HA Exam 2

13. A client has presented for care with complaints of persistent lower back pain. When using the mnemonic COLDSPA, which question should the nurse use to evaluate the "P"? A) "What makes it worse?" B) "When did it start?" C) "How does it feel?" D) "How would you rate your pain?"

A) "What makes it worse?"

27. A nurse is assessing an African-American client who has a longstanding diagnosis of hypertension. The nurse should be aware that the client may experience a greater-than- average effect of what medication? A) A diuretic B) An angiotensin-converting enzyme inhibitor C) A calcium channel blocker D) A beta-adrenergic blocker

A) A diuretic

The nurse is performing light palpation of the client's abdomen. How can the nurse best prevent voluntary guarding during this phase of assessment? A) Ask the client to breathe slowly and deeply. B) Perform auscultation prior to palpation. C) Explain the procedure to the client before palpating. D) Position the client sitting upright.

A) Ask the client to breathe slowly and deeply.

4. The nurse notes that an older adult client is wearing multiple layers of clothing on a warm fall day. Which of the following would be the nurse's priority assessment at this time? A) Asking whether the client often feels cold B) Assessing the client's developmental level C) Reviewing the client's culture for possible influence D) Observing the client's overall hygiene

A) Asking whether the client often feels cold

29. During the nurse's assessment of the client's exercise and activity habits, the client laughs and then states, "Unless you're including channel surfing, I don't really do much of anything." How should the nurse best follow up this client's statement? A) Briefly describe some of the potential benefits of regular exercise. B) Ask the client if he understands the risk factors for heart disease and diabetes. C) Explain to the client that he should be performing aerobic exercise for 20 to 30 minutes at least three times a week. D) Document the nursing diagnosis of Risk for Activity Intolerance related to sedentary lifestyle.

A) Briefly describe some of the potential benefits of regular exercise.

9. A nurse provides care in a rural hospital that serves a community that has few minority residents. When interviewing a client from a minority culture, the nurse has enlisted the assistance of a "culture broker." How can this individual best facilitate the client's care? A) By interpreting the client's language and culture B) By evaluating the client's culturally based health practices C) By teaching the client about health care D) By making the client feel comfortable and safe

A) By interpreting the client's language and culture

19. A nurse is creating a genogram of a client's family health history. The nurse should use which of the following symbols to denote the client's female relatives? A) Circle B) Square C) Triangle D) Rectangle

A) Circle

4. A client weighs 106 pounds and is 5 feet 5 inches tall. As a result, her ideal body weight is 120 pounds. After determining the client's percentage of ideal body weight, which of the following should the nurse conclude? A) Client is mildly malnourished. B) Client is experiencing moderate malnutrition. C) Severe malnutrition is present. D) The client's body weight is within 10% of ideal body weight.

A) Client is mildly malnourished.

30. A nurse admits to a colleague, I sometimes tend to avoid clients from other cultures because it's awkward and it's usually frustrating for me and for the client. This nurse is likely lacking in what construct of cultural competency? A) Cultural desire B) Cultural knowledge C) Cultural health D) Cultural harmony

A) Cultural desire

11. An emergency department nurse has utilized the Confusion Assessment Method (CAM) in the assessment of a 79-year-old client with a new onset of urinary incontinence. This assessment tool will allow the nurse to confirm the presence of what health problem? A) Delirium B) Vascular dementia C) Schizophrenia D) Psychosis

A) Delirium

23. During a new client's nutritional assessment, the nurse asks the client's height and usual weight. The client states that he has no idea how much he weighs. How should the nurse respond? A) Do you feel like your weight has increased, decreased, or stayed the same lately? B) Why do you feel that it's not important to monitor your weight? C) In a typical day, what do you eat and drink? D) How would you describe your feelings around your body type and body mass?

A) Do you feel like your weight has increased, decreased, or stayed the same lately?

5. A nurse is assessing a client of East Asian descent. Which biological variation would the nurse expect? A) Dry cerumen in the client's ears B) Profuse perspiration in the client's axillary area C) Strong body odor D) Longer eustachian tubes

A) Dry cerumen in the client's ears

6. The nurse should prioritize assessments related to overhydration for a client experiencing which of the following health problems? A) Early congestive heart failure B) Chronic emphysema C) Newly diagnosed hepatitis C virus infection D) Adult respiratory distress syndrome

A) Early congestive heart failure

11. A male Hispanic client describes the fact that he mixed hot and cold foods, causing them to lump together and get stuck in his intestines, causing diarrhea and abdominal pain. The nurse would document this as which of the following? A) Empacho B) Susto C) Mal ojo D) Mal puesto

A) Empacho

1. A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client database, which of the following actions should the nurse prioritize? A) Establishing a trusting relationship B) Determining the client's strengths C) Identifying potential health problems D) Making clinical inferences

A) Establishing a trusting relationship

21. A nurse's reflection of his practice reveals that he tends to see his own culture as the gold standard to which all other cultures should aspire. This nurse should create learning goals to address what phenomenon? A) Ethnocentrism B) Unconscious incompetence C) Stereotyping D) Acculturation

A) Ethnocentrism

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

A) Examining personal biases and prejudices

A nurse is reviewing the various causes associated with abdominal distention. Which of the following should the nurse identify? Select all that apply. A) Fat B) Stool C) Gas D) Hernia E) Fibroid tumors

A) Fat B) Stool C) Gas E) Fibroid tumors

28. A nurse at a long-term care facility is completing the nutrition assessment of a man who has just moved to the facility. The nurse has lowered the client's arm and observed how long it takes for venous filling, then raised the same arm and watched how long it takes to empty. After determining that venous filling and emptying each take approximately 10 seconds, the nurse should perform further assessments related to what health problem? A) Fluid volume deficit B) Third spacing C) Ascites D) Malnutrition

A) Fluid volume deficit

15. A nurse who provides care on a medical unit utilizes the Alcohol Use Disorders Identification Test (AUDIT) as part of the standard admission protocol. After obtaining a score of 9 from a recently admitted client, the nurse should recognize the possibility of which of the following? A) Hazardous and harmful alcohol use B) Imminent liver disease C) Acute pancreatitis D) Alcoholism

A) Hazardous and harmful alcohol use

13. The nurse analyzes the data obtained from a client's nutritional assessment and develops a health promotion diagnosis related to nutrition for a client. Which of the following would be the best example? A) Health-seeking behaviors related to desire and request to alter amount of food intake B) Imbalanced nutrition: less than body requirements related to inadequate caloric intake C) Imbalanced nutrition: more than body requirements related to excessive caloric intake D) Ineffective thermoregulation related to decreased adaptability to cold secondary to decreased subcutaneous tissue

A) Health-seeking behaviors related to desire and request to alter amount of food intake

11. When evaluating nutrition in an adult female client, which laboratory value would most concern the nurse? A) Hemoglobin A1c of 9% B) Serum albumin of 4.9 g/dL C) Total protein of 6.7 g/dL D) Hematocrit of 39%

A) Hemoglobin A1c of 9%

27. The nurse is assessing an adult client for the presence of Piaget's formal operations stage of development. What assessment question should the nurse ask the client? A) How do you usually go about making difficult decisions? B) Do you consider yourself to be an intelligent person? C) How would you describe your relationship with authority figures? D) In relationships, do you consider yourself to be a 'giver' or a 'taker'?

A) How do you usually go about making difficult decisions?

26. A 21-year-old woman has been admitted to the emergency department following an accident that is suspected of being a suicide attempt. When assessing the client's perceptions, what question should the nurse ask the client? A) How would you describe your health these days? B) Are you able to smell and taste as well as you've been able to in the past? C) If you found a stamped envelope on the street, what would you do? D) Can you tell me the circumstances surrounding your accident?

A) How would you describe your health these days?

25. What statement by a middle-aged adult would most clearly suggest successful achievement of Erikson's central task during this stage of development? A) I'm doing a lot of volunteering in order to give back to the community. B) I've started to exercise more regularly so that I don't put on extra weight. C) I socialize with my coworkers a lot more than I did when I was younger. D) Overall, my marriage is likely stronger than it was when we first got married.

A) I'm doing a lot of volunteering in order to give back to the community.

A nurse determines that the liver span of an older adult male client measures 6 cm. The nurse would interpret this as indicating which of the following? A) It is a normal-sized liver. B) The liver is larger than normal. C) It is a smaller-than-normal liver. D) The liver has atrophied.

A) It is a normal-sized liver.

5. The nurse is applying Piaget's theory of development to a client's health history. This approach to analysis will prioritize what activity on the part of the client? A) Learning B) Imitating C) Indulging D) Desiring

A) Learning

18. A nurse is assessing an Asian client and observes several reddened and bruised areas on the skin. Further assessment reveals that the client was using cupping to treat back pain. The nurse understands this as which of the following? A) Placing heated glass jars on the skin that are allowed to cool B) Rubbing ointment into the skin with a spoon C) Attaching smoldering herbs to acupuncture needles D) Placing warm burning herbs directly on the skin

A) Placing heated glass jars on the skin that are allowed to cool

A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present, and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. The nurse should document which of the following? A) Positive Rovsing's sign B) Psoas sign present C) Obturator sign positive D) Positive skin hypersensitivity test

A) Positive Rovsing's sign

7. A nurse is eliciting a client's health history and the client asks, "Can I take the herb ginkgo biloba with my other medications?" What action would be best if the nurse is unsure of the answer? A) Promise to find out the information for the client. B) Change the subject and return to this topic later. C) Teach the client to only take prescribed medications. D) Encourage the client to ask the pharmacist or primary care provider.

A) Promise to find out the information for the client.

7. The nurse is assessing a client who has been admitted with signs and symptoms that are consistent with malnutrition. Which of the following physiological phenomena would the nurse recognize as an early indicator of malnutrition? A) Protein stores are lower than normal B) Bone is metabolized to compensate for missing nutrients C) Calcium levels decrease D) Hemoglobin levels decrease

A) Protein stores are lower than normal

An adult client states that his mother has been living with peptic ulcer disease, and he is motivated to ensure that he does not develop the disease as he ages. What health promotion advice should the nurse provide? A) Quit smoking as soon as possible. B) Exercise for at least 30 minutes, three times per week. C) Eat several small meals a day rather than three larger meals. D) Attend screening clinics at least twice per year.

A) Quit smoking as soon as possible.

3. The nurse utilizes the Depression Questionnaire on a client who has recently moved to a long-term care facility. The total score is 22. Which of the following would be most appropriate for the nurse to do next? A) Refer for further evaluation. B) Evaluate benefits versus risks of a mental health label. C) Assess further for dementia. D) Document this as a normal score.

A) Refer for further evaluation.

1. Assessment of a client reveals a history of insulin-dependent diabetes mellitus, weight loss, polyuria, poor skin turgor, nausea, loss of appetite, and a blood glucose level measured by finger stick of 348 mg/dL. Which of the following nursing diagnoses would be the nurse's priority? A) Risk for imbalanced fluid volume related to inadequate oral intake and frequent urination B) Imbalanced nutrition: more than body requirements related to diabetes C) Potential complication: hypertension D) Powerlessness related to diabetes self-care and management

A) Risk for imbalanced fluid volume related to inadequate oral intake and frequent urination

30. The nurse is assessing an older adult client's mental status. Consistently, the client pauses after the nurse poses a question, but then the client provides a response that is correct or appropriate. How should the nurse best interpret this characteristic of the client? A) Slight delays in mental processing are normal in older adults. B) The client may be trying to anticipate the nurse's desired response. C) The client is displaying a sign of early Alzheimer's disease. D) The client may be experiencing an early sign of delirium.

A) Slight delays in mental processing are normal in older adults.

4. A nurse states, Hispanic people have no clue about primary prevention of illness. The nurse is demonstrating which of the following? A) Stereotyping B) Ethnicity C) Cultural incompetence D) Prejudice

A) Stereotyping

4. An infant was removed from her home by social services because of the dangerous and neglectful conditions that existed. According to Erikson, failure of the infant to resolve the central crisis of infancy may lead to what personality characteristics later in life? A) Suspicion and fear B) Aggression and antagonism C) Dependency and relational entanglement D) Depression and introversion

A) Suspicion and fear

2. The nurse's assessment reveals that a client is in a low percentile for midarm muscle circumference (MAMC) and a high percentile for triceps skin fold (TSF) thickness. Which of the following would be appropriate? A) Teaching the client muscle-building exercises B) Discussing ways to increase body fat stores C) Assisting client in reducing the amount of fluid build-up D) Encouraging the use of a multivitamin supplement

A) Teaching the client muscle-building exercises

18. What assessment finding would most clearly suggest to the nurse that a young adult client has failed to attain normal development within Piaget's framework? A) The client has difficulty understanding abstract reasoning in written form. B) The client has a recent history of tumultuous interpersonal relationships. C) The client is often defiant toward authority figures. D) The client is unwilling to accept responsibilities in the workplace.

A) The client has difficulty understanding abstract reasoning in written form.

The nurse is assessing the gastrointestinal system of an 81-year-old client. What age- related change should the nurse consider when collecting and analyzing assessment data? A) The client is more vulnerable to impaired nutrition due to decreased appetite. B) The client derives less nutritional value from food because of decreased enzyme production. C) The client's liver will be significantly larger than that of a younger client. D) The client will have greater bowel motility than a younger adult.

A) The client is more vulnerable to impaired nutrition due to decreased appetite.

27. A nurse in the emergency department is utilizing the SAD PERSONAS assessment guide during the mental status assessment of a client. What is the most likely rationale for the nurse's choice of this assessment tool? A) The client may have a high risk for suicide. B) The client may have major depression. C) The client may have schizophrenia or psychosis. D) The client may be using alcohol excessively.

A) The client may have a high risk for suicide.

6. The nurse is analyzing the data obtained from a client interview. When applying the principles of Kohlberg's theory of development, the nurse should prioritize data related to what domain? A) The client's moral behavior B) The client's relationships C) The client's health D) The client's sexual identity

A) The client's moral behavior

8. The nurse is preparing to assess the mental status of a 90-year-old client who is being admitted to the hospital from a long-term care facility. Which of the following should the nurse assess first? A) The client's sensory abilities B) The client's general intelligence C) The presence of any phobias D) The client's judgment and insight

A) The client's sensory abilities

When reviewing the medications currently taken by a 50-year-old client who is complaining of constipation, teaching is indicated when the nurse notes which medication? A) Vitamin supplement with iron B) Nonsteroidal anti-inflammatory drug C) Antidepressant D) Hormone replacement

A) Vitamin supplement with iron

16. The nurse is assessing the diet and nutritional status of a client from a different culture. Which of the following questions would be appropriate for the nurse to ask? Select all that apply. A) What foods do you commonly eat? B) Do you have any special routines for eating? C) Are there any foods that you can't eat? D) Do you eat three meals a day? E) Do you have certain foods to keep you healthy?

A, B, C, E A) What foods do you commonly eat? B) Do you have any special routines for eating? C) Are there any foods that you can't eat? E) Do you have certain foods to keep you healthy?

13. A woman brings her 69-year-old husband to the clinic for an evaluation because he has become increasingly forgetful. Which of the following would lead the nurse to suspect that the client has Alzheimer's disease? Select all that apply. A) He repeats the same story, word for word, over and over again. B) He took a fall when he was replacing a light bulb last month. C) I have to balance the checkbook now because he just won't do it. D) If I don't tell him when to shower, he won't and will fight me on it. E) He got lost walking to the pharmacy around the corner the other day.

A, C, D, E A) He repeats the same story, word for word, over and over again. C) I have to balance the checkbook now because he just won't do it. D) If I don't tell him when to shower, he won't and will fight me on it. E) He got lost walking to the pharmacy around the corner the other day.

26. The nurse is completing a review of systems for a client. Which of the following information would the nurse document related to the client's musculoskeletal system? Select all that apply. A) Joint stiffness B) Rhinorrhea C) Shortness of breath D) Chest pain E) Muscle strength F) Knee swelling

A, E, F A) Joint stiffness E) Muscle strength F) Knee swelling

Normal state of consciousness; awake, responsive, and responds appropriately.

Alert

21. During the interview, the client states, "Is today the 12th? My wife died 2 months ago today." Which of the following responses would be most appropriate? A) "What was the cause of your wife's death?" B) "How does that make you feel right now?" C) "You probably must be sad." D) "Are you feeling sad, depressed, angry, or upset?"

B) "How does that make you feel right now?"

28. A 60-year-old woman with a bunion will undergo surgery later today. The client tells the nurse in the surgical daycare admitting department, "I'm sure I've been asked these questions before. Can't we just focus on my foot and not all these other topics?" How should the nurse best explain the rationale for obtaining a health history? A) "In general, it's necessary for us to gather as much information about each client as possible." B) "We want to make sure your nursing care matches your needs as closely as possible." C) "The care team needs to cross-reference your diagnostic testing with the information that I'm asking you about." D) "We don't want to make the mistake of focusing solely on the medical problem that brought you here."

B) "We want to make sure your nursing care matches your needs as closely as possible."

12. A nurse weighs a client today and finds that the client's weight has increased 2.2 lbs from the previous day. The nurse interprets this finding as suggesting a fluid gain of which amount? A) 0.5 liters B) 1.0 liters C) 1.5 liters D) 2.0 liters

B) 1.0 liters

25. During an initial prenatal visit, the nurse is performing a nutritional assessment of a woman who has just learned that she is pregnant for the first time. The nurse has determined that the client has an average stature and is 5 feet, 3 inches tall. What is this client's ideal body weight? A) 105 lbs. B) 115 lbs. C) 125 lbs. D) 135 lbs.

B) 115 lbs.

21. A nurse is providing care for a client who has hepatic encephalopathy secondary to chronic alcohol abuse. The nurse's assessment reveals that the client often provides incorrect answers to assessment questions. As well, the client makes statements that are not grounded in reality. What nursing diagnosis is suggested by these assessment data? A) Impaired Verbal Communication related to hepatic encephalopathy AMB confusion B) Acute Confusion related to hepatic encephalopathy C) Ineffective Health Maintenance related to alcohol abuse AMB decreased cognition D) Ineffective Coping related to alcohol abuse

B) Acute Confusion related to hepatic encephalopathy

17. The nurse observes a client's entire body posture to be somewhat stiff, with his shoulders elevated upward toward the ears. The nurse would most likely interpret this to indicate that the client is experiencing which of the following? A) Confusion B) Anxiety C) Powerlessness D) Restlessness

B) Anxiety

17. During an assessment, the nurse determines that a client sees more than one primary care provider and has obtained prescriptions from each provider. Which method would be most appropriate to determine a client's current medication regimen? A) Ask the client to identify which medications taken every day. B) Ask the client to bring all the medications and supplements to an interview. C) Ask the caregiver whether the client is taking prescribed medications. D) Ask the client about the use of any over-the-counter medications.

B) Ask the client to bring all the medications and supplements to an interview.

A client's bladder is found to be distended. At which location should the nurse begin palpating? A) At the umbilicus B) At the symphysis pubis C) In the right lower quadrant D) In the left lower quadrant

B) At the symphysis pubis

The nurse is preparing to assess the abdomen of a client who is complaining of abdominal pain. Which statement by the nurse would be most appropriate? A) I'm going to examine the area where you're having pain first to get a better picture of what's going on. B) Before I get ready to examine the painful area, I will let you know in plenty of time. C) You don't need to worry about anything. I will make sure to be very gentle during the exam. D) Since you're having pain in a certain area, I won't have to do a very detailed exam there.

B) Before I get ready to examine the painful area, I will let you know in plenty of time.

1. The nurse is assessing a client's psychosocial development in light of Freud's theory. The nurse would interpret the client's status as the outcome of conflict between what variables? A) Cultural norms and personality traits B) Biological desires and social expectations C) Sexual desires and relational desires D) Sociocultural norms and health needs

B) Biological desires and social expectations

18. A group of students is reviewing information about general assessment indicators of nutritional status. The students demonstrate a need for additional review when they identify which of the following as an indicator of adequate nutritional status? A) Flat, firm abdomen B) Brittle hair C) Pink mucous membranes D) Elastic skin

B) Brittle hair

9. A client's recent episode of becoming lost near his home has prompted the nurse to use the Saint Louis University Mental Status (SLUMS) Assessment Tool. The nurse should begin this assessment by asking what question? A) How would you respond if someone said that you might have dementia? B) Can I ask you some questions about your memory? C) Do you generally consider yourself to be an intelligent person? D) I want to ask you some questions to see if you have Alzheimer's.

B) Can I ask you some questions about your memory?

17. During a nutritional assessment, the client asks the nurse for suggestions to improve her diet. The nurse identifies a nursing diagnosis of health-seeking behaviors related to desire to improve diet. Which of the following suggestions would be most appropriate? A) The majority of your diet should consist of whole grains. B) Choose low-fat versions of milk products such as yogurt. C) Drink at least 2 to 3 glasses of fruit juices a day. D) Eat fewer orange vegetables and more dark green vegetables daily.

B) Choose low-fat versions of milk products such as yogurt.

24. The nurse's assessment suggests that a 10-year-old has failed to achieve Erikson's central task of this stage of development. What nursing diagnosis should most likely be included in the child's plan of care? A) Risk for injury B) Chronic low self-esteem C) Fear D) Disturbed thought processes

B) Chronic low self-esteem

23. A nurse is caring for a 70-year-old client from a different culture whose breast cancer has metastasized. The nurse observes that the client tends to defer responsibility for decision making around treatment options to her eldest son. How should the nurse respond to this? A) Explain the disconnect between the client's practice and the principle of client autonomy. B) Confirm that the client wants her son to make decisions and follow those decisions accordingly. C) Attempt to dialogue with the client when her son is not present. D) Refer the family to social work in order to further explore alternative decision- making practices.

B) Confirm that the client wants her son to make decisions and follow those decisions accordingly.

9. Based on a colleague's feedback, a nurse learns that she is aware of cultural differences in a general way but does not know what the specific differences are or how to communicate with a person of a specific culture. This nurse exhibits which of the following? A) Unconscious incompetence B) Conscious incompetence C) Conscious competence D) Unconscious competence

B) Conscious incompetence

10. A group of students is reviewing material on cultural competence. The students demonstrate understanding of this concept when they identify which of the following as the starting point? A) Cultural awareness B) Cultural desire C) Cultural skill D) Cultural knowledge

B) Cultural desire

The nurse is preparing to assess the size of the client's aorta. The nurse should palpate at which location? A) Midline at the umbilicus B) Deep epigastrium to the left of midline C) Slightly above the suprapubic area D) Between the umbilicus and the symphysis pubis

B) Deep epigastrium to the left of midline

16. A nurse is assessing a client for possible fluid overload. Which of the following assessment findings is most consistent with this diagnosis? A) Venous filling of 3 seconds B) Distended neck veins with head elevated at 45 degrees C) Moist, plump tongue D) Boggy eyeball

B) Distended neck veins with head elevated at 45 degrees

13. The nurse is applying the principles of Freud's theory of psychosocial development during the health assessment of a young adult client. What assessment question is most likely to elicit data that are meaningful within this theoretical framework? A) Do you have a sufficient number of friends? B) Do you have a satisfying sexual relationship? C) How do you feel about your cultural background? D) Do you consider yourself to be a good person?

B) Do you have a satisfying sexual relationship?

A client exhibits many of the most common signs and symptoms of peptic ulcer disease. What interview question addresses the most plausible cause of the client's health problem? A) Do you feel like you're able to adequately address the stress in your life? B) Do you take painkillers like aspirin on a regular basis? C) Do you tend to eat foods that are quite high in fat? D) Are you currently taking vitamin supplements?

B) Do you take painkillers like aspirin on a regular basis?

7. The nurse is working with an older adult client and is attempting to determine whether the client deems her life to have been meaningful and valuable. As well, the nurse has addressed the client's acceptance of the inevitability of death. This nurse's actions are best understood within the ideas of which theorist? A) Freud B) Erikson C) Piaget D) Kohlberg

B) Erikson

20. A client has just been admitted to the postsurgical unit from postanesthetic recovery, and the nurse is in the introductory phase of the client interview. Which of the following activities should the nurse perform first? A) Collaborate with the client to identify problems. B) Explain the purpose of the interview. C) Determine the client's vital signs. D) Obtain family health history data.

B) Explain the purpose of the interview.

7. An African-American woman collapses at the funeral of her mother and later states that she could hear everything people were saying to her but, for a brief period, she could not move. The nurse interprets this as which of the following? A) Spell B) Falling out C) Empacho D) Susto

B) Falling out

29. A school nurse is working with kindergarten students. Within Kohlberg's framework of moral development, the nurse should recognize that these students' moral reasoning is primarily motivated by which of the following? A) An innate conscience B) Fear of the negative consequences of individual actions C) Motivation to exhibit behaviors that are culturally normalized D) Adherence to basic moral beliefs

B) Fear of the negative consequences of individual actions

17. When appraising a young adult's psychosocial development within the framework of Erikson's theory, what question should guide the nurse's data collection and analysis? A) Can the client successfully solve problems? B) Has the client successfully achieved intimacy? C) Has the client learned to trust others? D) Can the client teach life skills to others?

B) Has the client successfully achieved intimacy?

The nurse is percussing a client's liver and is assessing liver descent. The nurse should have the client do which of the following? A) Cough forcefully B) Hold the breath C) Breathe in and out deeply D) Perform the Valsalva maneuver

B) Hold the breath

29. A nurse is relying heavily on gestures and simplified language during the assessment of a client from another culture who speaks minimal English. During the lengthy assessment, the nurse asks the client if she is okay by making a circle with his thumb and forefinger. The nurse should be aware of which of the following? A) In some cultures, this gesture denotes confusion. B) In some cultures, this gesture is offensive. C) This gesture has meaning only in American cultures. D) In some cultures, this gesture denotes pain.

B) In some cultures, this gesture is offensive.

19. Assessment of an older adult client suggests that the client does not possess formal operational thinking. Within Piaget's framework of development, what nursing diagnosis is the most likely consequence of this developmental deficit? A) Spiritual distress B) Ineffective health maintenance C) Ineffective sexuality pattern D) Risk for suicide

B) Ineffective health maintenance

16. A nurse is assessing a client who is exhibiting decorticate posturing. Which of the following would the nurse observe? A) Extended upper extremities B) Internally rotated lower extremities C) Pronated forearms D) Flexed hands at the side of the body

B) Internally rotated lower extremities

3. A nurse educator is leading a group of nurses in exercises aimed at improving cultural competence. Which of the following would the educator use to best describe an aspect of the term culture? A) Transmission occurs to another generation through genetics. B) It is shared through norms for behaviors, values, and beliefs. C) It is adapted to a specific environment. D) It is experienced by all people even without human contact.

B) It is shared through norms for behaviors, values, and beliefs.

30. An obese teenage boy from a culture that values increased body mass has been referred to the clinic. The nurse is assessing him for malnutrition based on his electronic health record and current health complaints. His mother questions the nurse's rationale, stating, Anyone can see he's not malnourished. Just look at the size of him! How should the nurse best respond? A) People sometimes become obese because their bodies are storing up nutrients that they often lack. B) It's actually very possible for a person to be overweight but have inadequate nutrition. C) Assessment for malnutrition is a standard component of a larger nutritional assessment, which is very important for your son's health. D) Actually, there's very little relationship between body mass and nutritional state.

B) It's actually very possible for a person to be overweight but have inadequate nutrition.

19. A nurse educator is reviewing the unit's resources about religious groups and their views about blood and blood products, organ donation, and autopsy. A member of which group is most likely to refuse a blood transfusion? A) Christian Scientists B) Jehovah's Witnesses C) Orthodox Jews D) Roman Catholics

B) Jehovah's Witnesses

20. A nurse asks a client the following question: What do you do if you have pain? The nurse is assessing which of the following aspects of cognitive function? A) Orientation B) Judgment C) Abstract reasoning D) Memory

B) Judgment

7. A nursing student has been assigned to the care of a client whose history suggests the need for a mental status assessment. This client most likely has a history of health problems affecting what body system? A) Respiratory B) Neurologic C) Cardiovascular D) Renal

B) Neurologic

15. A client has been admitted following an unexplained weight loss of 15 pounds over the past 3 months. How should the nurse best assess the subjective component of the client's nutritional status? A) Ask the client to explain MyPlate. B) Obtain a 24-hour diet recall. C) Ask about the contents of one typical meal. D) Elicit the client's favorite foods.

B) Obtain a 24-hour diet recall.

A client has sought care because of chronic constipation. During the health history interview, the nurse should address what potential contributing factor? A) Excessive fat and sugar intake B) Overuse of laxatives C) Obesity D) Inadequate abdominal muscle tone

B) Overuse of laxatives

14. A nurse is modifying an Asian client's diet to accommodate the concept of hot and cold. The nurse demonstrates an understanding of this concept when identifying which of the following as a cold condition? A) Diabetes B) Pneumonia C) Sore throat D) Hypertension

B) Pneumonia

6. A client has presented to the emergency department and is having difficulty describing her vague sensation of physical discomfort and unease. How can the nurse best elicit meaningful assessment data about the nature of the client's complaint? A) Ignore the complaint for now and return to it later in the assessment. B) Provide a laundry list of descriptive words. C) Restate the question using simpler terms. D) Wait in silence until the client can determine the correct words.

B) Provide a laundry list of descriptive words.

Which of the following should a nurse suspect if dullness is percussed at the last left interspace at the anterior axillary line on deep inspiration? A) Hepatomegaly B) Splenomegaly C) Abdominal mass D) Intestinal air

B) Splenomegaly

The nurse is assessing a client who is in liver failure and who has developed ascites. When measuring the client's abdominal girth, the nurse should place the client in which position? A) Sitting B) Standing C) Supine D) Prone

B) Standing

14. The nurse is assessing a young adult client in light of Erikson's theory of psychosocial development. During this life stage, what assessment finding would most clearly suggest a lack of successful development? A) The client is dissatisfied with her current job. B) The client describes herself as lonely and isolated. C) The client has been diagnosed with bipolar disorder. D) The client had a child when she was in her late teens.

B) The client describes herself as lonely and isolated.

24. A clinic nurse is conducting a comprehensive assessment of a 70-year-old male client of Native American ethnicity. The nurse observes that the client rarely makes eye contact and holds his head low during the assessment. How should the nurse best interpret this practice? A) The client may not understand the purpose of the assessment. B) The client may be showing the nurse respect. C) The client may be a victim of intimate partner violence. D) The client may not trust the nurse's expertise.

B) The client may be showing the nurse respect.

29. The nurse is providing care for a client with a history of chronic heart failure. The client is in bed with the head of her bed at 45 degrees, and the nurse is assessing the client's neck veins. What assessment finding would be most consistent with a nursing diagnosis of fluid volume excess related to chronic heart failure? A) The client's carotid arteries are not palpable. B) The client's jugular veins are clearly visible and firm to palpation. C) The client's carotid pulses are asymmetrical and difficult to palpate. D) The client's carotid pulses are easier to palpate than the jugular pulses.

B) The client's jugular veins are clearly visible and firm to palpation.

8. The nurse begins the physical examination of a newly admitted client by assessing the client's mental status. What is the nurse's best rationale for performing the mental status exam early in the assessment? A) The client will be less anxious early, providing the nurse with more accurate and reliable data. B) The exam can provide clues about the validity of the client's responses now and throughout. C) The exam provides data about mental health problems that the client may be afraid to report. D) The client's fears about having a serious illness may be alleviated by the results of the exam.

B) The exam can provide clues about the validity of the client's responses now and throughout.

24. A hospital nurse is performing a nutritional assessment of a 39-year-old obese client who has been recently diagnosed with type 2 diabetes. The nurse has completed the collection of subjective data and is preparing to proceed with objective data collection. Which principle should guide the nurse's subsequent actions? A) There are likely to be inconsistencies between subjective data and objective data. B) The nurse should be aware that the client may find assessment embarrassing. C) The nurse should avoid performing anthropometric measurements due to the client's obesity. D) The assessment should be performed over a series of brief sessions rather than one continuous assessment.

B) The nurse should be aware that the client may find assessment embarrassing.

30. The school nurse has learned that a 14-year-old student is having social difficulties. According to Erikson, what is the most likely source of this child's stress? A) The student is experiencing moral dilemmas. B) The student is having difficulty creating an identity. C) The student is experiencing a sexual crisis. D) The student having difficulty understanding the viewpoints of others.

B) The student is having difficulty creating an identity.

2. A client admits to the nurse that she feels guilty for not providing more direct care for her ill mother. According to Freud, the moral component of this client's feelings results from which of the following? A) Defense mechanisms B) The superego C) The id D) The ego

B) The superego

4. A nurse is interviewing a 22-year-old client of the campus medical clinic. Which nonverbal behavior should the nurse adopt to best facilitate communication during this phase of assessment? A) Standing while the client is seated B) Using a moderate amount of eye contact C) Sitting across the room from the client D) Minimizing facial expressions

B) Using a moderate amount of eye contact

28. A nurse will be working in a clinic in South Asia for several weeks, where the majority of residents have darkly pigmented skin. The nurse should expect a higher-than-average incidence of what integumentary health problem? A) Contact dermatitis B) Vitiligo C) Psoriasis D) Eczema

B) Vitiligo

26. The nurse is assessing an adult client's self-image during the health history interview. What assessment question is most likely to elicit meaningful data? A) What are the activities that give you the most joy? B) What would you describe as your main strengths and weaknesses? C) Do you consider yourself to be a particularly religious person? D) What actions are you taking to improve your life?

B) What would you describe as your main strengths and weaknesses?

1. The nurse is preparing to assess the remote memory of a client who has a diagnosis of early stage Alzheimer's disease. Which question would be most appropriate for the nurse to use? A) Can you tell me what you have eaten in the last 24 hours? B) When did you get your first job? C) What did you do last evening? D) How are an apple and orange the same?

B) When did you get your first job?

2. A nurse is interpreting and validating information from an older adult client who has been experiencing a functional decline. The nurse is in which phase of the interview? A) Introductory B) Working C) Summary D) Closing

B) Working

Which precussion used for CVA?

Blunt Precussion

5. A nurse is providing feedback to a colleague after observing the colleague's interview of a newly admitted client. Which of the following would the nurse identify as an example of a closed-ended question or statement? A) "Tell me about your relationship with your children?" B) "Tell me what you eat in a normal day?" C) "Are you allergic to any medications?" D) "What is your typical day like?"

C) "Are you allergic to any medications?"

16. A client's elevated body mass index (BMI) has prompted the nurse to assess the client's activity and exercise level. Which statement would indicate to the nurse that the client is getting the recommended amount of exercise? A) "I walk briskly on the treadmill once or twice a week." B) "I play basketball with a team every Friday night without fail." C) "I go to a step class for an hour three times a week." D) "I swim for at least half an hour each Saturday morning."

C) "I go to a step class for an hour three times a week."

23. The nurse is obtaining information about a client's past health history. Which client statement would best reflect this component of assessment? A) "My mom's still alive, but my dad died 10 years ago of heart failure." B) "I have a brother with leukemia and a sister with hypertension." C) "I had surgery 5 years ago to repair an inguinal hernia." D) "I have been having some pain when I urinate for the last several days."

C) "I had surgery 5 years ago to repair an inguinal hernia."

14. A medical nurse has completed the review of systems component of the client's health history. Which assessment finding should the nurse document under the review of systems? A) "High school diploma plus 2 years of college" B) "Caregiver reliable source of information" C) "Menarche at age 13" D) "Lungs clear to auscultation bilaterally"

C) "Menarche at age 13"

12. A clinic nurse has reviewed a new client's available health record and will now begin taking the client's health history. Which of the following questions should the nurse ask first when obtaining the health history? A) "Do you have adequate health insurance coverage?" B) "Are you generally fairly healthy?" C) "What is your major health concern at this time?" D) "Did you bring all your medications with you?"

C) "What is your major health concern at this time?"

3. A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy, and the nurse is collecting subjective data prior to surgery. Which statement by the nurse could be construed as judgmental? A) "How often do your adult children typically visit you?" B) "Your husband's death must have been very difficult for you." C) "You must quit smoking because it affects others, not only you." D) "How would you describe your feelings about getting older?"

C) "You must quit smoking because it affects others, not only you."

15. A nurse in the intensive care unit is calculating an acutely ill client's 24-hour fluid balance. The nurse should include insensible fluid losses of what volume when performing this assessment? A) 100 to 300 mL B) 450 to 650 mL C) 800 to 1000 mL D) 1200 to 1400 mL

C) 800 to 1000 mL

29. During the mental status assessment of a new client, the nurse has asked the client to describe some of the similarities and differences between a tennis ball and a soccer ball. Despite adequate time and cuing, the client is unable to state any similarities or differences. The nurse should document what assessment finding? A) A deficit in practical intelligence B) An inability to follow directions accurately C) A deficit in abstract reasoning D) A lack of spatial orientation

C) A deficit in abstract reasoning

The nurse is caring for a client who has been diagnosed with colon cancer. When planning the client's care, the nurse should be aware of what function of the colon? A) Absorbing electrolytes B) Secreting digestive enzymes C) Absorbing large amounts of water D) Secreting bile

C) Absorbing large amounts of water

15. When reviewing cultural differences that relate to the incidence and prevalence of disease among various cultural groups, the nurse would expect to see the highest prevalence of asthma in which group? A) Non-Hispanic blacks B) Caucasians C) African Americans D) Southeast Asians

C) African Americans

2. When assessing the mental status of a 67-year-old woman, the nurse detects some difficulty with free-flow of thought and the woman's ability to follow directions. Which of the following would the nurse do first? A) Use a Geriatric Depression Scale. B) Refer for further medical evaluation. C) Assess the client's vision and hearing. D) Refer the client to social services for home assistance.

C) Assess the client's vision and hearing.

9. The nurse is preparing to perform a nutritional assessment of a newly admitted client. Which of the following questions would be most appropriate to use when initiating the assessment? A) Did you eat breakfast today? B) How many meals do you eat each day? C) Can you tell me what you've eaten in the last 24 hours? D) How often do you eat out?

C) Can you tell me what you've eaten in the last 24 hours?

6. A nurse who provides care in a busy, inner-city clinic performs physical examinations on clients of various cultures. In a client from which group would the nurse expect to find the greatest amount of body odor from perspiration? A) Inuit B) Asian C) Caucasian D) Native American

C) Caucasian

10. Assessment of a client who has suffered a recent stroke reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the client's level of consciousness as which of the following? A) Obtunded B) Stupor C) Coma D) Lethargy

C) Coma

A nurse suspects intra-abdominal bleeding in a client who was recently involved in a motor vehicle accident. Which finding would most likely lead the nurse to this suspicion? A) Tenderness on palpation B) Diastasis recti C) Cullen's sign D) Tympany on percussion

C) Cullen's sign

12. The nurse attends a Native-American Alcoholic Anonymous support group and develops close relationships with three group members. The nurse is demonstrating which of the following? A) Cultural desire B) Cultural awareness C) Cultural encounter D) Cultural knowledge

C) Cultural encounter

22. An older adult client has a body mass index of 15.5 and is consequently considered to be underweight. The client lives alone and states that she has never been a heavy eater. How can the nurse most accurately assess the client's nutritional habits? A) Assess the client's waist circumference and waist-to-hip ratio. B) Measure the client's mid-arm circumference. C) Elicit the client's 24-hour food recall. D) Have the client describe an ideal meal.

C) Elicit the client's 24-hour food recall.

While assessing a client's abdomen, the nurse observes involuntary reflex guarding on expiration. The nurse would interpret this as most likely indicating which of the following? A) Hernia B) Malignancy C) Infection D) Aneurysm

C) Infection

A group of students is preparing for their clinical experience, during which they are required to demonstrate the techniques for assessing the abdomen. The students demonstrate understanding of the proper sequence when they demonstrate the techniques in which order? A) Palpate, percuss, inspect, auscultate B) Auscultate, inspect, palpate, percuss C) Inspect, auscultate, percuss, palpate D) Percuss, inspect, auscultate, palpate

C) Inspect, auscultate, percuss, palpate

18. A nurse is reviewing a depression questionnaire completed by a client. Which of the following would the nurse interpret as being suggestive of depression? A) Occasionally I feel like my attention wanders. B) I haven't noticed any change in my appetite. C) It usually takes me over an hour to fall asleep. D) I might wake up once during the night but not often.

C) It usually takes me over an hour to fall asleep.

20. The nurse needs to obtain the height of a client who is unable to stand. Which of the following would the nurse do? A) Estimate the height while the client is lying in bed. B) Measure the distance from the top of the client's head to his ankles. C) Measure from client's arm span using one of his arms outstretched. D) Extend a ruler from the forehead to the tip of the client's toes.

C) Measure from client's arm span using one of his arms outstretched.

10. A nurse is assessing a client's skeletal muscle mass in the context of a comprehensive nutritional assessment. Which measurement would yield the most valid and reliable data? A) Body mass index B) Triceps skin fold measurement C) Mid-arm circumference D) Waist circumference

C) Mid-arm circumference

19. A gerontologic nurse is assessing the speech of an older adult client. Which of the following would the nurse characterize as an expected assessment finding? A) Repetition B) Rapid speech C) Moderate pace D) Loud tone

C) Moderate pace

11. During the health interview of a new client, the nurse has explored the client's decision- making strategies. These data are most essential to the developmental theory of which theorist? A) Freud B) Kohlberg C) Piaget D) Erikson

C) Piaget

To promote relaxation of the client's abdominal muscles, which of the following would be most appropriate for the nurse to do? A) Encourage the client to hold his or her breath. B) Cover the client in a warm blanket. C) Place a pillow under both of the client's knees. D) Assure the client that painful areas will not be examined.

C) Place a pillow under both of the client's knees.

24. A nurse is teaching a recent nursing graduate about the significance of verbal and nonverbal communication during client care. The new graduate demonstrates an understanding of these techniques by citing what example of verbal communication? A) Maintaining an open attitude B) Using silence appropriately C) Providing a laundry list of descriptors when needed D) Maintaining an open and encouraging facial expression

C) Providing a laundry list of descriptors when needed

9. The nurse is conducting a health interview and is addressing the client's current stressors. What is the primary rationale for including stress as a focus of psychosocial assessment? A) Stress provides the main impetus for psychosocial development and adaptation. B) Psychosocial development cannot progress normally in the presence of stress. C) Psychosocial stress has a major influence on health in many domains. D) The results of the health interview are distorted when the client is experiencing stress.

C) Psychosocial stress has a major influence on health in many domains.

1. The nurse is interviewing a female Hispanic client who is scheduled for a cardiovascular education program. The client states, I can't eat and I don't sleep because my daughter left to return to Mexico. I am sad and nervous. I need rest. The nurse suspects that she is suffering from susto. Which action by the nurse would be best? A) Give her a multivitamin supplement. B) Encourage her to exercise. C) Reschedule the education program. D) Refer her to a counselor.

C) Reschedule the education program.

The nurse is evaluating a new nursing graduate's ability to perform a rebound tenderness test for suspected appendicitis. The nurse identifies correct technique when the new graduate is observed pressing deeply at which abdominal location? A) Right upper quadrant B) Left upper quadrant C) Right lower quadrant D) Left lower quadrant

C) Right lower quadrant

5. A nurse is reviewing the laboratory test results of an adult client who has numerous chronic health challenges. Which assessment result would alert the nurse to potential malnutrition? A) Hemoglobin of 13.1 g/dL B) Hematocrit of 40% C) Serum albumin of 2.6 g/dL D) Total protein of 7 g/dL

C) Serum albumin of 2.6 g/dL

22. The nurse is using the mnemonic "COLDSPA" to assess a client's complaint of lower abdominal pain. The nurse asks the client to rate the pain on a scale of 0 to 10. The nurse is assessing which aspect of the complaint? A) Character B) Onset C) Severity D) Pattern

C) Severity

24. The intensive care nurse is working with a client who has increased intracranial pressure secondary to a traumatic brain injury. The nurse is performing the hourly assessment of the client's level of consciousness and observes that the client's eyes are closed. How should the nurse first stimulate the client to assess for arousability? A) Gently shake the client's right shoulder and then his left shoulder. B) Rub the client's sternum with the knuckles. C) Speak to the client clearly from a close distance. D) Press down on one of the client's nail beds.

C) Speak to the client clearly from a close distance.

The nurse is performing blunt percussion of a client's kidneys. For what abnormal finding is the nurse primarily assessing? A) Dullness B) Tympany C) Tenderness D) Hyperresonance

C) Tenderness

21. When applying Kohlberg's theory of moral development to the status of an older adult client, on what assessment finding would the nurse focus? A) The relationship between the client's stated beliefs and his actions B) The client's ability to discern the motivations of others C) The client's adherence to rules, laws, and norms D) The client's ability to tolerate differing views

C) The client's adherence to rules, laws, and norms

10. The nurse is conducting a health interview and has asked the client, How would you describe yourself to others? The client's response informs the nurse's assessment of which of the following? A) The client's morality and honesty B) The client's aspirations C) The client's self-concept D) The client's superego

C) The client's self-concept

23. A woman has accompanied her 80-year-old husband to a scheduled clinic visit and expresses concern about subtle declines in his cognition. Which of the following principles should guide the nurse's assessment of the client's mental status? A) The nurse must modify the cognitive assessment to exclude assessments requiring reading or writing. B) The nurse should first explain to the couple that senility is expected among adults over age 80. C) The nurse must differentiate between age-related changes and the signs and symptoms of dementia. D) The nurse must explain that the results of the assessment will be used to determine if admission to long-term care is necessary.

C) The nurse must differentiate between age-related changes and the signs and symptoms of dementia.

28. The nurse has observed that a client adheres rigidly to the norms of her family and her culture. In the context of Freud's theory of development, this pattern of behavior is attributable to the action of what component of personality? A) The id B) The ego C) The superego D) The identity

C) The superego

The nurse is percussing a client's abdomen. What predominant sound should the nurse expect to hear over the majority of the abdomen? A) Accentuated tympany B) Hyperresonance C) Tympany D) Dullness

C) Tympany

14. As part of a mental status assessment, the nurse asks a client to draw the face of a clock. This will allow the nurse to assess which of the following domains of mental status? A) Concentration and orientation B) Perceptions and thought processes C) Visual perceptual and constructional ability D) Expressions and feelings

C) Visual perceptual and constructional ability

19. When obtaining the nutritional health history from a female client, which of the nurse's questions would best elicit information about the client's knowledge of her own health status? A) Are you now or have you been on a diet recently? B) How much fluid do you drink in a day? C) What are your height and usual weight? D) Can you tell me what you consider to be a healthy meal?

C) What are your height and usual weight?

25. The admission of a new resident to a long-term care facility has necessitated a thorough health history. Place the following focuses in the correct sequence in which the nurse should perform them, beginning with the section obtained first. A) Family health history B) Reason for seeking care C) Biographic data D) Review of body systems E) History of present concern F) Past health history

C, B, E, F, A, D C) Biographic data B) Reason for seeking care E) History of present concern F) Past health history A) Family health history D) Review of body systems

26. A client's recent complaints of polyuria have prompted a full diagnostic work-up for diabetes mellitus, including a nutritional assessment. To determine the client's body mass index (BMI), the nurse must know which of the following assessment parameters? Select all that apply. A) Gender B) Age C) Weight D) Waist circumference E) Height

C, E C) Weight E) Height

completely unconscious; not arousable by pain or any other stimuli

Comatose

27. The nurse is completing an assessment of a 50-year-old female client who has sought care for recurrent migraines that have not responded to treatment. Following the review of systems, how should the nurse best document unremarkable results of the subjective portion of the gastrointestinal assessment? A) "Client's gastrointestinal health is within reference ranges for age." B) "Client denies GI signs and symptoms." C) "Gastrointestinal problems are absent." D) "Client denies recent constipation, diarrhea, bowel incontinence, or abdominal pain."

D) "Client denies recent constipation, diarrhea, bowel incontinence, or abdominal pain."

18. The nurse is preparing to assess an adult woman's activities related to health promotion and maintenance. Which question should the nurse ask to obtain the most objective and thorough assessment data? A) "Do you always wear your seatbelt when driving?" B) "How much beer, wine, or alcohol do you drink?" C) "Do you use condoms with each sexual encounter?" D) "Could you describe how you perform self-breast exams?"

D) "Could you describe how you perform self-breast exams?"

11. A nurse has admitted a client to the medical unit and is describing the purpose for obtaining a comprehensive health history. Which of the following purposes should the nurse describe? A) "This helps us to complete your health record accurately." B) "This helps us to establish a trusting interpersonal relationship." C) "This helps us to evaluate the seriousness of your risk factors for disease." D) "This helps us have an appropriate focus for the physical examination."

D) "This helps us have an appropriate focus for the physical examination."

10. Upon entering an exam room, the client states, "Well! I was getting ready to leave. My schedule is very busy and I don't have time to waste waiting until you have the time to see me!" Which response by the nurse would be most appropriate? A) "Our schedule is very busy also. We got to you as soon as we could." B) "No one is forcing you to be here, and you are free to leave at any time." C) "Would you like to report your complaints to someone with power?" D) "You're certainly justified in being upset, but I am ready to begin your exam now."

D) "You're certainly justified in being upset, but I am ready to begin your exam now."

3. An adult client weighs 175 pounds and is 5 feet 6 inches tall. The nurse determines that the client's body mass index is which of the following? A) 12 B) 18 C) 25 D) 28

D) 28

A young adult male who comes to the emergency department complaining of abdominal pain for the past 3 days is suspected of having a ruptured appendix. The nurse auscultates the client's bowel sounds, noting them to be which of the following? A) Normoactive B) Hyperactive C) Hypoactive D) Absent

D) Absent

12. The nurse is assessing a client using the Glasgow Coma Scale following an acute hypoglycemic episode and obtains a score of 14. The nurse interprets this as indicating which of the following? A) Deep coma B) Coma C) Obtunded D) Alert and oriented

D) Alert and oriented

28. An 88-year-old woman has been admitted to the acute medical unit for the treatment of a urinary tract infection that is thought to be progressing to urosepsis. When assessing the client's orientation, how should the nurse best gauge the client's orientation to time? A) Can you tell me approximately what time it is right now? B) Are you able to tell me today's date? C) Can you tell me the date and the day of the week? D) Are you able to tell the month and the year that we're in?

D) Are you able to tell the month and the year that we're in?

21. An older adult client has presented to the emergency department with signs and symptoms of dehydration. When assessing the client for risk factors that may have contributed to this condition, what question should the nurse prioritize? A) Do you use any over-the-counter dietary supplements? B) Are you familiar with the USDA's MyPlate recommendations? C) Have you ever been diagnosed with heart disease? D) Are you currently taking any diuretic medications?

D) Are you currently taking any diuretic medications?

25. A nurse is validating assessment findings with a client, and the client proceeds to describe some of the psychological and spiritual components that she believes underlie her disease process. This understanding of the cause of illness is most closely associated with which of the following? A) Northern European cultures B) The Western biomedical model C) African-American culture D) Asian cultures

D) Asian cultures

The nurse is inspecting a new client's abdomen and notes the presence of a tight, distended abdomen and visible arterioles on the abdominal skin surface. How should the nurse proceed with assessment? A) Review the client's blood work for low platelets and hemoglobin. B) Assess the client for signs and symptoms of fluid volume overload. C) Assess the client's nutritional status. D) Assess the client for other signs and symptoms of liver disease.

D) Assess the client for other signs and symptoms of liver disease.

20. A cardiac care nurse works with a diverse client population. The nurse would assess a client from which cultural group for an increased effect of an antihypertensive medication? A) Eskimos B) Native Americans C) Hispanics D) Chinese

D) Chinese

22. A nurse is participating in an educational exercise in which she is conducting a self- examination of her own biases. This activity addresses what construct of cultural competence? A) Cultural desire B) Cultural knowledge C) Cultural skill D) Cultural awareness

D) Cultural awareness

During deep palpation of the client's abdomen, the nurse identifies a soft, nontender, solid mass extending 2 to 3 cm below the right costal margin. Which of the following actions would be most appropriate? A) Refer the client for medical follow-up. B) Evaluate further for a problem with the spleen. C) Assess urinary output. D) Document the position of the liver.

D) Document the position of the liver.

3. A school nurse who provides care in a middle school works exclusively with adolescents. According to Erikson's theory of psychosocial development, what task will underlie much of the students' behavior? A) Exerting influence over others B) Evaluating the merits of their parents' beliefs C) Appraising religious dogma D) Establishing a personal identity

D) Establishing a personal identity

6. When preparing to obtain information about a client's mental and psychosocial status, which of the following would the nurse need to do first? A) Question the patient about his or her usual lifestyle and behaviors. B) Perform a neurologic examination to determine any deficits. C) Check the client's level of consciousness for changes. D) Explain the purpose of the exam and types of questions.

D) Explain the purpose of the exam and types of questions.

25. A nurse is conducting a mental status assessment of a 70-year-old male client who is being treated for depression. When assessing the client's facial expression and eye contact, the nurse should consider which of the following? A) The nurse should inform the client that his facial expression is being assessed. B) Reduced eye contact is an age-related physiological change. C) Facial expression should be disregarded if the client has a diagnosed mental illness. D) Eye contact is strongly influenced by cultural norms.

D) Eye contact is strongly influenced by cultural norms.

The nurse demonstrates the correct technique for assessing the psoas sign by which action? A) Applying deep palpation pressure to the client's right lower quadrant, then suddenly releasing B) Tapping fingerpads over the client's abdominal wall, feeling for a floating mass C) Percussing over the client's symphysis pubis with the client supine and then sitting upright D) Flexing the client's right hip, applying downward pressure on the right thigh

D) Flexing the client's right hip, applying downward pressure on the right thigh

22. During the health interview, a client demonstrates the ability to describe healthy and unhealthy aspects of her thinking patterns. The nurse would conclude that this client has attained which level of development within Piaget's framework? A) Circular operational B) Preoperational C) Concrete operational D) Formal operational

D) Formal operational

15. What action on the part of a middle-aged client would best exemplify Erikson's concept of generativity? A) Being able to accurately evaluate the merits of others' ideas B) Emphasizing the importance of one's knowledge and skill set C) Consistently increasing one's income D) Guiding and mentoring individuals who are younger

D) Guiding and mentoring individuals who are younger

22. A client has presented to the emergency department (ED) with a lower leg laceration that she suffered while I was on a bender last night. The nurse recognizes the need to screen for alcohol use and will implement the CAGE questionnaire. What question will the nurse ask during this assessment? A) Have you ever experienced a memory blackout after drinking? B) Have you ever vomited blood after drinking alcohol? C) Have you ever been treated for alcohol abuse? D) Have you ever felt guilty about your alcohol use?

D) Have you ever felt guilty about your alcohol use?

8. A client is receiving an intradermal injection to evaluate general immunity during a nutritional assessment. Which of the following conclusions is suggested if the client has no reaction? A) It indicates high cholesterol and triglyceride levels. B) It shows a sacrifice of skeletal muscle proteins and blood proteins. C) It is indicative of unhealthy dietary habits. D) It may be immunosuppression resulting from undernourishment.

D) It may be immunosuppression resulting from undernourishment.

The nurse is auscultating a client's abdomen and is unable to discern any bowel sounds. How should the nurse proceed with assessment? A) Repeat auscultation in four to six hours. B) Palpate the client's abdomen to stimulate bowel motility. C) Perform abdominal percussion, wait three to five minutes and then repeat auscultation. D) Listen for at least five minutes before documenting an absence of bowel sounds.

D) Listen for at least five minutes before documenting an absence of bowel sounds

13. The nurse is preparing to lead a health promotion activity among a group of clients from different cultures. The nurse would expect that which client would require the least amount of personal space? A) Latin American B) Asian C) American D) Middle Easterner

D) Middle Easterner

8. A nurse has identified the goal of becoming more culturally sensitive and competent. What is the primary rationale for cultural sensitivity in health care settings? A) Recognize that cultural diversity exists. B) Understand individual differences. C) Prevent offending the client. D) Obtain accurate assessment data.

D) Obtain accurate assessment data.

A nurse is preparing to palpate a client's spleen. Which position should the nurse use to best facilitate palpation? A) Sitting upright B) Prone C) Semi-Fowler's D) Right side-lying

D) Right side-lying

17. When considering the various cultural aspects associated with death rituals, which of the following should guide a nurse's practice? A) Most cultures have similar durations for the length of time a person grieves. B) A person's view of death is likely to be different from the original ethnic group's practice. C) Responses to death and grief are fairly consistent among different cultures. D) Rituals for burial and bereavement are likely to reflect original cultural practices.

D) Rituals for burial and bereavement are likely to reflect original cultural practices.

5. A nurse is working in a clinic in a low-income neighborhood and assesses a female adult client who states that she has a urinary tract infection. The nurse notes that the client is unkempt, wearing stained clothing, and has a strong body odor. The client mentions that she was evicted from her apartment two weeks ago. Which nursing diagnosis would the nurse most likely identify for this client? A) Caregiver role strain related to fatigue B) Impaired skin integrity related to neurologic deficits C) Deficient fluid volume related to possible urinary tract infection D) Self-care deficit related to possible homelessness

D) Self-care deficit related to possible homelessness

23. Assessment reveals that a young adult has failed to achieve Erikson's central task of his current stage of development. What nursing diagnosis would the nurse associate most closely with this finding? A) Risk for compromised human dignity B) Anxiety C) Ineffective sexuality pattern D) Social isolation

D) Social isolation

During palpation of the client's abdomen, the nurse feels a prominent, nontender, pulsating 6-cm mass above the umbilicus. What action should the nurse take? A) Refer the client to an oncologist. B) Provide a dietician consult for the client. C) Counsel the client regarding hernia repair. D) Stop palpating and get medical assistance.

D) Stop palpating and get medical assistance.

14. The nurse is collecting data from a client about his nutrition. Which of the following would the nurse document as objective data? A) Client states he is not eating well. B) Client complains of nausea and vomiting. C) Clients experiences urinary frequency. D) Tenting of client's skin observed upon skin pinch.

D) Tenting of client's skin observed upon skin pinch.

27. The nurse is completing a comprehensive nutritional assessment and has assessed and documented the client's triceps skin fold thickness (TSF) using calipers. This assessment finding allows the nurse to determine which of the following? A) The client's ratio of muscle to adipose tissue B) The client's body mass index C) The client's proportion of muscle mass D) The amount of the client's subcutaneous fat stores

D) The amount of the client's subcutaneous fat stores

12. The nurse is assessing an older adult's psychosocial development with reference to Freud's theory of development. What observation by the nurse would most clearly suggest healthy development within this theoretical framework? A) The client is able to describe challenges that he has overcome. B) The client has eliminated conflictual relationships from his life. C) The client is able to delegate care to others when necessary. D) The client appears to have dealt effectively with recent losses.

D) The client appears to have dealt effectively with recent losses.

20. The nurse has identified abnormal findings when reviewing a young adult client's health history. Within Kohlberg's theory of psychosocial development, what behavioral characteristic is the nurse most likely to observe? A) The client has difficulty trusting others. B) The client is easily manipulated by others. C) The client is unable to weigh options when presented with a dilemma. D) The client makes decisions without considering the impact on others.

D) The client makes decisions without considering the impact on others.

16. The nurse's interview with an older adult client reveals that he bitterly regrets some of the financial decisions that he made when he was younger. The nurse recognizes that unless the client is able to accept these undesirable aspects of life, what outcome is likely? A) The client will adopt antisocial behaviors late in life. B) The client will die prematurely. C) The client will gradually abandon significant relationships. D) The client will live with despair during his final years of life.

D) The client will live with despair during his final years of life.

30. A nurse is obtaining subjective data from an adult client who is new to the clinic. The nurse has asked the client, "Where do you usually turn for help in a time of crisis?" What domain is this nurse assessing? A) The client's family relationships B) The client's current level of social and relational stability C) The client's critical thinking and problem-solving abilities D) The client's stress management and coping strategies

D) The client's stress management and coping strategies

26. A nurse is working with a 22-year-old woman of Asian ethnicity who has been diagnosed with bipolar disorder. When planning culturally appropriate care, the nurse should consider which of the following? A) There may a lack of acceptance that the client's behavior is abnormal. B) The client's family may see her illness as punishment for misdeeds. C) The client's family may see her psychiatric disorder as evidence of bad character. D) There may be shame associated with having a psychiatric disorder.

D) There may be shame associated with having a psychiatric disorder.

8. The nurse is assessing a client's cultural identity and affiliation during the health interview. How best can the nurse elicit this information? A) What are your race and culture? B) Would you describe yourself as American? C) How would you describe your cultural values? D) With which cultural group do you most closely identify?

D) With which cultural group do you most closely identify?

a natural conscious and unconscious conditioning process of learning accepted cultural norms, values, and roles in society and achieving competence in one's culture through socialization

Enculturation

Inspection of abdominal includes what?

Fat, feces, fetus, fibroids, fluid, flatulence In other words: obesity, air/gas, ascites, ovarian cyst, pregnancy, feces, tumor

What is the order of the abdominal exam?

Inspection Asculation Percussion Palpation

not fully alert; can be observed drifiting to sleep, easily aroused and responds to stimuli appropriately

Lethargic

not lethargic but not in a stupor; sleeps mostly, difficult to arouse, speech maybe mumbled

Obtunded

Palmar surface of fingers

One-handed

Why is an empty bladder important before abdominal exam?

Patient will be more comfy is bladder is empty while having their abdominal checked.

spontaneously unconsciousness; responds only to apinful stimuli, and usually only moans/groans

Stupor

What is deep palaption used for?

To define abdominal organs and mass

Finger of the top hand apply pressure to the bottom hand, which feels for organs and masses

Two-Handed

What sound is heard when listening to the abdomen?

Tympany

Body Mass Index (BMI)

a measure of body fat based on your weight in relation to your height normal is 18.5-24.9

the circumstance when a person gives up the traits of their culture of origin as a result of context with another culture

acculturation

disorder in language production and production due to brain injury

aphasia

the gradual adoption and incorpration of characteristics of the prevailing culture

assimilation

left front lobe, trouble speaking but can understand speech

broca's aphasia

CAGE: alcohol abuse

c-cut down a-annoyed or angry g-gulity e-ever had a drink or drug first thing in the morning

Vitamin A deficiency

can result in conjunctival and corneal xerosis, kertomalacia, or bitot's spot

the totality of socially trasmitted behavioral patterns, arts, beliefs, values, customs, life ways, and all other products of human work and thought characteristic of a population or people that guide their worldview and decision making.

culture

Hypoactive Bowel sounds

decreased, follow abdominal surgery or with inflammation

an acute symptom

delirium

disorder of articulation

dysarthria

disorder of the voice

dysphonia

Triceps skin fold thickness

evaluates the degrees subcutanous fat stores

mid-arm cicumference

evalutes skeletal muscle mass and fat stores

sarcopenia

loss of muscle or lean body tissues

Hyperactive Bowel sounds

loud, high-pitched signal increased motility

waist circumference

measure at the umbilicus

smooth tongue

riboflavin (vitamin b2) deficiency

an oversimplification conception, opinon, or belief about an aspect of an individual or group.

stereotyping

cachexia

wasting syndrome

leukonychia

zinc deficiency