant handling and heat loss. The region of the temporal artery reflects rapid changes in core temperature. The oral cavity is not a preferred site to measure body temperature for a client with epilepsy, oral surgery, trauma, or shaking chills. In clients with diarrhea, rectal abnormalities, bleeding tendencies, and clients who underwent rectal surgeries, the rectum is not the preferred site for measuring body temperature.

What are physiologic symptoms assessed in a client with sleep deprivation? Select all that apply. Ptosis and blurred vision Agitation and hyperactivity Confusion and disorientation Increased sensitivity to pain Decreased auditory alertness

Ans:A,E Rationale Ptosis may result from a loss of elasticity of the eyelids, which is a physiologic symptom of sleep deprivation. Decreased auditory alertness and blurred vision are also physiologic symptoms of sleep deprivation. Agitation, hyperactivity, confusion, disorientation, and increased sensitivity to pain are psychologic symptoms of sleep deprivation.

While assessing the muscle tone of a client, the client demonstrates a full range of muscle motion against gravity with some resistance. What score on the Lovett scale can be given to the client? Fair (F) Good (G) Trace (T) Normal (N)

Ans:B Rationale According to the Lovett score, a full range of motion against gravity with some resistance can be categorized as G (good). F (fair) can be given if the client exhibits a full range of motion with no resistance. T (trace) score is given when the client exhibits slight contractility with no movement. N (normal) on the Lovett scale indicates full range of motion against gravity with full resistance.

A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documented as what? Vesicular Bronchial Crackles Rhonchi

Ans:C Rationale Crackles are abnormal breath sounds described as soft, crackling, bubbling sounds produced by air moving across fluid in the alveoli. Vesicular breath sounds are normal. They are quiet, soft, and inspiration sounds that are short and almost silent on expiration. They are heard over the lung periphery. Bronchial breath sounds are normal and consist of a full inspiration and expiratory phase with the expiratory phase being louder. They are heard over the trachea and large bronchi of the lungs. Rhonchi are abnormal breath sounds heard over the large airways of the lungs. They consist of a low pitch and are caused by the movement of secretions in the larger airways; they usually clear with coughing.

A registered nurse (RN) is performing a physical examination of a client with chronic obstructive pulmonary disease. Which abnormal nail bed patterns can be expected in this client? Spoon-shaped nails Transverse depressions in nails Softening of nail beds and flat nails Red or brown linear streaks in nail bed

Ans:C Rationale Softening of the nail bed and enlarged finger tips with flattened nails are signs of clubbing of the nails. Clubbing results in a change of the angle between the nail and nail base and is seen in conditions of oxygen deficiency, such as in heart or pulmonary diseases. Conditions such as iron deficiency anemia and syphilis cause curvature of nails, which is called koilonychia. Transverse depressions in nails indicate a temporary disturbance of nail growth called Beau lines. Red or brown linear streaks in the nail bed are caused by minor trauma to nails, subacute endocarditis, and trichinosis. They are called splinter hemorrhages.

A 50-year-old client with a 30-year history of smoking reports a chronic cough and shortness of breath related to chronic obstructive pulmonary disease (COPD). The clinical data on admission are as follows: a heart rate of 100, a blood pressure of 138/82, a respiratory rate of 32, a tympanic temperature 36.8 °C, and an oxygen saturation of 80%. Which vital signs obtained by the nurse during the therapy indicates a positive outcome? Select all that apply. Radial pulse: 70 Temperature: 37 °C Respiratory rate: 14 Blood pressure: 110/70 Oxygen saturation: 92%

Ans:C,D,E Rationale The respiratory rate ranges in older adults from 12 to 20 breaths/min and this range may be elevated in clients with chronic obstructive pulmonary disease (COPD). Thus a rate decrease to 14 breaths/min indicates a positive outcome. COPD may also cause high blood pressure. Thus, a blood pressure of 110/70 obtained during therapy indicates a positive outcome. The normal oxygen saturation rate should be 95 to 100%. An oxygen saturation increase from 88% to 92% indicates a positive outcome of the therapy. The radial pulse indicates a positive outcome of the therapy if the client has a history of heart disease. A body temperature reading of 36.8 °C is considered normal and not a sign of COPD.

While assessing a neonate's temperature, the nurse observes a drop in the body temperature. What is the most appropriate reason for this temperature drop? Increased basal metabolic rate Decreased involuntary shivering Increased voluntary movements Decreased nonshivering thermogenesis

Ans:D Rationale Neonates are susceptible to heat loss or cold stress. Nonshivering thermogenesis is a natural mechanism of heat production that occurs to minimize heat loss in a neonate. This mechanism's failure may lead to a drop in body temperature. The basal metabolic rate (BMR) accounts for heat production; an increased BMR may raise the body temperature. Shivering is an involuntary movement that produces heat, which may not be seen in neonates. Voluntary movements cause increases in body temperature.

The nurse recognizes that which is the mental process most sensitive to deterioration with aging? Judgment Intelligence Creative thinking Short-term memory

Ans:D Rationale During the aging process there is a progressive atrophy of the convolutions of the brain with a decrease in its blood supply, which may produce a tendency to become forgetful, a reduction in short-term memory, and susceptibility to personality changes. There should be little or no change in judgment. There is little or no intellectual deterioration; intelligence scores show no decline. Creativity is not affected by aging; many people remain creative until very late in life.

What does a nurse consider the most significant influence on many clients' perception of pain when interpreting findings from a pain assessment? Age and sex Physical and physiological status Intelligence and economic status Previous experience and cultural values

Ans:D Rationale Interpretation of pain sensations is highly individual and is based on past experiences, which include cultural values. Age and sex affect pain perception only indirectly because they generally account for past experience to some degree. Overall physical condition may affect the ability to cope with stress; however, unless the nervous system is involved, it will not greatly affect perception. Intelligence is a factor in understanding pain so it can be tolerated better, but it does not affect the perception of intensity; economic status has no effect on pain perception.

Which diagnosis made by the nurse is helpful in providing the right nursing interventions for the client? The nurse understands that the client has pain due to a tracheostomy. The nurse identifies that the client is anxious about the cardiac catheterization. The nurse realizes that the client has diarrhea and needs the bedpan frequently. The nurse identifies that the client is not aware of perineal care and has impaired skin integrity.

Ans:D Rationale The nurse observes that the client has impaired skin integrity due to lack of knowledge about perineal care. The nurse identifies the need for educating the client about perineal care. This nursing diagnosis is correct as it will help enhance the client's health outcomes. The nursing diagnosis should identify the problem caused by a treatment such as tracheostomy, not the treatment itself. A tracheostomy is a medical condition and should not be included in the nursing diagnosis. This client is likely to have pain following the trauma of the surgical incision. The nursing diagnosis should contain the client's response to the medical procedure rather than the medical procedure itself. The client is probably anxious due to lack of knowledge about the need for cardiac catheterization or the outcome of the procedure rather than the catheterization itself. A correct diagnosis helps the nurse put the client at ease by providing necessary teaching. The nurse should plan nursing interventions after identifying the client's problem. Therefore, the nurse should identify that the client has diarrhea due to food intolerance. This helps the nurse select appropriate interventions rather than just one intervention of offering bedpan.

During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? Adequate venous blood flow to the lower extremities. Estimated amount of body fat by an underarm skinfold. Degree of flexion and extension of the client's knee joint. Change in the circumference of the joint in centimeters.

Rationale The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring device that is placed over a joint as the individual extends or flexes the joint to measure the degrees of flexion and extension on the protractor. On the other hand, a doppler is used to measure blood flow; calipers are used to measure body fat; and a tape measure is used to measure circumference of body parts.

The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide? Inherited familial health disorders. Chronic health problems. Reason for seeking health care. Undetected disorders.

Ans: A Rationale A genogram that is used during the health assessment process identifies genetic and familial health disorders. It may not identify the client's chronic health problems. A genogram is not a diagnostic tool to detect disorders, such as those based on pathological findings or DNA.

After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A.Determine the etiology of the problem. B. Prioritize nursing care interventions. C. Plan appropriate interventions. D. Collaborate with the client to set goals.

Ans: A. Rationale Before planning care, the nurse should determine the etiology, or cause, of the problem, because this will help determine goals, plan of care and priorities of interventions.

Secobarbital (Seconal) 150 mg is prescribed at bedtime for a male client who is scheduled for surgery in the morning. The scored tablets are labeled 0.1 gram/tablet. How many tablets should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)

Ans: 1.5

A client with pericardial effusion has phrenic nerve compression resulting in recurrent hiccups. The healthcare provider prescribes metoclopramide (Reglan) liquid 10 mg PO q 6 hours. Reglan is available as 5 mg/5 ml. A measuring device marked in teaspoons is being used. How many teaspoons should the nurse administer?

Ans: 2 Rationale First, using the formula, Desired dose/dose on Hand x Quantity of volume on hand (D/H x Q), 10 mg / 5 mg x 5ml = 10 ml Next using the known conversion of 5 ml = 1 tsp: 5 ml : 1 tsp :: 10 ml : X 5 / 10 : 1 / X 5X = 10 X = 2

Docusate sodium (Colace) 0.3 grams is prescribed for a client who has frequent constipation. Each capsule contains 100 mg. How many capsules should the nurse administer?

Ans: 3

A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? Assist the ambulating client back to the bed. Encourage the client to ambulate to resolve pneumonia. Obtain a prescription for portable oxygen while ambulating. Move the oximetry probe from the finger to the earlobe.

Ans: A Rationale An oxygen saturation below 90% indicates inadequate oxygenation. First, the client should be assisted to return to bed to minimize oxygen demands. Ambulation increases aeration of the lungs to prevent pooling of respiratory secretions, but the client's activity at this time is depleting oxygen saturation of the blood. Increased activity increases respiratory effort, and oxygen may be necessary to continue ambulation, but first the client should return to bed to rest.

The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? Observe the appearance of the skin under the ice pack. Instruct the client regarding the need for the covering. Reapply the covering after filling with fresh ice. Ask the client how long the ice was applied to the skin.

Ans: A Rationale The client has been using an ice pack without the protective covering. The first action the nurse should take is to assess the skin for any possible thermal injury. If no injury to the skin has occurred, the nurse can then explain the need for a cover and reapply the ice pack with the cover in place.

The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? Avoid any types of sprays, powders, and perfumes. Wearing a mask while cleaning will not help to avoid allergens. Purchase any type of clothing, but be sure it is washed before wearing it. Pollen count is related to hay fever, not to allergens.

Ans: A Rationale The client with allergies should be instructed to reduce any exposure to pollen, dust, fumes, odors, sprays, powders, and perfumes. The client should be encouraged to wear a mask when working around dust or pollen. Clients with allergies should avoid any clothing that causes itching; washing clothes will not prevent an allergic reaction to some fabrics. Pollen count is related to allergens, and the client should be instructed to stay indoors when the pollen count is high.

The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? The client voluntarily signed the form. The client fully understands the procedure. The client agrees with the procedure to be done. The client authorizes continued treatment.

Ans: A Rationale The nurse signs the consent form to witness that the client voluntarily signs the consent, that the client's signature is authentic, and that the client is otherwise competent to give consent. It is the healthcare provider's responsibility to ensure that the client fully understands the procedure. The nurse's signature does not indicate that the client agrees to or authorizes treatment.

A male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? A. "It is important that you continue your medication while learning to meditate." B. "Spiritual meditation requires a time commitment of 15 to 20 minutes daily." C. "Obtain your healthcare provider's permission before starting meditation." D. "Complementary therapy and western medicine can be effective for you."

Ans: A Rationale The prolonged practice of meditation may lead to a reduced need for antihypertensive medications. However, the medications must be continued while the physiologic response to meditation is monitored. The healthcare provider should be informed, but permission is not required to meditate. Although it is true that this complementary therapy might be effective, it is essential that the client continue with antihypertensive medications until the effect of meditation can be measured.

Which term refers to a blowing sound created by turbulence caused by narrowing of arteries while assessing for carotid pulse? Bruit Ectropion Entropion Borborygmi

Ans: A Rationale A bruit is an audible vascular blowing sound associated with turbulent blood flow through a carotid artery. Ectropion is a condition in which the eyelid is turned outwards away from the eyeball. Entropion is a malposition resulting in an inversion of the eyelid margin. Borborygmi are rumbling or gurgling noises made by the movement of fluid and gas in the intestines

The nurse assessed a client's pulse rate and recorded the score as 3+. What is the strength of the pulse? Strong Bounding Expected Diminished

Ans: A Rationale A pulse strength of 3+ is considered full or strong. A bounding pulse is 4+. A pulse strength is considered normal and expected when it is 2+. The pulse strength is diminished or barely palpable when the score is 1+.

Which feature is characteristic of a risk nursing diagnosis? The diagnosis does not have related factors. The diagnosis can be used in any health state. The defining characteristics support the diagnostic judgment. The defining characteristics are supported by a client's readiness.

Ans: A Rationale A risk nursing diagnosis describes human responses to health conditions that may develop in a vulnerable individual, family, or community. Risk diagnoses do not have related factors or defining characteristics because they have not occurred yet. A risk diagnosis has risk factors that help the nurse plan preventive measures. A health promotion nursing diagnosis can be applied to any individual with a desire to enhance health behaviors in any health state. An actual diagnosis is formed when the defining characteristics support the diagnostic judgment. There must be sufficient nursing assessment data to establish an actual diagnosis. A health promotion nursing diagnosis is a clinical judgment of an individual's readiness to increase well-being.

Which response by the nurse during a client interview is an example of back channeling? "All right, go on..." "What else is bothering you?" "Tell me what brought you here." "How would you rate your pain on a scale of 0 to 10?"

Ans: A Rationale Back channeling involves the use of active listening prompts such as "Go on...", "all right", and "uh-huh." Such prompts encourage the client to complete the full story. The nurse uses probing by asking the client, "What else is bothering you?" Such open-ended questions help to obtain more information until the client has nothing more to say. The statement, "Tell me what brought you here" is an open-ended statement that allows the client to explain his health concerns in his or her own words. Closed-ended questions such as, "How would you rate your pain on a scale of 0 to 10?" are used to obtain a definite answer. The client answers by stating a number to describe the severity of pain.

A client with chronic kidney disease (CKD) selects a scrambled egg for his breakfast. Which action should the nurse take? A. Commend the client for selecting a high biologic value protein. B. Remind the client that protein in the diet should be avoided. C. Suggest that the client also select orange juice, to promote absorption. D. Encourage the client to attend classes on dietary management of CKD.

Ans: A Rationale Foods such as eggs and milk are high biologic proteins which are allowed because they are complete proteins and supply the essential amino acids that are necessary for growth and cell repair. Although a low-protein diet is followed, some protein is essential. Orange juice is rich in potassium, and should not be encouraged. The client has made a good diet choice, so classes on dietary management is not necessary.

An older adult with a history of diabetes reports giddiness, excessive thirst, and nausea. During an assessment, the nurse notices the client's body temperature as 105° F. Which condition does the nurse suspect in the client? Heat stroke Heat exhaustion Accidental hypothermia Malignant hyperthermia

Ans: A Rationale Older adults are more at a risk of heat stroke. Symptoms of heat stroke include giddiness, excessive thirst, nausea, and increased body temperature. Heat exhaustion is indicated by a fluid volume deficient. Heat exhaustion occurs when profuse diaphoresis results in excess water and electrolyte loss. Accidental hypothermia usually develops gradually and goes unnoticed for several hours. When the skin temperature drops below 95° F, the client suffers from uncontrolled shivering, memory loss, depression, and poor judgment. Malignant hyperthermia is an adverse effect of inhalational anesthesia that is indicated by a sudden rise in body temperature in intraoperative or postoperative clients.

Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? Chocolate pudding. Graham crackers. Sugar free gelatin. Apple slices.

Ans: A Rationale The client with myasthenia gravis is at high risk for altered nutrition because of fatigue and muscle weakness resulting in dysphagia. Snacks that are semisolid, such as pudding are easy to swallow, require minimal chewing effort, and provide calories and protein.Gelatin does not provide any nutritional value and the other options require energy to chew and are more difficult to swallow than pudding.

A client's spouse is learning passive range-of-motion for the client's contracted shoulder. The nurse observes that the spouse is holding the client's arm above and below the elbow. Which nursing action should the nurse implement? Acknowledge that the spouse is supporting the arm correctly. Encourage the spouse to keep the joint covered to maintain warmth. Reinforce the need to grip directly under the joint for better support. Instruct the spouse to grip directly over the joint for better motion.

Ans: A Rationale The client's spouse is correctly holding the arm above and below the elbow to perform passive range-of motion to the contracted shoulder. The nurse should acknowledge this fact. The joint that is being exercised should be uncovered while the rest of the body should remain covered for warmth and privacy.

A client who is in hospice care reports increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? Give an around-the-clock schedule for administration of analgesics. Administer analgesic medication as needed when the pain is severe. Provide medication to keep the client sedated and unaware of stimuli. Offer a medication-free period so that the client can do daily activities.

Ans: A Rationale The most effective management of pain is achieved using an around-the-clock schedule that provides analgesic medications on a regular basis and in a timely manner. Analgesics are less effective if pain persists until it is severe, so an analgesic medication should be administered before the client's pain peaks. Providing comfort is a priority for the client who is dying, but sedation that impairs the client's ability to interact and experience the time before life ends should be minimized. Offering a medication-free period allows the serum drug level to fall, which is not an effective method to manage chronic pain.

When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? A. Loosen the right wrist restraint. B. Apply a pulse oximeter to the right hand. C. Compare hand color bilaterally. D. Palpate the right radial pulse.

Ans: A Rationale The nurse has observed that a client's fingers are blue distal to a wrist restraint. The priority nursing action is to restore circulation by loosening the restraint, because blue fingers (cyanosis) indicates decreased circulation. Assessing the depth of color change and the radial pulse are also important nursing interventions, but do not have the priority of removing the restraint. Pulse oximetry measures the saturation of hemoglobin with oxygen and is not indicated in situations where the cyanosis is related to mechanical compression (the restraints).

The client reports difficulty in breathing. The nurse auscultates lung sounds and assesses the respiratory rate. What is the purpose of the nurse's action? Data collection Data validation Data clustering Data interpretation

Ans: A Rationale The nurse is gathering objective data to support the subjective data. The client's report of difficulty breathing is subjective data that needs to be supported by data from physical examination. The nurse reviews the database after data collection to decide if it is accurate and complete. This step is called data validation. Grouping of data that forms a pattern is called data clusters. The nurse uses critical thinking to interpret the data and analyze it before it is classified and organized into data clusters.

Which pulse site is used to perform Allen's test? Ulnar Brachial Femoral Dorsalis pedis

Ans: A Rationale The ulnar pulse site is used to perform Allen's test. The brachial pulse site is used to assess the status of circulation to the lower arm and to auscultate blood pressure. The femoral site is used to assess the character of the pulse during physiological shock or cardiac arrest. The dorsalis pedis site is used to assess the status of circulation in the foot.

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis? Planning Evaluation Assessment Implementation

Ans: A Rationale The planning phase of the nursing process is directly affected if the nurse does not make a nursing diagnosis. The nurse cannot plan or interpret correctly if the client's problems are not clear. The evaluation phase of the nursing process is not directly affected by the nursing diagnosis. A nursing diagnosis is based on an accurate assessment. The nurse must obtain and document a comprehensive assessment. In the absence of nursing diagnosis, the nurse cannot implement appropriate nursing interventions. The implementation phase is directly affected if there is no plan of care.

On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? Assault. Battery. Malpractice. False imprisonment.

Ans: B Rationale Civil laws protect individual rights and include intentional torts, such as assault (an intentional threat to engage in harmful contact with another) or battery (unwanted touching).Performing any procedure against the client's wishes can potentially create a legal issue, such as battery, even if the procedure is of questionable benefit to the client.

The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A college-age track runner with a sprained ankle. A lactating woman nursing her 3-day-old infant. A school-aged child with Type 2 diabetes. An elderly man being treated for a peptic ulcer.

Ans: B Rationale A lactating woman has the greatest need for additional protein intake. Orthopedic injuries, typoe 2 diabetes, and peptic ulcers are all conditions that require protein, but do not have the increased metabolic protein demands of lactation.

During shift change report, the nurse receives report that a client has abnormal heart sounds. Which placement of the stethoscope should the nurse use to hear the client's heart sounds? APlace the stethoscope bell at random points on the posterior chest. Use the stethoscope bell over the valvular areas of the anterior chest. Move the diaphragm of the stethoscope over the left anterior chest. Position the diaphragm of the stethoscope at Erb's point on the chest.

Ans: B Rationale Abnormal heart sounds are best heard with the bell of the stethoscope, which picks up lower-pitched sounds, that is placed at points on the anterior chest.

A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? Sexual activity patterns. Nutritional history. Leisure activities. Financial stressors.

Ans: B Rationale Caffeine, sugars, and alcohol can lead to increased levels of anxiety, so a nutritional history (C) should be obtained first so that health teaching can be initiated if indicated. (A and C) can be used for stress management. Though (D) can be a source of anxiety, a nutritional history should be obtained first.

When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action should the nurse implement first? Establish a new nursing diagnosis. Note which actions were not implemented. Add additional nursing orders to the plan. Collaborate with the healthcare provider to make changes.

Ans: B Rationale First, the nurse should review which actions in the original plan were not implemented in order to determine why the original plan did not produce the desired outcome. Appropriate revisions can then be made, which may include revising the expected outcome, or identifying a new nursing diagnosis.

The nurse is examining a male client who reports itching on his right arm, The nurse observes a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? A. Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. C. Several areas of red, papular lesions from pinpoint to 0.5 cm in size. D. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter.

Ans: B Rationale Macules are localized flat skin discolorations less than 1 cm in diameter. However, when recording such a finding the nurse should describe the appearance rather than simply naming the condition. Vesicles are fluid-filled blisters. Papules are solid elevated lesions and petechiae are pinpoint red to purple skin discolorations that do not itch.

Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? Reassure the client that he will become accustomed to the stoma appearance in time. Instruct the client that the stoma will become smaller when the initial swelling diminishes. Offer to contact a member of the local ostomy support group to help him with his concerns. Encourage the client to handle the stoma equipment to gain confidence with the procedure.

Ans: B Rationale Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished. This will help reduce the client's anxiety and promote acceptance of the colostomy.

The nurse is assisting an 82-year-old client to ambulate. Which is the center of gravity for an elderly person? Arms. Upper torso. Head. Feet.

Ans: B Rationale The center of gravity for adults is the hips. However, as the person grows older, a stooped posture is common because of the changes from osteoporosis and normal bone degeneration, and the knees, hips, and elbows flex. This stooped posture results in the upper torso becoming the center of gravity for older persons. Although arms are part, or an extension of the upper torso, this is not the best and most complete answer.

The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? Immediately after exhalation. During the inhalation. At the end of three inhalations. Immediately after inhalation.

Ans: B Rationale The client should be instructed to deliver medication through a metered inhaler during the last part of inhalation. After the medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed and hold the breath for several seconds to allow for distribution of the medication.

Which degree of edema will result in a 6-mm deep indentation upon pressure application? 4+ 3+ 2+ 1+

Ans: B Rationale The depth of pitting determines the degree of pitting edema. An indentation of 6 mm is scored to be a 3+ degree edema. An indentation of 8 mm is scored as 4+. An indentation of 4 mm is scored as 2+. An indentation of 2 mm is scored as 1+.

Which type of breathing pattern alteration is manifested with hypercarbia? Eupnea Tachypnea Hypoventilation Kussmaul's respiration

Ans: C Rationale Hypercarbia may occur during hypoventilation. The respiratory rate is abnormally low and the depth of ventilation is depressed in hypoventilation. In eupnea, the normal rate and depth of respiration is interrupted while singing. The rate of breathing is regular, but abnormally rapid in tachypnea. Respirations are abnormally deep, regular, and the rate is increased in Kussmaul's respirations.

A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial action is most important for the nurse to take? A. Ask about any past history of drug abuse or addiction. B. Measure the pulse volume and capillary refill distal to the infiltration. C. Compress the infiltrated tissue to measure the degree of edema. D. Evaluate the extent of ecchymosis over the forearm area.

Ans: B Pain and diminished pulse volume (B) are signs of compartment syndrome, which can progress to complete loss of the peripheral pulse in the extremity. Compartment syndrome occurs when external pressure (usually from a cast), or internal pressure (usually from subcutaneous infused fluid), exceeds capillary perfusion pressure resulting in decreased blood flow to the extremity. (A) should not be pursued until physical causes of the pain are ruled out. (C) is of less priority than determining the effects of the edema on circulation and nerve function. Further assessment of the client's ecchymosis can be delayed until the signs of edema and compression that suggest compartment syndrome have been examined (D).

While examining a client, a nurse finds a circumscribed elevation of the skin filled with serous fluid on the cheek. The lesion is 0.6 cm in diameter. What does the nurse suspect the finding to be? Papule Vesicle Nodule Pustule

Ans: B Rationale A circumscribed elevation of the skin that is filled with serous fluid and a lesion size of less than 1 cm describes a vesicle. A papule is palpable, circumscribed, and has a solid elevation and a size smaller than 1 cm. A nodule is an elevated solid mass, deeper and firmer than a papule and of 1-2 cm in diameter. A pustule is a circumscribed elevation of the skin that is similar to a vesicle but filled with pus and varies in size.

Which statement best describes a diagnostic label? It is a condition that responds to nursing interventions. It describes the essence of the client's response to health conditions. It describes the characteristics of the client's response to health conditions. It is identified from the client's assessment data and associated with the diagnosis.

Ans: B Rationale A diagnostic label is the name of the nursing diagnosis as approved by the North American Nursing Diagnosis Association International (NANDA-I). It describes the essence of the client's response to health conditions in as few words as possible. The etiology of a nursing diagnosis is a condition that responds to nursing interventions. All NANDA-I approved diagnoses have a definition that describes the characteristics of the client's response to health conditions. The related factor of a nursing diagnosis is identified from the client's assessment data and associated with the diagnosis.

Which activity by the community nurse can be considered an illness prevention strategy? Encouraging the client to exercise daily Arranging an immunization program for chicken pox Teaching the community about stress management Teaching the client about maintaining a nutritious diet

Ans: B Rationale An illness prevention program protects people from actual or potential threats to health. A chickenpox immunization program is an illness prevention program. It motivates the community to prevent a decline in health or functional levels. A health promotion program encourages the client to maintain the present levels of health. The nurse promotes the health of the client by encouraging the client to exercise daily. Wellness education teaches people how to care for themselves in a healthy manner. The nurse provides wellness education by teaching about stress management. The nurse promotes the health of the client by teaching the client to maintain a nutritious diet.

A client who is 5 foot 5 inches tall and weighs 200 pounds is scheduled for surgery the next day. Which question is most important for the nurse to include during the preoperative assessment? "What is your daily calorie consumption?" "What vitamin and mineral supplements do you take?" "Do you feel that you are overweight?" "Will a clear liquid diet be okay after surgery?"

Ans: B Rationale In the preoperative assessment, the nurse should assess the client's use of vitamin and mineral supplements. These products may impact medications used during the operative period. The nature of the surgery and anesthesia will determine the need for a clear liquid diet, rather than the client's preference. Addressing long-term diet therapy is best done after surgery and recovery.

Which position is indicated to assess the musculoskeletal system and is contraindicated in clients with respiratory difficulties? Sims position Prone position Supine position Knee-chest position

Ans: B Rationale Prone position is indicated to assess the musculoskeletal system in clients, but it is indicated with caution in clients with respiratory difficulties because they cannot tolerate this position well. Sims position is indicated to assess the rectum and vagina. Supine position is indicated for general examination of head and neck, anterior thorax, breast, axilla, and pulses. Knee-chest position is indicated for rectal assessment.

The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, which action should the nurse take next? Clamp the tube for 20 minutes. Flush the tube with water. Administer the medications as prescribed. Crush the tablets and dissolve in sterile water.

Ans: B Rationale The NGT should be flushed before, after, and in between each medication administered. Once all medications are administered, the NGT should be clamped for 20 minutes.Other options may be implemented only after the tubing has been flushed.

An older client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan? In 8 weeks you will be able to bend at the waist to reach items on the floor. Place a pillow between your knees while lying in bed to prevent hip dislocation. It is safe to use a walker to get out of bed, but you need assistance when walking. Take pain medication 30 minutes after your physical therapy sessions.

Ans: B Rationale The client's affected hip joint following a hemiarthroplasty (partial hip replacement) is at risk of dislocation for 6 months to a year following the procedure. Hip precautions to prevent dislocation include placing a pillow between the knees to maintain abduction of the hips. Clients should be instructed to avoid bending at the waist, to seek assistance for both standing and walking until they are stable on a walker or cane, and to take pain medication 20 to 30 minutes prior to physical therapy sessions, rather than waiting until the pain level is high after their therapy.

A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. Which action should the nurse take first? Irrigate the nasogastric tube with sterile normal saline. Reposition the client on her side. Advance the nasogastric tube an additional five centimeters. Administer an intravenous antiemetic prescribed for PRN use.

Ans: B Rationale The nurse has identified two things suggesting the the nasogastric tube is not functioning properly; the client is nauseated and no drainage from the tube in 2 hours. The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention should be attempted first. This includes repositioning the client to her side. The tube may need to be irrigated or advanced but these actions should follow repositioning the client.

A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? 9 a.m., 1 p.m., and 5 p.m. 8 a.m., 4 p.m., and midnight. Before breakfast, before lunch, and before dinner. With breakfast, with lunch, and with dinner.

Ans: B Rationale Theophylline should be administered on a regular, around-the-clock schedule to provide the best bronchodilating effect and to reduce the potential for adverse effects. Food may alter absorption of the medication, so it should not be taken with meals.

What action should the nurse implement when assessing an implanted infusion port for a client who receives long term IV medications? Place a sterile dressing over the port. Insert a Huber-point needle into the port Cleanse the site with iodine solution Flush tubing with 5mL of normal saline

Ans: B Rationale An implanted infusion port needs to be accessed using a Huber-point needle (B) non-coring to prevent damage to the self-sealing septum of the port. The other options are not necessary when accessing an implanted infusion port.

In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly A. is to be expected, and progresses with age. B. often follows relocation to new surroundings. C. is a result of irreversible brain pathology. D. can be prevented with adequate sleep.

Ans: B Rationale Relocation (B) often results in confusion among elderly clients--moving is stressful for anyone. (A) is a stereotypical judgment. Stress in the elderly often manifests itself as confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for confusion.

A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump? A. 13 ml/hour. B. 63 ml/hour. C. 80 ml/hour. D. 125 ml/hour.

Ans: B Rationale To calculate this problem correctly, remember that the dose of KCl is not used in the calculation. 250 ml/4 hours = 63 ml/hour.

A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? A. Administer the medication more rapidly using the same IV site. B. Initiate an alternate site for the IV infusion of the medication. C. Notify the healthcare provider before administering the next dose. D. Give the client a PRN dose of aspirin while the medication infuses.

Ans: B Rationale: A cephalosporin antibiotic that is administered IV may cause vessel irritation. Rotating the infusion site minimizes the risk of thrombophlebitis, so an alternate infusion site should be initiated (B) before administering the next dose. Rapid administration (A) of intravenous cephalosporins can potentiate vessel irritation and increase the risk of thrombophlebitis. (C) is not necessary to initiate an alternative IV site. Although aspirin has antiinflammatory actions, (D) is not indicated.

What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A. It is more difficult to find a superficial vein in the feet and ankles. B. A decreased flow rate could result in the formation of a thrombosis. C. A cannulated extremity is more difficult to move when the leg or foot is used. D. Veins are located deep in the feet and ankles, resulting in a more painful procedure.

Ans: B Rationale: Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs. Handling a leg or foot with an IV (C) is probably not any more difficult than handling an arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult, this is not the most important reason for using the upper extremities. Pain (D) is not a consideration.

When should the nurse consider family members as the primary source of information? Select all that apply. The client is an elderly adult. The client is an infant or child. The client is brought in as an emergency. The client is critically ill and disoriented. The client visits the outpatient department.

Ans: B,C,D Rationale The nurse interviews the parents who care for the infant or child. Thus, the parents become the primary source of information. A client who is brought to the emergency department may not be in a position to explain the circumstances that led to the visit. In this case, the family or significant others who accompany the client become the primary source of information. The family becomes the primary source of information when the client is critically ill, disoriented, and unable to answer questions. Generally, the client is the primary source of information. The elderly adult who is conscious, alert, and able to answer the nurse's questions is the primary source of information. The client who visits the outpatient department is capable of providing accurate answers to the nurse's questions. This client is the primary source of information during assessment.

Which action is most important for the nurse to implement when donning sterile gloves? A. Maintain thumb at a ninety degree angle. B. Hold hands with fingers down while gloving. C. Keep gloved hands above the elbows. D. Put the glove on the dominant hand first.

Ans: C Rationale Gloved hands held below waist level are considered unsterile. While it may be helpful to put the glove on the dominant hand first, it is not necessary to ensure asepsis.

A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? Record the coughing incident. No further action is required at this time. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.

Ans: C Rationale Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any other action. The auscultating method has been found to be unreliable for small-bore feeding tubes.

The nurse assigns an unlicensed assistive personnel (UAP) to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? Remain calm with the client and record abnormal results in the chart. Notify the medication nurse immediately if the pulse or blood pressure is low. Report the results of the vital signs to the nurse. Reassure the client that the vital signs are normal.

Ans: C Rationale Interpretation of vital signs is the responsibility of the nurse, so the unlicensed assistive personnel (UAP) should report vital sign measurements to the nurse. Any instructions requiring the UAP to interpret the vital signs causes the UAP to function beyond the scope of the UAP's authority.

During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem? Restatement of responses. Open-ended questions. Closed-ended questions. Problem-seeking responses.

Ans: C Rationale Lay descriptors of health problems can be vague and nonspecific. To efficiently obtain specific information, the nurse should use closed-ended questions that focus on common signs and symptoms about a client's health problem.Other question types are used when therapeutically interacting and should be used after specific information is obtained from the client.

The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? Thalamus. Hypothalamus. Frontal lobe. Parietal lobe.

Ans: C Rationale The frontal lobe of the cerebrum controls higher mental activities, such as memory, intellect, language, emotions, and personality. On the other hand, the thalamus is an afferent relay center in the brain that directs impulses to the cerebral cortex. The hypothalamus regulates body temperature, appetite, maintains a wakeful state, and links higher centers with the autonomic nervous and endocrine systems, such as the pituitary. The parietal lobe is the location of sensory and motor functions.

What is the appropriate blood pressure of a 12-year-old client? 95/65 mm Hg 105/65 mm Hg 110/65 mm Hg 119/75 mm Hg

Ans: C Rationale A 12-year-old client typically has a blood pressure of 110/65 mm Hg. A 1-year-old client would typically have a blood pressure of 95/65 mm Hg. A 6-year-old client would typically have a blood pressure of 105/65 mm Hg. A 14- to 17-year-old client has a typical blood pressure of 119/75 mm Hg.

A client who underwent a physical examination reports itching after 2 days. Which condition should the nurse suspect? Eczema Hypersensitivity Contact dermatitis Anaphylactic shock

Ans: C Rationale A client who is allergic to latex may experience an allergy after a physical examination with latex gloves. Itching is one of the clinical signs of latex allergy. Contact dermatitis is a delayed immune response that occurs 12 to 48 hours after exposure. Eczema is a skin condition that can be worsened with excessive drying. Hypersensitivity is an immediate allergic reaction that occurs due to chemicals that are used to make gloves. Anaphylactic shock is also an immediate allergic reaction that occurs due to natural rubber latex.

A nurse is planning to provide self-care health information to several clients. Which client should the nurse anticipate will be most motivated to learn? A 55-year-old client who had a mastectomy and is very anxious about her body image An 18-year-old client who smokes cigarettes and is in denial about the dangers of smoking A 56-year-old client who had a heart attack last week and is requesting information about exercise A 47-year-old client who has a long-leg cast after sustaining a broken leg and is still experiencing severe pain

Ans: C Rationale A client who is requesting information is indicating a readiness to learn. When a nurse is caring for a person who is coping with the diagnosis of cancer and a change in body image, the nurse should encourage the expression of feelings, not engage in teaching. People in denial are not ready to learn because they do not admit they have a problem. In addition, many adolescents believe that they are invincible. A person who is in pain is attempting to cope with a physiological need. This client is not a candidate for teaching until the pain can be lessened; pain can preoccupy the client and prevent focusing on the information being presented.

Which response by a client with a nursing diagnosis of "Spiritual distress," indicates to the nurse that a desired outcome measure has been met? Expresses concern about the meaning and importance of life. Remains angry at God for the continuation of the illness. Accepts that punishment from God is not related to illness. Refuses to participate in religious rituals that have no meaning.

Ans: C Rationale Acceptance that her illness is not God punishing her, indicates a desired outcome for some degree of resolution of spiritual distress.

While inspecting the external eye structure of a client, a nurse finds bulging of the eyes. Which condition can be suspected in the client? Eye tumors Hypothyroidism Hyperthyroidism Neuromuscular injury

Ans: C Rationale Bulging eyes may indicate hyperthyroidism. Tumors are characterized by abnormal eye protrusions. Hypothyroidism can be revealed by the coarseness of the hair of the eyebrows and the failure of the eyebrows to extend beyond the temporal canthus. Crossed eyes or strabismus may result from neuromuscular injury or inherited abnormalities.

The nurse finds that the client's fever spikes and falls without a return to a normal level. Which pattern of fever is this a characteristic of? Relapsing Sustained Remittent Intermittent

Ans: C Rationale In a remittent pattern, fever spikes and falls without returning to normal temperature levels. Periods of febrile episodes coupled with periods of acceptable temperature values are called a relapsing pattern. A constant body temperature continuously above 38° C (100.4° F) with little fluctuation refers to a sustained pattern. In an intermittent pattern, fever spikes are interspersed with normal temperature levels.

Which term refers to the exaggeration of the posterior curvature of the thoracic spine? Lordosis Scoliosis Kyphosis Osteoporosis

Ans: C Rationale Kyphosis is an excessive outward curvature of the spine that causes hunching of the back. Lordosis is the excessive inward curvature of the lumbar part of the spine. Scoliosis is the abnormal lateral curvature of the spine. Osteoporosis is characterized by a loss of bone mass and a deterioration of bone tissues.

The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? "If I exercise at least two times weekly for one hour, I will lower my cholesterol." "I need to avoid eating proteins, including red meat." "I will limit my intake of beef to 4 ounces per week." "My blood level of low density lipoproteins needs to increase."

Ans: C Rationale Limiting saturated fat from animal food sources to no more than 4 ounces per week is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week. Red meat and all proteins do not need to be eliminated to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2-ounce servings). The low density lipoproteins need to decrease rather than increase.

A client is admitted with a suspected malignant melanoma on the arm. When performing the physical assessment, what would the nurse expect to find? Large area of petechiae Red birthmark that has recently become lighter in color Brown or black mole with red, white, or blue areas Patchy loss of skin pigmentation

Ans: C Rationale Melanomas have an irregular shape and lack uniformity in color. They may appear brown or black with red, white, or blue areas. Petechiae are pinpoint red dots that indicate areas of bleeding under the skin. A red birthmark is a vascular birthmark and often fades over time. A patchy loss of skin pigmentation indicates vitiligo.

Which physical skin finding indicates opioid abuse? Diaphoresis Red, dry skin Needle marks Spider angiomas

Ans: C Rationale Needle marks of the skin indicate opioid abuse. Diaphoresis indicates sedative hypnotic abuse. Red, dry skin indicates phencyclidine abuse. Spider angiomas indicate alcohol abuse.

A nurse assesses for hypocalcemia in a postoperative client. What is one of the initial signs that might be present? Headache Pallor Paresthesias Blurred vision

Ans: C Rationale Normally, calcium ions block the movement of sodium into cells. When calcium is low, this allows sodium to move freely into cells, creating increased excitability of the nervous system. Initial symptoms are paresthesias. This can lead to tetany if untreated. Headache, pallor, and blurred vision are not signs of hypocalcemia.

The nurse is evaluating a client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? A. Tossed salad, low-sodium dressing, bacon and tomato sandwich. B. New England clam chowder, no-salt crackers, fresh fruit salad. C. Skim milk, turkey salad, roll, vanilla ice cream. D. Macaroni and cheese, diet Coke, a slice of cherry pie.

Ans: C Rationale Skim milk, turkey, bread, and ice cream, while containing some sodium, are considered low-sodium foods. Bacon, canned soups (especially those with seafood), hard cheeses, macaroni, and most diet drinks are very high in sodium.

An older client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? The nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. The nurse assigned to care for the client who was at lunch at the time of the fall. The nurse who transferred the client to the chair when the fall occurred. The charge nurse who completed rounds 30 minutes before the fall occurred.

Ans: C Rationale The four elements of malpractice are: breach of duty owed, failure to adhere to the recognized standard of care, direct causation of injury, and evidence of actual injury. The hip fracture is the actual injury and the standard of care was "frequent monitoring." The nurse most at risk for malpractice is the one in which duty was owed (transferring the client safely) and the injury occurred while the nurse was in charge of the client's care.

An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? Position the client on the right side of the bed in reverse Trendelenburg. Fill the enema container with 1000 mL of warm water and 5 mL of castile soap. Reposition in a Sims' position with the client's weight on the anterior ilium. Raise the side rails on both sides of the bed and elevate the bed to waist level.

Ans: C Rationale The left-sided Sims' position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client in the Sims' position, which distributes the client's weight to the anterior ilium. The reverse Trendelenburg is inaccurate. The other options should be implemented once the client is positioned.

The nurse is developing a nursing diagnosis for a client after surgery. The nurse documents the "related to" factor as first time surgery. Which assessment activity enabled the nurse to derive this conclusion? The nurse notes nonverbal signs of discomfort. The nurse observes the client's position in bed. The nurse asks the client to explain the surgery. The nurse asks the client to rate the severity of pain.

Ans: C Rationale The nurse must assess the client's knowledge about the surgery to determine if the client is aware of the outcome of surgery. The nurse observes for nonverbal signs of discomfort because some clients may not state that they are in pain. The nurse observes the client's positioning in bed to determine any abnormal signs such as discomfort or pain. The nurse asks the client to rate the severity of pain to determine a nursing diagnosis of pain related to a surgical wound.

A 50-year-old client being seen for a routine physical asks why a stool specimen for occult blood testing has been prescribed when there is no history of health problems. What is an appropriate nursing response? "You will need to ask your healthcare provider; it is not part of the usual tests for people your age." "There must be concern of a family history of colon cancer; that is a primary reason for an occult blood stool test." "It is performed routinely starting at your age as part of an assessment for colon cancer." "There must have been a positive finding after a digital rectal examination performed by your healthcare provider."

Ans: C Rationale The primary reason for a stool specimen for guaiac occult blood testing is that it is part of a routine examination for colon cancer in any client over the age of 40. Age, family history of polyps, and a positive finding after a digital rectal examination are factors related to colon cancer and secondary reasons for the occult blood test (guaiac test).

Which site is best used to inspect a client who is suspected to have jaundice? Skin Palm Sclera Conjunctiva

Ans: C Rationale The sclera is the best site to inspect for jaundice. Because the skin may become pale due to anemia or jaundice, a skin inspection is not recommended. The palms and conjunctiva are inspected to assess pallor.

A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? A. Healthcare provider notified of failure to collect specimens for prescribed blood studies. B. Blood specimens not collected because client no longer wants blood tests performed. C. Healthcare provider notified of client's refusal to have blood specimens collected for testing. D. Client irritable, uncooperative, and refuses to have blood collected. Healthcare provider notified.

Ans: C Rationale When a client refuses a treatment, the exact words of the client regarding the client's refusal of care should be documented in a narrative format. The nurse should not editorialize, make judgments, or document assumptions about the client's wishes.

The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A. Infuse normal saline at a keep vein open rate. B. Discontinue the IV and flush the port with heparin. C. Infuse 10 percent dextrose and water at 54 ml/hr. D. Obtain a stat blood glucose level and notify the healthcare provider.

Ans: C Rationale TPN is discontinued gradually to allow the client to adjust to decreased levels of glucose. Administering 10% dextrose in water at the prescribed rate (C) will keep the client from experiencing hypoglycemia until the next TPN solution is available. The client could experience a hypoglycemic reaction if the current level of glucose (A) is not maintained or if the TPN is discontinued abruptly (B). There is no reason to obtain a stat blood glucose level (D) and the healthcare provider cannot do anything about this situation.

The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute? A. 80 B. 8 C. 21 D. 25

Ans: C Rationale The accepted formula for figuring drops per minute is: amount to be infused in one hour × drop factor/time for infusion (min)= drops per minute. Using this formula: 1,000/8 hours = 125 ml/ hour 125 × 10 (drip factor) = 1,250 drops in one hour. 1,250/ 60 (number of minutes in one hour) = 20.8 or 21 gtt/min (C).

How does the World Health Organization (WHO) define "health"? A condition when people are free of disease A condition of life rather than pathological state An actualization of inherent and acquired human potential A state of complete physical, mental, and social well-being

Ans: D

An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? Generalized dry skin. Localized dry skin on lower extremities. Red flush over entire skin surface. Rashes in the axillary, groin, and skin fold regions.

Ans: D Rationale Immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes (D), skin breakdown, and the development of pressure ulcers. (A, B, and C) do not address the concepts of inflammation and tissue integrity.

Which of the following is a description of the percussion technique? Listening to sounds that the body makes Using the sense of touch to assess and collect data Carefully looking for abnormal findings Tapping the skin with the fingertips to vibrate underlying tissues

Ans: D Rationale Percussion is a technique used to assess the skin by tapping the skin with the fingertips to vibrate underlying tissues and organs. Auscultation involves listening to the sounds that the body makes. Palpation involves using the sense of touch to assess and collect data. Generally during an inspection, the nurse should carefully look for abnormal findings.

A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? Demonstrates loss of remote memory. Exhibits expressive dysphasia. Has a diminished attention span. Is disoriented to place and time.

Ans: D Rationale The client is exhibiting disorientation. Loss of remote memory refers to memory of the distant past. The client is able to express himself without difficulty, and does not demonstrate a diminished attention span.

Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse? "That means you have derived the maximum benefit, and the heat can be removed." "Your blood vessels are becoming dilated and removing the heat from the site." "We will increase the temperature 5 degrees when the pad no longer feels warm." "The body's receptors adapt over time as they are exposed to heat."

Ans: D Rationale Thermal adaptation occurs 20 to 30 minutes after heat application. This means the client may not feel the same level of heat as at the start of the treatment. The nurse should not increase the heat setting.

A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV every 24 hours is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? Contact the healthcare provider and complete a medication variance form. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. Notify the charge nurse and complete an incident report to explain the missed dose. Give the missed dose at 1300 and change the schedule to administer daily at 1300.

Ans: D Rationale To ensure that a therapeutic level of medication is maintained, the nurse should administer the missed dose as soon as possible, and revise the administration schedule accordingly to prevent dangerously increasing the level of the medication in the bloodstream. The nurse should document the reason for the late dose, but contacting the healthcare provider or the charge nurse are not warranted.

Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? Apply a condom catheter. Apply a skin protectant. Encourage increased fluid intake. Assess for bladder distention.

Ans: D Rationale Urinary retention is the inability to void all urine collected in the bladder, which leads to uncomfortable bladder distention. Assessing for distention is more important than applying a catheter or applying skin protectant.

An older resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A. Reaffirm the client's desire for no resuscitative efforts. B. Transfer the client to a hospice inpatient facility. C. Prepare the family for the client's impending death. D. Notify the healthcare provider of the family's request.

Ans: D Rationale When a family requests hospice care, the nurse should first communicate with the healthcare provider. Hospice care is provided for clients with a limited life expectancy, which must be identified by the healthcare provider. Once the healthcare provider supports the transfer to hospice care, the nurse can collaborate with the hospice staff and healthcare provider to determine what additional care should be implemented.

The unlicensed assistive personnel (UAP) working on a chronic neuro unit asks the nurse to help determine the safest way to transfer an older client with left-sided weakness from the bed to the chair. Which method describes the correct transfer procedure for this client? Place the chair at a right angle to the bed on the client's left side before moving. Assist the client to a standing position, then place the right hand on the armrest. Have the client place the left foot next to the chair and pivot to the left before sitting. Move the chair parallel to the right side of the bed, and stand the client on the right foot.

Ans: D Rationale When positioning a client for transfer from bed to chair when the client has left-sided weakness, use the client's stronger side, the right side, for weight-bearing during the transfer. In this case, the client should stand on the right foot during the transfer.

While performing a physical assessment, the nurse notices a minute, nonpalpable change in the skin color of a client. What might be the type of skin lesion involved? Wheal Papule Vesicle Macule

Ans: D Rationale A macule is a flat, nonpalpable change in skin color, which is smaller than 1 cm. A wheal is a localized edema, usually caused by a mosquito bite. Wheals are irregular in shape and have elevated surfaces. Papules are palpable, circumscribed solid elevations in the skin, smaller than 1 cm. Vesicles are small, circumscribed skin elevations, filled with serous fluid.

Which integumentary finding is related to skin texture? Elasticity Vascularity Fluid buildup Character of the surface

Ans: D Rationale Assessing for texture refers to the character of the surface of the skin. Assessing for elasticity determines the turgor of the skin. Assessing for vascularity determines skin circulation. Fluid buildup in the tissues indicates edema.

The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? The belief is held that the "evil eye" enters the child if anything cold is ingested. After surgery the child probably has refused all foods except broth. Eating broth strengthens the child's innate energy called "chi." "Hot" remedies restore balance after surgery, which is considered a "cold" condition.

Ans: D Rationale Common parental practices and health beliefs among Hispanic, Chinese, Filipino, and Arab cultures classify diseases, areas of the body, and illnesses as "hot" or "cold" and must be balanced to maintain health and prevent illness. The perception that surgery is a "cold" condition implies that only "hot" remedies, such as soup, should be used to restore the healthy balance within the body.

A Sub-Saharan African widowed immigrant woman lives with her deceased husband's brother and his family, which includes the brother-in-law's children and the widow's adult children. Each family member speaks fluent English. Surgery is recommended for this client. What is the best plan to obtain consent for surgery for this client? Obtain an interpreter to explain the procedure to the client. Encourage the client to make her own decision regarding surgery. Ask the family members to provide a clarification of the surgeon's explanation to the client. Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow.

Ans: D Rationale Customary law in some rural sub-Saharan countries encompasses wife inheritance and polygamy; the widow becomes the inherited wife of the her husband's brother. In those rural areas women live in a patriarchal family where decisions are made by men. Most likely, the brother-in-law will make the decision for his inherited wife, so it is important to provide the surgeon with culturally sensitive information. Since all family members speak fluent English, there is no need for a translator. It is culturally insensitive to encourage the woman to go against her wishes to follow her cultural worldview.

During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? A. Provide additional coffee on the client's breakfast tray. B. Exchange the client's grape juice for cranberry juice. C.Bring the client additional fruit at mid-morning. D. Encourage additional oral intake of juices and water.

Ans: D Rationale Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to increase fluid intake (D). Caffeine, however, is a diuretic (A), and may worsen the fluid volume deficit. Any type of juice will be beneficial (B), since the client is not dysuric, a sign of an urinary tract infection. The client needs to restore fluid volume more than solid foods (C).

The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A. Encourage the client to cough to help loosen secretions. B. Advise the client to increase the intake of oral fluids. C. Rotate the suction catheter to obtain any remaining secretions. D. Re-oxygenate the client before attempting to suction again.

Ans: D Rationale Nasotracheal suctioning should not be continued for longer than ten to fifteen seconds, since the client's oxygenation is compromised during this time. Additional suctioning may continue after the client has received oxygen.

An obese adult develops an abscess after abdominal surgery. The wound is healing by secondary intention and requires repacking and redressing every 4 hours. Which diet should the nurse expect the healthcare provider to prescribe to best meet this client's immediate nutritional needs? Low in fat and vitamin D High in calories and fiber Low in residue and bland High in protein and vitamin C

Ans: D Rationale Protein and vitamin C promote wound healing; this is a postoperative priority. Although a low-fat diet is preferred for an obese client, vitamin D, as well as other vitamins, should not be limited. A high-calorie diet can increase obesity, and there is no indication that this client is at risk for constipation requiring a high-fiber diet. A low-residue bland diet can cause constipation; the priority is for nutrients to promote healing.

A client presents to the healthcare facility with abdominal pain. Which question should the nurse ask the client to obtain information about concomitant symptoms? "Can you describe the pain?" "Where exactly do you feel the pain?" "Which activities make the pain worse?" "What other discomfort do you experience?"

Ans: D Rationale Symptoms that accompany the primary symptom of the illness and worsen the health condition are called concomitant symptoms. An example is nausea that may accompany the primary symptom of pain. The nurse assesses the quality of the pain by asking the client to describe it. The nurse gathers information about the location of the illness by asking the client to identify the exact location. The nurse tries to understand the precipitating factors by asking the client about the activities that aggravate the pain.

A nurse is assessing a client's nails and finds a slight convex curve at the angle from the skin to nail base of about 160 degrees. Which condition does the nurse suspect? Clubbing Paronychia Koilonychia Normal finding

Ans: D Rationale The client's nail, which has a slight convex curve at the angle from the skin to nail base of about 160 degrees, is normal. In clubbing, there is a change in the angle between the nail and the nail base that is larger than 180 degrees. Paronychia is the inflammation of the skin at the base of nail. Koilonychia is the concave curves on the nail.

Which statement is true for collaborative problems in a client receiving healthcare? They are the identification of a disease condition. They include problems treated primarily by nurses. They are identified by the primary healthcare provider. They are identified by the nurse during the nursing diagnosis stage.

Ans: D Rationale The nurse assesses the client to gather information to reach diagnostic conclusions. Collaborative problems are identified by the nurse during this process. If the client's health problem requires treatment by other disciplines such as medical or physical therapy, the client has a collaborative problem. A medical diagnosis is the identification of a disease condition. Problems that require treatment by the nurse are referred to as nursing diagnoses. A medical diagnosis is identified by the primary healthcare provider based on the results of diagnostic tests.

A client complains of pain in the ear. While examining the client, a nurse finds swelling in front of the left ear. Which lymph node does the nurse expect to be involved? Mastoid Occipital Submental Pre-auricular

Ans: D Rationale The pre-auricular lymph node is located in front of the ear and in this situation would be edematous. The mastoid or posterior auricular lymph node is present behind the ear. The occipital lymph nodes are located in the back of the head, near the occipital bone of the skull. Submental lymph nodes are located below the chin.

An older client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? A. Massage any reddened areas for at least five minutes. B. Encourage active range of motion exercises on extremities. C. Position the client laterally, prone, and dorsally in sequence. D. Gently lift the client when moving into a desired position.

Ans: D Rationale To avoid shearing forces when repositioning, the client should be lifted gently across a surface. Reddened areas should not be massaged since this may increase the damage to already traumatized skin. To control pain and muscle spasms, active range of motion may be limited on the affected leg.

A nurse is assessing a client's degree of edema and finds 8 mm of depth. How does the nurse document this condition? 1+ 2+ 3+ 4+

Ans: D Rationale Edema of 8 mm is documented as 4+. If the edema has a depth of 2 mm, then it is documented as 1+. If the edema has a depth of 4 mm, it is documented as 2+. If the edema has a depth of 6 mm, then it is documented as 3+.

The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? A. 31 gtt/min. B. 62 gtt/min. C. 93 gtt/min. D. 124 gtt/min.

Ans: D Rationale: Convert lbs to kg: 182/2.2 = 82.73 kg. Determine the dosage for this client: 5 mcg × 82.73 = 413.65 mcg/min. Determine how many mcg are contained in 1 ml: 250/50,000 mcg = 200 mcg per ml. The client is to receive 413.65 mcg/min, and there are 200 mcg/ml; so the client is to receive 2.07ml per minute. With a drip factor of 60 gtt/ml, then 60 × 2.07 = 124.28 gtt/min (D) OR, using dimensional analysis: gtt/min = 60 gtt/ml X 250 ml/50 mg X 1 mg/1,000 mcg X 5 mcg/kg/min X 1 kg/2.2 lbs X 182 lbs.

The nurse observes an unlicensed assistive personnel (UAP) checking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. Which action is most important for the nurse to implement? Tell the UAP to use a larger cuff at the next scheduled assessment. Reassess the client's blood pressure using a larger cuff. Have the unit educator review this procedure with the UAPs. Teach the UAP the correct technique for assessing blood pressure.

Ans:B Rationale An unlicensed assistive personnel (UAP) is using the wrong sized cuff to check a blood pressure. The most important action is to ensure that an accurate blood pressure reading is obtained. The nurse should reassess the blood pressure with the correct size cuff. Reassessment should not be postponed.