HA EAQ Review
Which Korotkoff sound represents the diastolic pressure in children? a) First b) Second c) Fourth d) Fifth
c) Fourth 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.
While assessing a client, the nurse finds bluish coloration of the skin. Which condition would be suspected? a) Anemia b) Liver disease c) Heart disease d) Autoimmune disease
c) Heart disease A bluish discoloration of the skin indicates cyanosis. This condition may be caused by increased amounts of deoxygenated hemoglobin, which may lead in heart disease or lung disease. In clients with anemia, the skin has a pallor due to a reduced amount of oxyhemoglobin. In clients with liver disease, the skin appears yellow or orange due to increased deposits of bilirubin. In autoimmune diseases, the skin will lose its pigmentation.
Which type of breathing pattern is manifested with hypercarbia? a) Eupnea b) Tachypnea c) Hypoventilation d) Kussmaul respiration
c) Hypoventilation Hypercarbia may occur during hypoventilation. The respiratory rate is abnormally low and the depth of ventilation is depressed in hypoventilation
While collecting a client's urine sample, which condition would the nurse suspect if the sample has a strong odor of ammonia? a) Malabsorption b) Bladder cancer c) Diabetic ketoacidosis d) Urinary tract infection
d) Urinary tract infection
Presbyopia definition
decreased accommodative ability of the lens that occurs with aging
Allen test
determining the patency of the radial and ulnar arteries by compressing one artery site and observing return of skin color as evidence of patency of the other artery -- this could be done before cardiac bypass surgery
Pellagra
disease caused by vitamin B3 deficiency seen in chronic alcoholism primary --> due to diets low in niacin and tryptophan secondary --> due to altered absorption seen in alcoholism, chronic GI disorders, cirrhosis, etc
s/sx large bowel obstruction
distesion, nausea, vomiting, cramping pain, high pitched tinkling sounds with gurgling and rushing.
rhonchi can be heard when?
during inspiration and expiration often described as a snoring rattling sound
asking the client to say the letter E several times while the thorax is being auscultated is assessing for?
egophony over consolidated tissue the E will be heard with a nasal quality like a goat's bleating. over healthy tissue it will sound soft like a regular E
Deflating the BP cuff too slowly results in
false high diastolic reading.
Repeated assessments of blood pressure too often result in
false high systolic reading.
Application of the stethoscope too firmly against antecubital fossa will do what to blood pressure?
false low diastolic reading
signs of cocaine withdrawal
fatigue, lethargy, apathy
what is associated with prinzmetal's angina
history of migraine headaches prinzmetal angina is intermittent chest pain caused by coronary artery vasospasms and often have migraines which is another manifestations
s/sx hypoparathyroidism
hyocalcemia -- trousseau sign aka carpal tunnel sign when assessing BP), Chvesok sign (facial twitching while tapping along facial nerve) - tetany (Parkinsonism)
sx of hypermagnesia
hypotension
apraxia
inability to perform particular purposive actions, as a result of brain damage (dementia) --> cannot follow a simple command
apraxia
inability to perform particular purposive actions, as a result of brain damage.
agnosia
inability to recognize objects that are usually familiar
Common causes of vesicles
include herpes, herpes zoster, and dermatitis associated with poison oak or ivy.
TB skin test induration ranges
induration of 10mm and greater is considered positive for healthcare workers, IV drug users, immigrants from high prevalence of countries induration of 5mm and greater considered positive for high risk patients (organ transplant, HIV, cancer, etc)
common sites for TB test (intra-dermal injections)
inner lower arms, upper chest, and back beneath the scapula
rhonchi
loud rumbling sounds heard on auscultation of bronchi indicating obstruction of lower airway
Borborygmi
loud, gurgling bowel sounds signaling increased motility or hyperperistalsis; occurs with early bowel obstruction, gastroenteritis, diarrhea
secondary hypothyroidism
low T3 and T4 and low TSH
important intervention prior to examination of the older adult
lower the exam table!!
The biomedical belief system
maintains that health and illness are related to physical and biochemical processes with disease being a breakdown of the processes.
Macular degeneration
marked by a blurring of central vision caused by progressive degeneration of the center of the retina.
Presentation of Cytomegalovirus
may cause a serious viral infection in persons with human immunodeficiency virus (HIV), resulting in retinal, gastrointestinal, and pulmonary manifestations.
Sumatriptan
medication for migraine headaches --> taken as soon as patient develops a migraine (prn) and should not be taken daily because it does not prevent migraines - Serotonin receptor agonist that can have dangerous effects if used in conjunction with SSRIs or MAOIs.
Positive Brudzinski sign is an indication of?
meningitis
Hallmark sign of varicella-zoster virus or chicken pox
mild fever and pustular rash that crusts over
Function of the thalamus
motor and sensory functions
palpating the liver
move fingertips towards the right costal margin (RUQ) while the client takes deep breathes. smooth soft edge is healthy firm well defined edge = cirrhosis
signs that puberty is being delayed in males
no signs of sexual maturation such as small testicles testicular enlargement is the first sign of puberty
Explain START algorithm for triaging patients during a mass casualty
nurse should triage in order of green, red, yellow, and black "simple triage and rapid treatment"
Hyperthermia
occurs when the body is exposed to temperatures higher than 101.3°F (38.5°C).
Which is expected for ARDS?
oxygen saturation remains low despite increasing oxygen flow rate ARDS is characterized by acute lung injury and severe hypoxemia.
how would lymph nodes present in lymphangitis
pain and edematous lymph nodes
how would lymph nodes present in laignancy
painless, enlarged lymph nodes
palpable, circumscribed area of skin with solid elevation, and a size smaller than 1 cm
papule
acute pericarditis demonstrates which heart sound?
pericardial friction rub
pinpoint red spots on the skin
petechiae commonly seen in platelet disorders
What does red, dry skin indicate (substances)
phencyclidine abuse
metabolic syndrome is also known as
prediabetes client should start exercise program slowly and gradually after receiving clearance from provider. Should plan to exercise at least 150 minutes a week in short intervals
A loss of lens elasticity may lead to...
presbyopia, which causes impaired near vision.
conjunctivitis causes
presence of redness indicates allergic or infectious conjunctivitis
what position should the patient be placed in to aid in palpation of the poplieteal artery?
prone position
s/sx of icteric phase of acute hepatitis
pruritus, jaundice, brown urine
circumscribed elevation of the skin similar to a vesicle but filled with pus and varies in size.
pustule
what finding indicates a newborn is dehydrated?
rapid pulse, dry mucus membranes, sunken fontanel, decreased capillary refill, increased breathing frequency, cool/pale skin
signs of heroine withdrawal
rhinorrhea, yawning, insomnia, irritability, panic, diaphoresis, cramps, nausea, vomiting, muscle aches, chills, fever, lacrimation, and diarrhea
2-year-old child has aspirated a penny. where should the nurse expect this coin will be lodged?
right main bronchus! aspirated items are most likely to enter the right main bronchus and/or right lower lobe this is because the left main bronchus is smaller in diameter and slightly angled only larger items would get stuck in the trachea
best site to assess for juandie
sclera
fine crackles
short, high pitched sounds heard at the end of inspiration not cleared by coughing inhaled air colliding with previously deflated airways, which suddenly pop open
best position to assess lateral lung sounds
side-lying position
what organs are found in the LLQ
sigmoid colon, part of the descending colon, left ureter, left ovary
best position to assess posterior lung fields
sitting position while leaning forward or in a side lying position
clients with malnutrition are at risk for?
skin breakdown and poor wound healing nurse should implement interventions to address skin care and skin protection and assess skin daily
hypoactive bowel sounds
slow/sluggish/diminished or absent bowel sounds signal decreased motility as a result of inflammation as seen with peritonitis; from paralytic ileus as following abdominal surgery; or from late bowel obstruction. Also occurs with pneumonia.
what organs are found in the LUQ
stomach, spleen, body of pancreas, left liver lobe
S/sx of IV site infection
there will be findings that include redness, heat, swelling at catheter-skin entry point, and possible purulent drainage.
Presentation of Human papillomavirus
typically manifests as warts on the hands and feet, as well as mucous membrane lesions of the oral, anal, and genital cavities. It may be transmitted without the presence of warts through body fluids, with some forms associated with cancerous and precancerous conditions.
Accidental hypothermia
usually develops gradually and goes unnoticed for several hours. When the skin temperature drops below 95°F (35°C), the client suffers from s/sx: - uncontrolled shivering - memory loss - depression - poor judgment.
What does S3 heart sound indicate
ventricular dysfunction likely due to heart failure (right-sided)
A circumscribed elevation of the skin filled with serous fluid and a lesion size of less than 1 cm
vesicle
What is thrush?
yeast infection of the oral cavity that presents as white patchy plaques on the oral mucosa
Stages of Health Behavior Change in Order
1) Precontemplation 2) Contemplation 3) Preparation 4) Action 5) Maintenance
respiratory rate for infant (0-12 months)
30-60 per minute
Normal oral temperature
36 - 36.8 Celsius
Normal respiratory range for newborns
40 breaths/min
Paleness of the conjunctivae indicates?
Anemia
koilonychias.
Concavely curved nails
Paget Disease
Could be sign of intraductal carcinoma in the breast --> patient would present with flakey, crusty, erythematous skin around the nipple
Where is the reservoir for Gonorrhea
Gonorrhea is contained in the genitourinary tract
purple lesions over the arms, legs, and face are indications of?
Kaposi's sarcoma which is often the presenting symptom of HIV/AIDS
Nail polish and oxygen saturation
Nail polishes interfere with the ability of the oximeter
Dorsalis Pedis pulse
Pulse on the top of the foot lateral to the large tendon of the big toe - to assess circulation in the foot
Skin pigmentation and oxygen saturation
Skin pigmentation will overestimate the saturation.
True or False: apical pulse cannot be palpated on 50% of the population?
True
Scoliosis
abnormal lateral curvature of the spine
LDL
bad cholesterol ---> high levels indicate over nutrition
What are expected sx for pneumonia?
client reports chest pain when breathing and has increased tactile fremitus
Function of the medulla
controls heartbeat and breathing
tenting of the skin is seen in?
dehydration
An obstruction of the aqueous humor outflow can lead to...
glaucoma!
Eupnea means:
he normal rate and depth of respiration are interrupted while singing.
Where is the reservoir for Herpes
saliva
are absent bowel sounds expected after an abdominal surger?
yes
sinemet medication?
• Carbidopa/levodopa • First-line treatment for Parkinson's Disease • Common side effects: nausea, anorexia, dysgeusia
Increased AP diameter
"barrel chest" 1:1 emphysema, COPD, cystic fibrosis
low pitched crackles
"coarse" crackles often heard with pneumonia
Brachial pulse
- assess status of circulation or lower arm - auscultate BP
Cluster headahce s/sx
- bouts of frequent headache attacks known as clusters, that may last from weeks to months during remission, headaches may stop for months to years - common sx: ptsosis, small pupils, watery eyes, agitation, flushing, sweating, runny nose
s/sx of pancreatitis
- flatulence - dull skin, brittle nails, hair loss - recurrent epigastric pain that radiates to the left lumbar region
expected finding of pneumothorax
- hyper-resonance of affected side - NO rales - diminished breath sounds on affected side - tracheal displacement to opposite side
Classic triad of mononucleosis
- low grade fever - cervical lymphadenopathy - pharyngitis --> want to inspect throat and oral cavity
symptoms of sleep deprivation?
-Fatigue, headache, nausea, increased sensitivity to pain, decreased neuromuscular coordination, irritability, and difficulty concentrating also slurred speech, flat facial affect, red conjunctiva
Which is the correct order of steps of the nursing diagnostic process?
1) Assess the client's health status. 2) Look for defining characteristics. 3) Identify the client's needs. 4) Cluster data. 5) Validate the data with other sources. 6) Interpret the meaning of the data. 7) Formulate nursing diagnoses.
Hierarchy of Needs
1) physiological needs 2) safety and security 3) love and belonging 4) self-esteem 5) self-actualization
Arrange the steps of the bimanual deep palpation technique in the correct sequence. Place the sensing hand on the skin Relax the sensing hand Apply pressure on the sensing hand Place the active hand on the sensing hand Depress the area to be examined to 2 inches
1. Place the active hand on the sensing hand 2. Relax the sensing hand 3. Place the sensing hand on the skin 4. Apply pressure on the sensing hand 5. Depress the area to be examined to 2 inches
Which would be a normal blood pressure of a 12-year-old client? 95/65 mm Hg 105/65 mm Hg 110/65 mm Hg 119/75 mm Hg
110/65 mm Hg - 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.
Hgb A1c of 7% likely has blood glucose reading around?
155
heat should not be used to treat a soft tissue injury for at least ________ hours after injury.
24
normal respiratory rate for a toddler
24-40 per minute
Normal respiratory range for a toddler
25-32 breaths per min
Normal rectal temperature
36.6 - 37.2. Celsius
Normal respiratory range for infants
50 breaths/min
When assessing a patient for malnutrition, the nurse would monitor for an increase in liver enzymes and a decrease in which water-soluble vitamin? Select all that apply. Biotin Niacin Folic acid Riboflavin Vitamin C
ALL!
adventitious breath sounds
Abnormal breath sounds such as wheezing, stridor, rhonchi, and crackles. general term
Phlebitis (Def, s/sx)
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.
The nurse applies the nursing process while caring for clients. Which is the correct order of steps of the nursing process? Assessment Implementation Evaluation Planning Diagnosis
Assessment Diagnosis Planning Implementation Evaluation
While assessing the pupils of a client, a health care professional notices pupillary dilatation. Which drug would have resulted in this condition? Heroin Atropine Morphine Pilocarpine
Atropine (eye medication) Heroin, morphine, and pilocarpine cause pupillary constriction.
loss of sensation over the lower extremities can be signs of what deficiency?
B12/folate
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
Cranial nerve XI Cranial nerve XI (the spinal accessory nerve) is the motor nerve that coordinates the movement of head and shoulders.
screening for over age of 65
DEXA scan for osteoporosis screening
pre-contemplation phase
Denial, ignorance of the problem
Which physical assessment of the skin indicated chronic abuse of sedative hypnotics.
Diaphoresis
hairy white plaques on lateral side of tongue that cannot be scraped away in the setting of concurrent symptoms of recent weight loss, chronic diarrhea, frequents respiratory tract infections ....what disease?
HIV
What is the sitting position used to assess?
Heart, thorax, and lung assessments **this position should be avoided in physically weakened clients**
Where is the reservoir for Hepatitis B
Hepatitis B is contained in the blood.
wheezing
High pitched sound heard in the lungs typically on expiration common in patients with asthma/lung disease
Intermittent fever definition
If the temperature returns to an acceptable value at least once in a 24-hour interval
aphasic
Inability generate or understand language due to damage to the brain. Either inability to create words i.e. expressive aphasia; or inability to understand spoken words i.e. receptive aphasia ex: says apple instead of flower
Intravascular dyes and oxygen saturation
Intravascular dyes will artificially lower the oxygen saturation
Best sites to assess for cyanosis?
Lips and nail beds
what organs are found in the RUQ
Liver, gallbladder, head of pancreas, part of colon, small intestine, duodenum, right kidney
After assessment, the nurse documents auscultation of course rhonchi in the anterior upper lung fields bilaterally that clears with coughing. Which would be the cause of these sounds? a) Parietal pleura rubbing against visceral pleura b) Random, sudden reinflation of groups of alveoli c) Turbulence due to muscular spasm and fluid or mucus in the larger airways d) High-velocity airflow through severely narrowed or an obstructed airway
Loud, low pitched, rumbling coarse sounds heard over the trachea and bronchi are due to turbulence caused by muscular spasm when fluid or mucous is present in the larger airways. Pleural rub produces a dry or grating quality sound, best heard in the lower portion of the anterior lateral lung. Random and sudden reinflation of groups of alveoli produces crackling sounds predominantly heard in the left and right lung bases. High-velocity airflow through severely narrowed or obstructed airways results in a wheezing sound heard all over the lung.
early onset menopause is a risk factor for?
MI
Function of the pons
Maintaining level of consciousness, regulates respiration, swallowing, facial muscle movements
vesicular breath sounds
Normal breath sounds made by air moving in and out of the alveoli. "swishing sounds"
Which food would the nurse recommend to a client when instructing to increase potassium intake? Select all that apply. Onion Celery Orange Cheese Oatmeal
Orange
screening procedures for 60 year old female
PAP smear every 3 years mammography every 2 years
Relapsing type of fever definition
Periods of febrile episodes and periods with acceptable temperature values
splinter hemorrhages
Red or brown linear streaks in the nail bed are caused by minor trauma to nails, subacute endocarditis, and trichinosis.
splinter hemorrhages.
Red or brown linear streaks in the nail bed are caused by minor trauma to nails, subacute endocarditis, or trichinosis
tophi
Small, whitish yellow, hard, nontender nodules in or near contain greasy, chalky material of uric acid crystals and are a sign of GOUT. -- can be seen on the ear
true or false, clients with PVD may experience cramping in the legs with exercise?
TRUE
presence of periorbital edema indicates?
The client may have kidney disease
What is the dorsal recumbent position used to assess?
The dorsal recumbent position is used for an abdominal assessment and to assess the head, neck, and lungs.
What is the supine position used to assess?
The supine position is used to assess the heart, abdomen, extremities, and pulses.
Beau lines.
Transverse depressions in nails indicate a temporary disturbance of nail growth
Beau lines
Transverse depressions in nails indicating a temporary disturbance of nail growth
No toenails in newborns is commonly seen in what disorder?
Turner syndrome
absent of corneal reflex is an abnormality of what cranial nerve?
V -- trigeminal
unable to puff out cheeks is an abnormality of what cranial nerve?
VII -- facial
Which physical assessment of the skin indicates cocaine abuse
Vasculitis
inability to shrug shoulders is an abnormality of what cranial nerve?
XI - accessory
tongue deviating to the left is an abnormality of what cranial nerve?
XII hypoglossal
Cataract
a condition in which the opacity of the lens will be increased; this disorder is commonly related to age.
Hypothermia
a condition in which the skin temperature drops below 96.8°F (36°C)
Cataract definition
a condition involving increased opacity of the lens that blocks light rays from entering the eye.
Contact dermatitis
a delayed immune response that occurs 12 to 48 hours after exposure.
Eczema
a skin condition that can be worsened with excessive drying
Which client is suspected to have an increased risk of hyperlipidemia? Select all that apply. a) Client with corneal arcus b) Client with periorbital edema c) Client with decreased skin turgor d) Client with paleness of conjunctivae e) Client with yellow lipid lesions on eyelids
a) Client with corneal arcus e) Client with yellow lipid lesions on eyelids 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.
A client with a recent history of head trauma is at risk for orthostatic hypotension. Which assessment finding(s) observed by the nurse would relate to this diagnosis? a) Fainting b) Headache c) Weakness d) Lightheadedness e) Shortness of breath
a) Fainting c) Weakness d) Lightheadedness
The nurse is performing a skin assessment of a client. Which findings may indicate a risk of skin cancer? Select all that apply. a) Lesion b) Lumps c) Rashes d) Bruising e) Dryness
a) Lesion b) Lumps c) Rashes
While assessing a client, the nurse finds inflammation of the skin at the bases of the client's nails. Which would be the reason behind this condition? a) Trauma b) Trichinosis c) Pulmonary disease d) Iron-deficiency anemia
a) Trauma 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.
anaboic steroids
acne increased sweat high blood pressure in teens male baldness gynecomastia aggression decreased testicular volume
presbycusis
age related hearing loss (normal finding)
ABCDE
airway/spine, breathing, circulation, disability/neuro, exposure
Tropia
aka eye turn --> generally occurs at birth
Hyperopia
aka farsightedness --> can occur during any developmental level or be congenital.
Myopia
aka nearsightedness --> can occur during any developmental level or be congenital
What do spider angiomas indicate (substances)
alcohol abuse
Cheyne-Stokes breathing
alternating periods of apnea and deep/rapid breathing
Anaphylactic shock
an immediate allergic reaction that occurs
Presentation of Histoplasmosis
an infection caused by inhalation of spores of the fungus Histoplasma capsulatum and is characterized by fever, malaise, cough, and lymphadenopathy.
Pulse deficit
apical pulse - radial pulse
how to assess for hernia
ask the client to strain while holding his breath client will also complain of mild aching pain and occasional swelling in the groin area
Femoral pulse
assess character of pulse during shock or cardiac arrest
Which clients suffer from impaired near vision? Select all that apply. a) A client with myopia b) A client with presbyopia c) A client with hyperopia d) A client with retinopathy e) A client with macular degeneration
b) A client with presbyopia c) A client with hyperopia A loss of elasticity of the lens causes impaired near vision in presbyopia. Light rays focusing behind the retina are the cause of impaired near vision in clients with hyperopia. Myopia is caused by a refractive error where the light rays focus in front of the retina. Retinopathy is a noninflammatory change in the retinal blood vessels. Macular degeneration is a blurring of central vision caused by progressive degeneration of the central retina.
While assessing a client, the nurse finds that the ratio of the anteroposterior diameter and transverse diameter of the chest is 1:1. Which is indicated by this finding? Select all that apply. a) Client has lordosis. b) Client is an older adult. c) Client has osteoporosis. d) Client has a history of smoking. e) Client has chronic lung disease.
b) Client is an older adult. d) Client has a history of smoking. e) Client has chronic lung disease. seen in COPD, emphysema, cystic fibrosis
During a survey, the community nurse meets a client who has not visited a gynecologist after the birth of her second child. The client says that her mother or sister never had annual gynecologic examinations. Which factor is influencing the client's health practice? a) Spiritual belief b) Family practices c) Emotional factors d) Cultural background
b) Family practices
While assessing the muscle tone of a client, the client demonstrates a full range of muscle motion against gravity with some resistance. Which score on the Lovett scale would be given to this client? a) Fair (F) b) Good (G) c) Trace (T) d) Normal (N)
b) Good (G) N (normal) = full range of motion against gravity with full resistance. G (good) = full range of motion against gravity with some resistance F (fair) = full range of motion with no resistance. T T (trace) = slight contractility with no movement.
The nurse is assessing an 89-year-old client with a history of severe congenital spinal deformity. Which condition would describe the nurse's finding? a) Lordosis b) Kyphosis c) Presbycusis d) Osteoporosis
b) Kyphosis
delayed onset of menopause is a risk factor for what disease?
breast cancer!
diaphragmatic breathing
breathing with the use of the diaphragm to achieve maximum inhalation and slow respiratory rate. abdomen expands on inhalation can be used to relieve anxiety
when asking a client to repeatedly state the number 99, what is the nurse assessing?
bronchophony client's voice will be heard clearly over areas of consolidation (abscess, pleural effusion, or pna). It is BARELY AUDIBLE over areas of HEALTHY lung tissue
Which physical assessment of the skin indicates alcohol abuse
burns on the skin
While assessing a client who experienced an accident, the nurse found that the client is unable to move the eyeballs laterally. Which nerve damage led to this condition in the client? a) Optic nerve b) Facial nerve c) Abducens nerve d) Oculomotor nerve
c) Abducens nerve 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.
The nurse recognizes that a common conflict experienced by older adults is the conflict between which? a) Youth and old age b) Retirement and work c) Independence and dependence d) Wishing to die and wishing to live
c) Independence and dependence
While auscultating the heart, a health care provider notices S 3 heart sounds in four clients. Which client is at highest risk for heart failure? a) Child client b) Pregnant client c) Older adult client d) Young adult client
c) Older adult client The S 3 is the third heart sound heard after the normal "lub-dub." It is indicative of congestive heart failure in adults over 30 years old. In young, pregnant, and under 30-year-old clients, the third heart sound is often considered to be a normal parameter.
When teaching about aging, the nurse explains that older adults usually have which characteristic? a) Inflexible attitudes b) Periods of confusion c) Slower reaction times d) Some senile dementia
c) Slower reaction times A decrease in neuromuscular function slows reaction time. The ability to be flexible has less to do with age than with character. Confusion is not necessarily a process of aging, but it occurs for various reasons such as multiple stresses, perceptual changes, or medication side effects. Most older adults do not have organic mental disease.
R-to-R interval
can be used to calculate heart rate place 60 over R-toR interval and dividing
hallmark signs of whooping cough
cough with extreme fatigue
stabismus
cross-eyed / lazy eyed best assessed with cover/uncover eye test
koilonychia.
curvature of nails "spoon shapped" caused by conditions such as iron-deficiency anemia and syphilis
A registered nurse (RN) is teaching a nursing student how to assess for edema. Which statement made by the student is incorrect? a) "Edema results in the separation of skin from pigmented and vascular tissue." b) "Pitting edema leaves an indentation on the site of application of pressure." c) "Trauma or impaired venous return should be suspected in clients with edema." d) "If the pressure on an edematous site leaves an indentation of 2 mm, a score of 2+ is given."
d) "If the pressure on an edematous site leaves an indentation of 2 mm, a score of 2+ is given." 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. A 3+ score is given if the depth of edema is 6mm A 4+ score is given if the depth of edema is 8mm 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 leaves an indentation for some time. Edema results from a direct trauma to the tissue or by impaired venous return.
An 82-year-old retired schoolteacher is admitted to a nursing home. During the physical assessment, the nurse would identify which ocular problem common to persons at this client's developmental level? a) Tropia b) Myopia c) Hyperopia d) Presbyopia
d) Presbyopia
s/sx of perforated tympanic membrane?
decreased hearing, tinnitus, dizziness/vertigo, bleeding from ear - pain may also suddenly and quickly resolved after perforation due to decreased pressure
pursed lip breathing function
decreases air trapping in the lungs - often seen with asthma/COPD patients that are short of breath
Formula for Celsius to Farenheit
degrees celsius x 1.8 +32
yin/yang belief system
does not consider illness as a punishment.
24 hour recall
does not give an accurate assessment of nutrition given patient's may omit information or recall incorrectly
Diploplia
double vision
upward slant eyes is commonly seen in what disorder?
down syndrome -- common chromosomal disorder in the setting of trisomy 21
s/sx of hypothyroidism
dry skin hair loss slow heart rate cold extremities cold intolerance
s/sx of eczema
dry, cracked, scaly skin often of the extremities
what is heard when percussing a solid organ?
dullness (liver, spleen, heart)
popping in the ear is a sign of ??
eustachian tubes collapsing
Lordosis
excessive inward curvature of the lumbar part of the spine
Kyphosis
excessive outward curvature of the spine that causes hunching of the back
IV drug abuse would be explored to assess risk of ??
exposure to blood-borne pathogens such as Hepatitis B.
hallmark s/sx of erythema infectiosum
fiery red, edematous cheeks and runny nose "slapped cheek" appearance typically presents before erythematous rash develops on the trunk and extremities. Many also have non-specific symptoms like runny nose, headache, poor appetite, or mild fever
Macule
flat, nonpalpable change in skin color that is smaller than 1 cm.
how to assess for developmental dysplasia of the hip in a newborn
flex the hips to 90 degrees. Gently adduct the thighs to midline while applying downward and lateral pressure
The belief of determinism
focuses on outcomes that are externally preordained and cannot be changed.
expressive aphasia effects which lobe (context of stroke)
frontal lobe
what food does simvastatin interact with
grapefruit juice is an inhibitor of p450 drug metabolism machinery in the liver and prevents breakdown of certain drugs. This results in increased drug activity. High levels of simvastatin can cause muscle pains and muscle breakdown
clients with obstruction are at risk for developing ?
hypovolemic shock due to nausea subsequent reduced intake, vomiting, and shift of fluid from circulation to the bowel
s/sx of hypertensive retinopathy
in the setting of dx of HTN: headache, scleral edema, blurred vision --> signs of damage to retinal vasculature as result of poorly controlled HTN diagnosis of hypertensive retinopathy requires funduscopic examination so nurse should identify the MD
anormia
inability to name an object
Heat Exhaustion Indications?
indicated by fluid volume deficient. Heat exhaustion occurs when profuse diaphoresis results in excess water and electrolyte loss.
orchitis
inflammation of one or both testes caused by bacterial pathogen. Symptoms include fever, chills, malaise, lower abd pain, followed by rapid testicular swelling, induration, and apin. would need to ask about vaccination history as orchitis can develop in males unvaccinated against MMR. would also need to ask about sexual history as gonorrhea is the most common cause of orchitis ages 16-35 need to ask about recent tenderness/swelling over bilateral cheeks --> could be an early sign
Paronychia
inflammation of skin at the base of nail
involuntary hand shaking when reaching for an item can be defined as ?
intention tremor
s/sx PAD
intermittent claudication thin atrophic skin with absent hair absence of pedal pulses hypertrophic toenails
craving for ice cream, clay, and dirt
iron deficiency --> known as PICA
glossitis, fatigue, feeling cold, and upward curved fingernails are signs of??
iron deficiency and possibly anemia
which nutrient deficiencies can cause anemia
iron, vitamin B9, vitamin B12, vitamin E
where is the sigmoid colon located within the abdomen
left iliac region
where is the point of maximum impulse palpated?
left mid-clavicular line 5th intercostal space aka the apical pulse
central vision of 20/200 with corrective lenses would indicate?
legally blind
hallmark signs of hand-foot-and-mouth disease
lesions on the soles of feet, palms, and oral cavity
Injury to the oculomotor nerve causes...
limits the extraocular movements and pupillary responses.
wheal
localized edema, usually caused by a mosquito bite. Wheals are irregular in shape and have elevated surfaces.
s/sx vitamin C deficiency
loose teeth, swollen purple gums, petechiae on the skin, dry brittle air that curls like a corkscrew
Injury to the facial nerve causes...
loss of facial expressions and loss of taste perception from the anterior third of the tongue.
sarcopenia
loss of muscle mass, strength, and function common finding in older adults
primary hypothyroidism lab value
low T3 and T4 and high TSH
The progressive degeneration of the center of the retina indicates...
macular degeneration! And leads to blurred central vision
how to assess for medial nerve function s/p carpal tunnel release surgery?
make the OK sign
interventions to manage residual limb edema
muscle strengthening wrapping limb in elastic bandage NOT: - elevated limb first few weeks after surgery - assessing for redness, swelling, warmth - applying sequential compression hose
s/sx heroin withdrawal?
nausea, vomiting, cramping, rhinorrhea, diarrhea
ptosis and webbed fingers in newborns are commonly seen in what disorder?
newborns with genetic defect of trisomy 18
elevated solid mass, deeper and firmer than a papule, and 1 to 2 cm in diameter
nodule
knee chest position is used to assess
rectal exam
Sims position is used to assess
rectum and vagina
Which physical assessment of the skin indicates that a client is addicted to phencyclidine?
red and dry skin
Tachypnea is:
respiration greater than 24 per minute
Friction rub in the abdomen
rough, grating sound caused by the rubbing together or organs or an organ rubbing on the peritoneum
stridor
strained, high-pitched sound heard on inspiration caused by obstruction in the pharynx or larynx (upper airway) EAQ example: a child swallows a button
where should tip of catheter be for left subclavian central venous catheter?
superior vena cava
best position to assess anterior lung fields
supine and in low-fowlers
Abdominal bruit
swish, swish pulsating blowing sound in the abdominal region
s/sx of dermatofibroma
tan colored hard nodule 0.6mm in size that is freely moveable over the underlying tissue and dimples when pinched usually results after a bug bite
involuntary mouth and tongue movements are associated with what condition?
tardive dyskinesia
which lobe of the brain involves auditory perception
temporal lobe
Allen test
test that determines the patency of the radial and ulnar arteries by compressing one artery site and observing return of skin color as evidence of patency of the other artery
toxic vs allergic/bacterial/viral conjunctivitis
toxic is usually caused by chemical or mechanical origin and typically only affects one eye allergic/bacterial/viral affects bilateral eyes
true of false: plural friction rub can be heard in patient's with pneumonia
true
true or false: floaters in the eye are normal signs of aging
true
what are normal abdominal sounds
tympanic
where is the pancreas, transverse colon, and part of small intestine
umbilical region
s/sx of viral vs bacterial rhinosinusitis
viral: - cough and clear nasal discharge - typically resolves spontaneously within 10 days bacterial: - symptoms last longer than 10 days - high fever - purulent nasal discharge - may require abx treatment
damage to parietal lobe results in
visual field deficits because the optic tract travels through the parietal lobe
how would lymph nodes present in bacterial infection that has spread to the axillary lymph nodes
warm and tender lymph nodes
When does frostbite occur?
when the body is exposed to ice-cold temperatures. & the tissue begins to freeze, usually signaled by burning pain and numbness in the affected area
auscultating lung sounds while the client whispers numbers in sequence is assessment of ?
whispered pectoriloquy
s/sx of venous insufficiency
-Stasis dermatitis → inflammatory skin disease, cause brown/red discoloration -Chronic venous stasis ulcers → pooling of venous blood leading to ulcerations, can be incredibly hard to heal b/c blood leaks in surrounding tissue -Edema b/c damage to venous system
Pulses (1+ - 4+)
1+ --> barely palpable 2+ --> normal and expected 3+ --> strong and full 4+ --> bounding
Which physical change would the nurse observe in a client with malnutrition? Select all that apply. Hypotension Dry, dull hair Abdominal edema Delayed wound healing Depletion of muscle mass
ALL!
Arrange the sequence of events occurring during a fever in chronological order. Pyrogens are destroyed. The set point of the hypothalamus is raised. Heat loss responses are initiated. Immune system response is triggered. Body temperature is increased.
Immune system response is triggered. The set point of the hypothalamus is raised. Body temperature is increased. Pyrogens are destroyed. Heat loss responses are initiated.
Which question would the nurse ask a client who has developed pneumonia when assessing risk factors? a) "Are you diabetic?" b) "Have you traveled recently?" c) "What do you use for contraception?" d) "Do you have a history of intravenous [IV] drug abuse?"
a) "Are you diabetic?" Chronic diseases such as diabetes are a risk factor for developing infections such as pneumonia. Travel history inquiry would apply to infections such as malaria. Contraception would be explored in sexual barrier devices for sexually transmitted infections.
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 would include which question when completing the initial assessment? a) "Does walking for long periods of time increase your pain?" b) "Does standing without moving decrease your pain?" c) "Have you had your potassium level checked recently?" d) "Have you had any broken bones in your lower extremities?"
a) "Does walking for long periods of time increase your pain?" Clients with a medical history of heart disease, hypertension, phlebitis, diabetes, or varicose veins often experience vascular-related complications. The nurse would 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 registered nurse is teaching a nursing student about when a client with high blood pressure would follow up with the primary health care provider. Which statement made by the nursing student indicates effective learning? a) "I will advise a client with a blood pressure of 130/80 mm Hg to follow up in a year." b) "I will advise a client with a blood pressure of 110/70 mm Hg to follow up in a year." c) "I will advise a client with a blood pressure of 150/90 mm Hg to follow up in a month." d) "I will advise a client with a blood pressure of 185/115 mm Hg to follow up in a month."
a) "I will advise a client with a blood pressure of 130/80 mm Hg to follow up in a year." 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 2 years. Clients with stage 1 hypertension have a BP between 140/90 and 159/99 mm Hg. These clients should be rechecked in 2 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 1 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.
A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse would monitor for which initial symptom of fluid overload? a) Crackles in the lungs b) Decreased heart rate c) Decreased blood pressure d) Cyanosis of nailbeds
a) Crackles in the lungs Crackles, or rales, in the lungs are an early sign of pulmonary congestion and edema caused by fluid overload. Clients with fluid overload will usually demonstrate an increased heart rate and increased blood pressure. A decreased heart rate and decreased blood pressure and cyanosis in a client with fluid overload would be very late and fatal signs.
A student nurse is assessing the blood pressure of a client with the client's arm unsupported. Which is the expected error in the obtained reading? a) False high reading b) False low diastolic reading c) False high systolic reading d) False high diastolic reading
a) False high reading If the client's arm is unsupported, or if the arm is below the heart level, the resulting outcome is a false high reading.
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 (40.6°C), orally. Which condition would the nurse suspect in the client? a) Heat stroke b) Heat exhaustion c) Accidental hypothermia d) Malignant hyperthermia
a) Heat stroke Older adults are more at a risk of heat stroke. Symptoms of heat stroke include giddiness, excessive thirst, nausea, and increased body temperature. Clients undergoing diuretic therapy are at risk of heatstroke when exposed to temperatures higher than 104°F (40°C).
Which error will result in false high diastolic readings while measuring a client's blood pressure during a physical examination? a) Inflating the cuff too slowly b) Wrapping the cuff too loosely c) Applying the stethoscope too firmly d) Repeating the assessment too quickly
a) Inflating the cuff too slowly 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.
The nurse is assessing an older adult during a regular checkup. Which finding(s) during the assessment is/are normal? Select all that apply. a) Loss of turgor b) Urinary incontinence c) Decreased night vision d) Decreased mobility of ribs e) Increased sensitivity to odors
a) Loss of turgor c) Decreased night vision d) Decreased mobility of ribs In older adults, the skin loses its turgor or elasticity, and there is fat loss in the extremities. Visual acuity declines with age; therefore decreased night vision is a normal finding in older adults. Decreased mobility of the ribs is found in older adults due to calcification of the costal cartilage. Urinary incontinence is an abnormal finding in older adults. In older adults, diminished sensitivity to odor, not increased sensitivity, is often found.
The nurse is assessing a client with a history of marijuana use. Which long-term effects are associated with marijuana? Select all that apply. a) Lung cancer b) Emphysema c) Heart disease d) Laryngeal disorder e) Stroke f) Chronic nasal irritation
a) Lung cancer b) Emphysema c) Heart disease
Nurses care for clients in a variety of age groups. In which age group is the occurrence of chronic illness the greatest? a) Older adults b) Adolescents c) Young children d) Middle-aged adults
a) Older adults
Which are physiologic symptoms assessed in a client with sleep deprivation? Select all that apply. a) Ptosis and blurred vision b) Agitation and hyperactivity c) Confusion and disorientation d) Increased sensitivity to pain e) Decreased auditory alertness
a) Ptosis and blurred vision e) Decreased auditory alertness Agitation, hyperactivity, confusion, disorientation, and increased sensitivity to pain are psychologic symptoms of sleep deprivation. (??)
Which sites would be safer and less expensive for temperature measurement? Select all that apply. a) Skin b) Oral c) Axilla d) Rectal e) Tympanic membrane
a) Skin c) Axilla The skin and axilla are safe and inexpensive sites of the body for temperature measurement. T 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.
when assessing a two year old client, where do you place the stethoscope to determine if breath sounds are diminished or absent?
a) apex of the lungs To identify absent or diminished breath sounds the nurse should place the stethoscope over the lung apices since the distance between the lungs is the greatest at this area
Fully vaccinated child that has a cough...what are they likely NOT experiencing sx from? a) pertussis b) croup c) RSV virus
a) pertussis 1-year-old child has received the DPT vaccine that consists of Diphtheria, pertussis, and tetanus. croup is often caused by human parainfluenza virus which there are no vaccines for RSV vaccine is not part of regular immunization programs/requirements. Only provided to children in high risk groups adenovirus is a common cause of upper respiratory symptoms and there is no vaccine for this in standard immunization
Which actions by the nurse help set the stage for a client-centered interview? Select all that apply. a) Close the door after entering the room. b) Greet the client using his or her last name. c) Open the curtains to allow plenty of light in the room. d) Introduce oneself with a smile and explain the reason for the visit. e) Obtain an authorization from the client after the interview.
a, b, d
Which are the benefits of using standard formal nursing diagnostic statements? Select all that apply. a) Fosters development of nursing knowledge b) Allows nurses to communicate with the client c) Provides precise definition of the client's problem d) Distinguishes the nurse's role from that of other care providers e) Enables the primary health care provider to deliver effective health care
a, c, d 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 health care 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 health care professionals and the public. A nursing diagnosis helps the nurse focus on the scope of nursing practice and to deliver effective health care.
A client suffers hypoxia and a resultant increase in deoxygenated hemoglobin in the blood. Which is/are the best site(s) to assess this condition? Select all that apply. a) Lips b) Sclera c) Mouth d) Sacrum e) Nail beds f) Shoulders
a, c, e
Hypersensitivity
an immediate allergic reaction that occurs due to chemicals that are used to make gloves
fatigue, shortness of breath on exertion, pale mucus membranes, cool white extremities, and rapid pulse are all signs of ?
anemia
what organs are found in the RLQ
appendix, cecum, right ovary, right ureter
An older adult is found to have a thin white ring around the margin of the iris. Which condition would this suggest? a) Cataract b) Arcus senilis c) Conjunctivitis d) Macular degeneration
b) Arcus senilis In older adults, the iris becomes faded and a thin white ring (known as arcus senilis) appears around the margin of the iris.
The student nurse prepares a concept map while caring for a client. Which would be the first step that the student nurse would take when preparing the concept map? a) Assess the client and gather information. b) Arrange cues into clusters that form patterns. c) Identify patterns reflecting the client's problem. d) Identify specific nursing diagnoses for the client.
b) Arrange cues into clusters that form patterns. 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.
Which factor would elevate the oxygen saturation during an assessment? a) Nail polishes b) Carbon monoxide c) Intravascular dyes d) Skin pigmentation
b) Carbon monoxide Carbon monoxide artificially elevates the oxygen saturation during assessment.
While performing a physical assessment of a female client, the nurse notices hair on the client's upper lip, chin, and cheeks. Which condition may result in this condition? a) Aging b) Poor nutrition c) Endocrine disease d) Arterial insufficiency
c) Endocrine disease 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.
The nurse is gathering a client's health history. Which information would the nurse classify as biographical information? Select all that apply. a) Symptoms b) Client's age c) Family structure d) Type of insurance e) Occupation status
b) Client's age d) Type of insurance e) Occupation status Biographical information is factual demographic data about the client usually obtained by the admitting office staff. The client's age, types of insurance, and occupation status are considered biographical information. If the client presents with an illness, the nurse gathers details about the symptoms of the illness, which is descriptive information, not biographical information. The nurse obtains information about family structure while assessing the family history of the client. It is not biographical information.
Which clinical finding would the nurse anticipate when admitting a client with an extracellular fluid volume excess? a) Rapid, thready pulse b) Distended jugular veins c) Elevated hematocrit level d) Increased serum sodium level
b) Distended jugular veins 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.
When would the nurse observe the client to assess his or her level of functioning? Select all that apply. b) During mealtime c) When talking about pain d) When preparing medication e) During the assessment interview f) When administering insulin injections
b) During mealtime d) When preparing medication f) When administering insulin injections An observation of the functional level of the client often occurs during a return demonstration. The nurse may also observe the client while the client is 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.
After an eye assessment, the nurse finds that both of the client's eyes are not focusing on an object simultaneously and appear crossed. Which could be the cause for this condition? a) Loss of elasticity of the lens b) Impairment of the extraocular muscles c) Obstruction of the aqueous humor outflow d) Progressive degeneration of the center of the retina
b) Impairment of the extraocular muscles Strabismus is a condition where the eyes appear crossed; this condition is caused by the impairment of the extraocular muscles. A loss of lens elasticity may lead to presbyopia, which causes impaired near vision. An obstruction of the aqueous humor outflow may lead to glaucoma. The progressive degeneration of the center of the retina indicates macular degeneration and leads to blurred central vision.
The nurse is teaching a health awareness class. Which situation would the nurse teach as being the highest risk factor for the development of a deep vein thrombosis (DVT)? a) Pregnancy b) Inactivity c) Aerobic exercise d) Tight clothing
b) Inactivity
While assessing a client, the nurse finds adventitious breath sounds. Upon further evaluation, the nurse finds loud, low-pitched, rumbling coarse sounds during inspiration. This sound can be clearly heard while the client is coughing. Which could be the reason behind these sounds? a) Inflammation of the pleura b) Muscular spasms in the larger airways c) Sudden reinflation of groups of alveoli d) High velocity airflow through an obstructed airway
b) Muscular spasms in the larger airways Adventitious breathing sounds (rhonchi) can be heard when there are loud, low-pitched, rumbling, and coarse sounds during inspiration. These sounds can also be clearly heard while the client is coughing. Rhonchi may be caused by muscular spasms in the larger airways. Inflammation of the pleura may lead to a pleural friction rub sound. A crackling sound can be heard when there is a reinflation of groups of alveoli. In case of high-velocity airflow through an obstructed airway, wheezes or sibilant wheeze sounds may be heard.
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? a) Axilla b) Oral cavity c) Temporal artery d) Tympanic membrane
b) Oral cavity 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 position is indicated to assess the musculoskeletal system but is contraindicated in clients with respiratory difficulties? a) Sims position b) Prone position c) Supine position d) Knee-chest position
b) Prone position
In which situation would the nurse consider family members as the primary source of information? Select all that apply. a) The client is an older adult. b) The client is an infant or child. c) The client is brought in as an emergency. d) The client is critically ill and disoriented. e) The client visits the outpatient department.
b) The client is an infant or child. c) The client is brought in as an emergency. d) The client is critically ill and disoriented.
A client experiencing chills and fever is admitted to the hospital. After assessing the client's vitals and medical history, the nurse concludes that the client's fever pattern is remittent. Which assessment finding led to this conclusion? a) The client's temperature returns to an acceptable value at least once in the past 24 hours. b) The client's fever spikes and falls without a return to normal temperature levels. c) Periods of febrile episodes and periods with acceptable temperature values occur. d) The client has a constant body temperature continuously above 100.4°F (38°C) with minimal fluctuation.
b) The client's fever spikes and falls without a return to normal temperature levels.
Which finding during assessment prompts the nurse to don a protective gown? a) Open sore b) Abrasions of the skin c) Excessive wound drainage d) Productive, moist coughing
c) Excessive wound drainage An open sore and abrasions to the skin should be approached with gloved hands. A moist, productive cough should prompt the nurse to provide a mask to the client.
Which factors would cause the nurse identify an illness as chronic? Select all that apply. a) The illness is reversible and often severe. b) The illness persists for longer than 6 months. c) The client may develop a life-threatening relapse. d) The symptoms are intense and appear abruptly. e) The illness affects the functioning of one or more systems.
b) The illness persists for longer than 6 months. c) The client may develop a life-threatening relapse. e) The illness affects the functioning of one or more systems. A chronic illness usually lasts longer than 6 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 caring for a client with diarrhea. The nurse anticipates a decrease in which clinical indicator? a) Pulse rate b) Tissue turgor c) Specific gravity d) Body temperature
b) Tissue turgor ---> dehydration! 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.
what should the nurse expect when assessing the hip for Legg-Calve-Perthes disease?
b) gaurding condition that affects boys between 4 and 8 years old
best method for evaluation for residual urine
bladder scan
PUD s/sx and lab values
bloating, burning/gnawing pain in the upper and middle abdomen which may immediately worsen after meals or 2-3 hours. pain awakening in the middle of the night is also common as is heartburn, nausea, vomiting, intolerance of spicy foods, tarry stools. Low hemoglobin and hematocrit are seen with PUD also
s/sx of hypertensive crisis
blurry vision, nausea, recent headaches BP > 180 systolic and >120 diastolic are expected before symptoms occur
Sustained fever definition
body temperature is constantly above 100.4°F (38°C) and has little fluctuation.
Function of hypothalamus
body temperature, sleep, appetite, emotions, control of the pituitary gland
manifestations of low phosphorus levels
bone pain, confusion, joint stiffness, intention tremor
A client is diagnosed with acquired immunodeficiency syndrome (AIDS). When examining the client's oral cavity, the nurse assesses white patchy plaques on the mucosa. The nurse recognizes that this finding most likely represents which opportunistic infection? a) Cytomegalovirus b) Histoplasmosis c) Candida albicans d) Human papillomavirus
c) Candida albicans White patchy plaques on the oral mucosa would most likely be a result of C. albicans, a yeast-like fungal infection. This condition is also known as " thrush."
A client presents with hearing loss in the right ear. When the nurse performs a Weber test with a tuning fork, the client hears the sound better with the right ear. Which condition would the nurse suspect from these results? a) Normal hearing b) Mixed hearing loss c) Conduction hearing loss d) Sensorineural hearing loss
c) Conduction hearing loss During a Weber test, conduction hearing loss often causes the tuning fork to be heard better and more clearly in the impaired ear. People with sensorineural hearing loss will hear the sound better in the normal (in this case the left) ear. Mixed hearing loss is a combination of both conduction and sensorineural hearing loss and would not result in the findings observed with the Weber test.
While assessing the eyes of a client, a health care provider notices there is an obstruction to the outflow of aqueous humor. Which additional finding would be noted to support a diagnosis of glaucoma? a) Blurred central vision b) Increased opacity of the lens c) Elevated intraocular pressure d) Changes in retinal blood vessels
c) Elevated intraocular pressure
The nurse is preparing to teach a community health program for senior citizens. Which physical findings would the nurse include that are typical in older adults? a) Increased skin elasticity and an increase in testosterone production b) Impaired fat digestion and an increase in pepsin production c) Increased blood pressure and decreased cardiac output d) An increase in body warmth and some swallowing difficulties
c) Increased blood pressure and decreased cardiac output With aging, narrowing of the arteries causes some increase in the systolic and diastolic blood pressures. Decreases occur in diastolic pressure, diastolic filling, and beta-adrenergic stimulation; increases occur in arterial pressure, systolic pressure, wave velocity, and left ventricular end diastolic pressure. Decreased cardiac output and cardiac reserve decrease the older adult's response to stress.
The nurse is caring for a client who underwent cardiac catheterization. The client's skin was found to be cool, tender to touch, with edema of 15.2 cm (1-6 inches) at the site of catheterization. Which condition would the nurse suspect? a) Phlebitis b) Infection c) Infiltration d) Circulatory overload
c) Infiltration 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.
A pregnant woman in her second trimester arrived at the hospital for a general health checkup for a pelvic examination. Which position is correct for assessing the client in this condition? a) Sims position b) Supine position c) Lithotomy position d) Dorsal recumbent position
c) Lithotomy position Lithotomy position provides maximum exposure to the female genitalia and easy examination of the region; this position is recommended for examining pregnant women. Sims position is indicated for rectal and vaginal examinations.
Which finding is inferred from a grade 4 intensity of heart murmurs? a) Thrill is easily palpable b) Quiet and clearly audible thrill c) Loud murmur associated with thrill d) Moderately loud murmur without thrill
c) Loud murmur associated with 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.
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 dietitian and walking for 45 minutes daily for the past 8 months. Which would the nurse document the client's stage based on the transtheoretical model of health behavior change? a) Action b) Preparation c) Maintenance d) Contemplation
c) Maintenance
Which physical skin finding indicates opioid abuse? a) Diaphoresis b) Red, dry skin c) Needle marks d) Spider angiomas
c) Needle marks
The nurse assesses a client who complains of rapid, involuntary movement of the eyes after a minor eye injury. Which condition would the nurse suspect? a) Cataract b) Glaucoma c) Nystagmus d) Strabismus
c) Nystagmus 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 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? a) Skin b) Axilla c) Oral cavity d) Temporal artery
c) Oral cavity 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, and possibly aspirating the broken pieces. T
The nurse assesses for hypocalcemia in a postoperative client. Which is one of the initial signs that might be present? a) Headache b) Pallor c) Paresthesias d) Blurred vision
c) Paresthesias 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 documents the data gathered during the assessment in a client's medical record. Which would the nurse do to ensure that the data is meaningful to other health care providers? a) Record subjective information in own words. b) Form judgments through written communication. c) Record objective information using accurate terminology. e) Compare data from the physical examination with client behavior.
c) Record objective information using accurate terminology. The nurse would document all objective information using accurate terminology. The nurse would pay attention to the facts and report findings exactly as seen, felt, or smelled. If the information is not specific, another health care provider reading the data gets only general impressions. The nurse would record subjective information in quotations, exactly as described by the client. The nurse would 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.
A registered nurse (RN) is performing a physical examination of a client with chronic obstructive pulmonary disease. Which abnormal nail bed patterns would be expected in this client? a) Spoon-shaped nails b) Transverse depressions in nails c) Softening of nail beds and flat nails d) Red or brown linear streaks in nail bed
c) Softening of nail beds and flat nails 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.
When assessing a client with Hepatitis A, the nurse is particularly careful with which substance to prevent transmission of the disease? 1) Urine b) Saliva c) Blood d) Fecal matter
d) Fecal matter The reservoir for Hepatitis A is fecal matter, so the nurse is particularly careful with any contact with fecal matter to prevent transmission of infection.
The registered nurse (RN) notices reddish linear streaks in the nail bed of the client. Which systemic condition would the RN suspect in the client based on these assessment findings? a) Syphilis b) Iron-deficiency anemia c) Subacute bacterial endocarditis d) Chronic obstructive pulmonary disease
c) Subacute bacterial endocarditis 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.
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? a) The nurse notes nonverbal signs of discomfort. b) The nurse observes the client's position in bed. c) The nurse asks the client to explain the surgery. d) The nurse asks the client to rate the severity of pain.
c) The nurse asks the client to explain the surgery.
Circulatory overload
can occur if intravenous solutions are infused too rapidly or in great amounts.
spoon nails (koilonychia)
caused by nutritional deficiency
Injury to the optic nerve causes...
changes in visual acuity.
Migraine headaches s/sx
characterized by recurrent episodes of severe and often unilateral headaches associated with visual or sensory symptoms (aura). Pain is usually intensified by movement, light, sounds, and may last between 4-72 hours. Can also experience nausea, vomiting, chills, and lightheadedness
The nurse suspects that a client has interacted with poison ivy because assessment findings reveal vesicles on the arms and legs. Which is the description of a vesicle? a) A lesion filled with purulent drainage b) An erosion into the dermis c) A solid mass of fibrous tissue d) A lesion filled with serous fluid
d) A lesion filled with serous fluid A vesicle is a small blisterlike elevation on the skin containing serous fluid. Vesicles are usually transparent. A lesion filled with purulent drainage is known as a pustule, an erosion into the dermis is known as an excoriation or ulcer, and a solid mass of fibrous tissue is known as a papule.
The nurse assesses a client with dry and brittle hair, flaky skin, a beefy-red tongue, and bleeding gums. The nurse recognizes that these clinical manifestations are a result of which? a) A food allergy b) Noncompliance with medications c) Side effects from medications d) A nutritional deficiency
d) A nutritional deficiency
While performing a physical assessment of a client, the nurse notices patchy areas with loss of pigmentation on the skin, hands, and arms. Which is the probable cause for this condition? a) Anemia b) Pregnancy c) Lung disease d) Autoimmune disease
d) Autoimmune disease Patchy areas with loss of pigmentation on skin, hands, and arms are due to vitiligo, which is caused by an autoimmune or congenital disease. Anemia results in pallor due to a reduced amount of oxyhemoglobin. A tan-brown color of the skin is noticed in pregnancy due to an increased amount of melanin. Lung disease or heart failure can cause cyanosis due to an increased amount of deoxygenated hemoglobin.
While assessing a neonate's temperature, the nurse observes a drop in the body temperature. Which would be the reason for this temperature drop? a) Increased basal metabolic rate b) Decreased involuntary shivering c) Increased voluntary movements d) Decreased nonshivering thermogenesis
d) Decreased nonshivering thermogenesis 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.
Which site would be monitored for a pulse to assess the status of circulation to the foot? a) Carotid artery b) Femoral artery c) Popliteal artery d) Dorsalis pedis artery e) Posterior tibial artery
d) Dorsalis pedis artery e) Posterior tibial artery The dorsalis pedis pulse and posterior tibial pulse are sites of assessments of circulation to the foot. The carotid pulse, located along the medial edge of the sternocleidomastoid muscle in the neck, is an easily accessible site to assess physiologic shock or cardiac arrest. The femoral artery pulse and popliteal artery pulses are helpful in assessing the circulation to the lower leg.
While assessing the client's skin, the nurse notices a skin condition. The nurse realizes the pathophysiology involves increased visibility of oxyhemoglobin caused by an increased blood flow due to capillary dilation. Which skin condition is associated with this client? a) Pallor b) Vitiligo c) Cyanosis d) Erythema
d) Erythema 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 complains of difficulty breathing. The nurse auscultates wheezing in the anterior bilateral upper lobes. Which could be the possible reason for this sound? a) Inflammation of the pleura b) Muscular spasms in the larger airways c) Sudden reinflation of groups of alveoli d) High velocity airflow through an obstructed airway
d) High velocity airflow through an obstructed airway Wheezing is a high-pitched sound that may be caused by a high velocity airflow through an obstructed or narrowed airway. Inflammation of the pleura may produce pleural friction rubs. Muscular spasms in larger airways or any new growth causing turbulence may produce rhonchi, which is a loud and low-pitched sound. Sudden reinflation of groups of alveoli may produce crackling sounds.
Which positioning would be avoided while assessing a client with a history of asthma? a) Sitting b) Supine c) Dorsal recumbent d) Lateral recumbent
d) Lateral recumbent The lateral recumbent position is used to assess heart function. A client with asthma or other respiratory problems may not tolerate the lateral recumbent position.
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 is the client communicating? a) Yin/Yang balance b) Biomedical belief c) Determinism belief d) Magicoreligious belief
d) Magicoreligious belief 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.
When preparing to assess a client with active tuberculosis, which piece of protective equipment is necessary for the nurse before entering the client room? a) Isolation gown b) Surgical mask c) Shoe covers d) N95 respiratory mask
d) N95 respiratory mask Active tuberculosis places a client on airborne precautions where the nurse must wear an N95 respiratory mask to prevent personal respiratory exposure to the infectious droplets. An isolation gown, surgical mask, or shoe covers are not necessary protective devices in the assessment of a client with active tuberculosis.
A client with internal bleeding is in the intensive care unit (ICU) for observation. At the change of shift an alarm sounds, indicating a decrease in blood pressure. Which is the correct nursing action? a) Continue the change-of-shift report and include the decrease in blood pressure. b) Lower the diastolic pressure limits on the monitor during the change-of-shift report. c) Turn off the alarm temporarily and alert the oncoming nurse to the decrease in blood pressure. d) Perform an assessment of the client before resuming the change-of-shift report.
d) Perform an assessment of the client before resuming the change-of-shift report.
A client has relocated to a new city for work. The client is unable to continue the practice of walking for 30 minutes daily and exercising 5 days a week. Which stage of the transtheoretical model of health behavior change is the client experiencing? a) Action b) Preparation c) Maintenance d) Precontemplation
d) Precontemplation The client is experiencing a relapse while attempting to make behavioral changes to his or her lifestyle. When relapse occurs, the client returns to the contemplation or precontemplation stage before attempting to change again. The action stage lasts for up to 6 months during which the client is actively engaged in strategies to change behavior. During the preparation stage, the client begins to believe that advantages outweigh disadvantages of behavior change. The maintenance stage begins 6 months after the change has started and continues indefinitely.
Which would the nurse consider the most significant influence on a client's perception of pain when interpreting findings from a pain assessment? a) Age and sex b) Physical and physiological status c) Intelligence and economic status d) Previous experience and cultural values
d) Previous experience and cultural values 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.
The nurse is caring for an unconscious client who underwent head surgery. Which site would be correct to monitor body temperature? a) Skin b) Oral c) Axilla d) Rectal
d) Rectal 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; thus this measurement may not be reliable. The axilla temperature may underestimate the core temperature.
The nurse recognizes which mental process is associated with deterioration that accompanies aging? a) Judgment b) Intelligence c) Creative thinking d) Short-term memory
d) Short-term memory
Where is the nurse positioned when performing a Romberg test? a) Sitting next to the client b) Standing behind the client c) Standing in front of the client d) Standing to the side of the client
d) Standing to the side of the client The nurse would be standing to the side of the client when performing a Romberg test because the client is most likely to sway side to side. Sitting does not safely position the nurse to rescue an unbalanced client. Standing behind or in front of the client is not optimal for safety because the client is most likely to sway side to side.
The nurse is caring for a client who has lost an arm in a motor vehicle accident. Which reaction cues the nurse to realize that the client is in the withdrawal phase of adjusting to the change in body image? a) The client is going through a grieving period. b) The client talks as if another person is affected. c) The client is willing to learn techniques to adapt. d) The client recognizes the reality and becomes anxious.
d) The client recognizes the reality and becomes anxious. The client with a change in body image after 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.
