Health Assessment : Set 1
PREHYPERTENSION
120-139/ 80-89
CL- SOURCES AND LOSSES
Enters body via gastrointestinal tract Almost all chloride in diet comes from salt Found in foods high in sodium, processed foods
Which area is typically included in a cultural assessment? A. Marital status B. Employment status C. Food preferences D. Ethics
Food preferences
A person loses approximately 30 mEq of potassium.
TRUE
During a staff meeting, nurses discuss the problems with accessing research studies to incorporate evidence-based clinical decision making into their practice. Which suggestion by the nurse manager would help these problems?
Teach the nurses how to conduct electronic searches for research studies.
A patient repeatedly seems to have difficulty coming up with a word. He says, I was on my way to work, and when I got there, the thing that you step into that goes up in the air was so full that I decided to take the stairs. The nurse will note on his chart that he is using or experiencing:
circumlocution
Hypovolemia
deficiency of blood plasma
Autologous transfusion
occurs when a patient donates one's own blood for a transfusion
Potassium (K+): major cation of ICF; the normal serum concentration of potassium:
3.5-5.0 mEq/L
The nurse measures a client's pupils and documents the size. Which size would the nurse document as normal?
4 mm Pupils are normally equal in size and range from 3 to 5 mm. Size outside this range are considered abnormal.
29. The nurse is assessing CN V (trigeminal nerve) in a newly admitted client. What instruction should the nurse provide to the client during this phase of assessment? A) ìClench your teeth together tightly.î B) ìClose your left eye and look at me with your right.î C) ìLook straight at me while I shine this light in your eye.î D) ìOpen your mouth wide and say 'ah.'î
A
BRADYPNEA
ABNORMALLY SLOW BREATHING RATE (LESS THAN 12 IN A MINUTE)
A SOLUTION WITH A HIGH CONCENTRATION OF HYDROGEN IONS IS
ACIDIC AND HAS A LOW PH
A SOLUTION WITH A LOW CONCENTRATION OF HYDOGEN IONS IS
BASIC AND HAS A HIGH PH
COURSE
BUBBLY SOUND= CHF
A 16-year-old boy has just been admitted to the unit for overnight observation after being in an automobile accident. What is the nurses best approach to communicating with him?
Be totally honest with him, even if the information is unpleasant.
interstitial fluid is
10-15% of body fluid
normal blood pressures
120/80
ALKOLOSIS OCCURS WHEN THE PH IS
ABOVE 7.45
The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination?
At the end of the examination
CHRONIC PAIN LASTS MORE THAN 6 MONTHS
Chronic pain is often defined as any pain lasting more than 12 weeks. Whereas acute pain is a normal sensation that alerts us to possible injury, chronic pain is very different. Chronic pain persists—often for months or even longer.
HIGH PHOSPHORUS EQUALS LOW
CALCIUM
Which critical thinking skill helps the nurse see relationships among the data?
Clustering related cues
Which of the following assessment findings is most congruent with chronic arterial insufficiency?
Cool foot temperature and ulceration on the client's great toe Pigmentation, medial ankle ulceration, and thickened, scarred skin are associated with venous insufficiency, while low temperature and toe ulceration are more commonly found in cases of arterial insufficiency. (less)
PULMONARY ARTERIES RECEIVE
DEOXYGENATED BLOOD FROM THE RIGHT SIDE OF THE HEART AND CARRY IT TO THE LUNGS FOR OXYGENATION.
VEINS CARRY WHAT KIND OF BLOOD
DEOXYGENATES BLOOD EXCEPT FOR PULMONARY VEINS
When reviewing the use of alcohol by older adults, the nurse notes that older adults have several characteristics that can increase the risk of alcohol use. Which would increase the bioavailability of alcohol in the blood for longer periods in the older adult?
Decreased liver and kidney functioning
During a breast health interview, a patient states that she has noticed pain in her left breast. The nurses most appropriate response to this would be:
I would like some more information about the pain in your left breast.
TACHYPNEA
INCCREASED RATE OF RESPIRATION. INDICATED BY RR OF GREATER THAN 20 BREATHS PER MINUTE
According to Schuster (2008), what is the fourth step in developing a concept map? -Label and analyze nursing diagnosis relationships -Identify goals, outcomes, and interventions -Develop a basic skeleton diagram -Analyze and categorize data
Identify goals, outcomes, and interventions
Types of Health Assessments
Emergency assessment: life-threatening situation Comprehensive assessment: annually on outpatient basis Focused assessment: based on patient issues
CARDIAC ASSESSMENT Subjective Data Collection
Equipment Preparation Common and specialty/advanced techniques
PULMONARY VEINS
Return fresh blood to Left Atrium through mitral valve to left ventricle
During the interview portion of data collection, the nurse collects __________ data.
Subjective
A nurse is auscultating a client's heart sounds. What action should the nurse perform during this assessment?
Systematically listen to the entire precordium. When auscultating heart sounds, the nurse would need to emphasize the need to cover the entire precordium, using a systematic approach moving the stethoscope from left to right across the entire heart area from the base to the apex or from the apex to the base. Both the diaphragm and bell are used. Inspection and palpation usually precede auscultation. It is not necessary to begin with breath sounds. (less)
Variables Affecting Message Exchange & Decoding
Variables Affecting Message Exchange & Decoding
Edema
accumulation of fluid in extracellular spaces
MEDIASTINUM
a membranous partition between two body cavities or two parts of an organ, especially that between the lungs.
acidosis
condition characterized by a proportionate excess of hydrogen ions in the extracellular fluid, in which the pH falls below 7.35
The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the __________ of the underlying tissue.
density
his system buffers as much as 90% of the H+ of the
ecf
Rapid fluid administration can result in fluid overload, and manifestations may include
elevated blood pressure, edema in the tissues, and crackles in the lungs
both babies and pregnant women have
higher heart rates
When performing a physical assessment, the first technique the nurse will always use is:
inspection
hypomagnesemia:
insufficient amount of magnesium in the extracellular fluid
A patient drifts off to sleep when she is not being stimulated. The nurse can easily arouse her by calling her name, but the patient remains drowsy during the conversation. The best description of this patients level of consciousness would be:
lethargic
Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms indicative of what?
phlebitis Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, pus, warmth, induration, and pain.
when calcium is low
phosphate is high
adh vassopressin two functions
retain water in the body constrict blood vessels
systole (TOP NUMBER)
when the heart contracts
diastole (BOTTOM NUMBER)
when the heart relaxes
body weight percentage in adult men
INTRRAVASCULAR -4% INTERSTITIAL- 11% INTRACELLULAR- 45% TOTAL = 60% WATER
Antibody
Immunoglobin produced by the body in response to a specific antigen
Respiration "Breathing"
Involuntary (automatic) & controlled by the respiratory center located in the brain stem
When examining the eye with an ophthalmoscope, where would the nurse look to visualize Medially toward the nose Laterally toward the ear Upward toward the forehead Downward toward the chin
Medially toward the nose
PRIMARY METHOD OF TRANSPORTING BODY FLUIDS IS
OSMOSIS
HIGH CALCIUM EQUALS LOW
PHOSPHORUS
The nurse would use bimanual palpation technique in which situation?
Palpating the kidneys and uterus
first heart sound LUB
S1 caused by closure of the mitral and tricuspid valves and the two sounds tend to merge as one
the output of urine normally approximates/RESEMBLES
THE INGESTION OF LIQUIDSD
PRIMARY SOLVENT IN THE BODY IS
WATER
Hyperphosphatemia
above-normal serum concentration of inorganic phosphorus
agglutinin
an antibody that causes a clumping of specific antigens
BACTERIAL REACTIONS
fever, hypertension, dry, flushed skin, and abdominal pain occur
interstitial fluid is
fluid in the tissue space between and around cells.
When preparing to perform a physical examination on an infant, the nurse should:
have the parent remove all clothing except the diaper on a boy.
bicarbonate
hco3-
acid
substance containing a hydrogen ion that can be liberated or released
blood typing
the laboratory examination to determine a person's blood type
The nurse is preparing to assess a patients abdomen by palpation. How should the nurse proceed?
The assessment begins with light palpation to detect surface characteristics and to accustom the patient to being touched.
Cross-Matching
act of determining the compatibility of two blood specimens
What nursing interventions would be appropriate for a patient diagnosed with deficient fluid volume? (Select all that apply.)
• Intravenous therapy • Electrolyte management • Nutrition management
HYPERTENSION STAGE 1
140-159/90-99
STENOSIS
ABNORMAL NARROWING OF A PASSAGE WITHIN THE BODY.
SOMEONE WITH EXTRA FLUID IN THEIR LUNGS CAN'T
CATCH THEIR BREATH
pth regulates the levels of
calcium and phospgorus
OLDCART PAIN SCALE
O-ONSET L-LOCATION D-DURATION C-CHARACTERSITIC SYMPTOMS A-AGGRAVATING FACTORS R- RELIEVING FACTORS T-TREATMENT
A client reports sharp and stabbing chest pain that worsens with deep breathing and coughing. A cardiac cause to this pain is ruled out. The description of the pain is consistent with what respiratory condition?
Pleurisy Pleurisy can follow inflammation of the parietal pleura. Patients usually describe such pain as sharp or stabbing, worsening with deep breathing or coughing. Pneumonia does not always cause pain on respiration nor does asthma. Rales are an adventitious breath sound, not a respiratory condition. (less)
A nurse has recently completed the administration of seasonal influenza vaccinations for the residents of a long-term care facility. Which of the following aims of nursing has the most clearly demonstrated? -Restoring health -Preventing illness -Promoting health -Facilitating coping
Preventing illness
During a class on cultural practices, the nurse hears the term cultural taboo. Which statement illustrates the concept of a cultural taboo?
Refusing to accept blood products as part of treatment
FUNCTIONS OF SODIUM ELECTROLYTE
Regulates extracellular fluid volume; Na+ loss or gain accompanied by a loss or gain of water Affects serum osmolality Role in muscle contraction and transmission of nerve impulses Regulation of acid-base balance as sodium bicarbonate
second heart sound DUB
S2 caused by closure of the aortic and pulmonary valves.
What structure is found midline in the tracheal area just beneath the mandible? A. Cricoid cartilage B. Hyoid bone C. Thyroid cartilage D. Adam's apple
Hyoid bone
Constipation is a sign of
hypercalcemia
25. The nurse has positioned a client supine and asked her to perform the heel-to-shin test. An inability to run each heel smoothly down each shin should prompt the nurse to perform further assessment in what domain? A) Balance and coordination B) Light touch sensation C) Deep tendon reflexes D) Leg strength
A
APNEA
ABSENCE OF BREATHING
APNEA
ABSENCE OF SPONTANEOUS RESPIRATION RATE FOR MORE THAN 10 SECONDS
As metabolic demands increase the heart responds by accelerating its ____ to increase ________.
ACCELERATING ITS RATE AND INCREASING ITS METABOLIC OUTPUT
K+ SOURCES AND LOSSES
Adequate quantities via a well-balanced diet Leading food sources: fruits and vegetables, dried peas and beans, whole grains, milk, meats Lost via kidneys, stool, sweat, emesis Gastrointestinal (GI) secretions contain potassium in large quantities, so can be lost through vomitus
What population is at greatest risk for hypertension?
African American Race is a factor in hypertension, a disorder characterized by high blood pressure. It is more prevalent and more severe in African-American men and women.
When talking with a client, the nurse notes that the client keeps backing up. What would be the most appropriate response? A. Ask the client about his personal space preferences. B. Back away from the client. C. Ask the client why he is backing away. D. Move closer to the client.
Ask the client about his personal space preferences.
A nurse working in a coronary care unit resuscitates a client who had expressed wishes not to be resuscitated. Which tort has the nurse committed? A. Assault B. Battery C. Libel D. Slander
Battery
A nurse is conducting a cultural assessment of a client. Which person would the nurse identify as the expert? A. Older family member B. Client C. Nurse D. Health care provider
Client
Body temperature is not impacted by which of the following factors?
Diet Body temperature varies with diurnal cycle, physical activity, age, gender, and state of health. It also normally fluctuates with activity and time of day. Of the choices offered, the only correct answer is diet. (less)
A nurse has performed a head and neck assessment of an adult patient and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action? Document this as an expected assessment finding Refer the patient to the primary care provider promptly Perform a focused endocrine assessment Position the patient supine and reattempt palpation
Document this as an expected assessment finding
MG2+ REGULATION
Eliminated by kidneys Regulated by parathyroid hormone
PO4- REGULATION
Eliminated by kidneys Regulation by parathyroid hormone and by activated vitamin D Phosphate and calcium are inversely proportional; an increase in one results in a decrease in the other
Primary headaches are more worrisome than secondary headaches.
False
The muscles of the ciliary body control the thickness of the lens, allowing the eye to:
Focus on near or distant objects The muscles of the ciliary body allow the lens to focus light appropriately for discerning far and near objects clearly. They do not control extraocular movements or intraocular pressure. The iris controls the amount of light entering the eye. (less)
When observing a patients verbal and nonverbal communication, the nurse notices a discrepancy. Which statement is true regarding this situation? The nurse should:
Focus on the patient's nonverbal behaviors, because these are often more reflective of a patient's true feelings.
An older Mexican-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally sensitive nurse would
Further assess the patient's cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires
A client on a medical-surgical unit reports pain of 10 on a scale of 0 to 10 and wants more pain medication. The nurse does not think the pain is as bad as the client says. The physician left orders for prn morphine for breakthrough pain. What is the priority nursing action?
Give the prn morphine Pain is what the client says it is, and it exists whenever the client says it does. It would not be appropriate to hold the medication for 30 minutes, call the physician to check the order, or just document the client's pain. (less)
On palpation, the nurse notes that a client's thyroid gland is diffusely enlarged. Which of the following health problems would the nurse want to rule out? A. A tumour B. Hypothyroidism C. Graves' disease D. Nephrotic syndrome
Graves' disease
The Standards of Practice provide nurses with what? -Guidelines for providing care -Legislation for health care reform -Measurement criteria for payment -Evaluation of care provided by nurses
Guidelines for providing care
When documenting the findings from a physical examination of the head and neck, what will the nurse include when describing the client's head? A. Sclera color B. Hair color C. Nasal mucosa color D. Facial skin color
Hair Color
A patient is brought to the emergency department. He is restless, has dilated pupils, is sweating, has a runny nose and tearing eyes, and complains of muscle and joint pains. His girlfriend thinks he has influenza, but she became concerned when his temperature went up to 39.4 C. She admits that he has been a heavy drug user, but he has been trying to stop on his own. The nurse suspects that the patient is experiencing withdrawal symptoms from which substance?
Heroin
The nurse is assessing orientation in a 79-year-old patient. Which of these responses would lead the nurse to conclude that this patient is oriented?
I know my name is John. I am at the hospital in Spokane. I couldnt tell you what date it is, but I know that it is February of a new year2010.
HOW OFTEN DO YOU CHANGE IV TUBINGS?
IV tubings are generally changed every 72 hours or as per the facility's policy
When discussing the use of the term subculture, the nurse recognizes that it is best described as:
Identifying fairly large groups of people with shared characteristics that are not common to all members of a culture.
What should the nurse assess to test the function of the temporal lobe?
Impulses from the ear The function of the temporal lobe is assessed by testing for impulses from the ear. To assess the function of the parietal lobe, the nurse should test for tactile sensation. Assessment of the frontal lobe is done by testing the client's communication. To assess the function of the occipital lobe, the nurse should test the ability to read.
A nurse is auscultating the bronchi of a client. The nurse understands that the bronchi are located in which of the following locations in the body?
In the mediastinum Explanation: The thoracic cavity consists of the mediastinum and the lungs, and is lined by the pleural membranes. The mediastinum refers to a central area in the thoracic cavity that contains the trachea, bronchi, esophagus, heart, and great vessels.
The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem?
Individual with shortness yf breath and respiratory distress
The nurse is assessing a client's heart and neck vessels. Which technique would be most appropriate to use when examining the client's jugular venous pulse?
Inspect the suprasternal notch or around the clavicles.
FLUID OUTPUT % IN ORGANS (KIDNEYS, SKIN, LUNGS, GI) 2,600 ML
KIDNEYS-1,500 ML SKIN- 600 ML LUNGS- 300 ML GI- 200 ML
A nurse is using the FLACC (Face, Legs, Activity, Cry, Consolability) scale for pediatric pain assessment to assess for pain in a 6-month-old client. Which of the following findings on this assessment tool would indicate the strongest pain in the client?
Kicking According to the FLACC scale for pediatric pain assessment, kicking or the legs being drawn up is a strong sign indicating pain, as it would receive a 2. An occasional grimace or frown and whimpering are weaker signs of pain, as they would each warrant only a 1. Lying quietly is a normal activity and indicates the absence of pain; thus, it would receive a 0. (less)
LYMPHATIC SYSTEM
Lymphatic System Supports the vascular system by returning excess fluid from tissues to vascular network
During a session on substance abuse, the nurse is reviewing statistics with the class. For persons aged 12 years and older, which illicit substance was most commonly used?
Marijuana
When delivering nursing care, which of the following theories assists nurses in prioritizing the care to be implemented? -Freud's theory -Unitary man theory -Health care systems theory -Maslow's theory
Maslow's theory
EUPNEA
NORMAL BREATHING/RESPIRATION
Normal pulse oximetry
Normal pulse oximetry is SpO2 from 95% to 100% SpO2 of 85% to 89% may be acceptable for patients with certain chronic conditions such as emphysema Documentation
The client's plan of care is created by the nurse using which guideline for nursing practice? -ANA Standards of Nursing Practice -Nursing's Social Policy Statement -Nursing process -Nursing practice act
Nursing process
"FINE" CRACKLES CAN BE FINE, MEDIUM, AND COURSE
PT CANNOT CLEAR COUGH
The nursing student is assessing a community in regard to safety and security. Which of the following would be inappropriate for the nursing student to include under this basic need category? -Housing and zoning codes -Police and fire departments -Sanitation facilities -Parks and swimming pools
Parks and swimming pools
The nurse is planning health teaching for a 65-year-old woman who has had a cerebrovascular accident (stroke) and has aphasia. Which of these questions is most important to use when assessing mental status in this patient?
Please point to articles in the room and parts of the body as I name them.
The nurse enters the client's room in the acute care unit immediately after he experiences a generalized tonic-clonic type seizure in bed. What is the first action the nurse should take? A. Reorient the client to person, place, and time. B. Notify the physician. C. Position the client in a side-lying position. D. Document the type of seizure in the client's health record
Position the client in a side-lying position.
PULMONARY VEINS RECEIVE
RECEIVE OXYGENATED BLOOD FROM THE LUNGS AND CARRY IT TO THE LEFT ATRIUM OF THE HEART.
HCO3- FUNCTIONS
Regulates acid-base balance
Various sounds are heard when assessing a blood pressure. What does the first sound heard through the stethoscope represent?Systolic pressure
Systolic pressure The first sound heard through the stethoscope, which is the onset of phase I of Korotkoff sounds, represents the systolic pressure.
(POTENTIAL HYDROGEN) PH OF 7 IS NEUTRAL PH BELOW 7 IS ACIDIC PH ABOVE 7 IS ALKALINE (BASIC) PH OF BLOOD IS PH OF STOMACH ACID IS
THE PH OF BLOOD IS BETWEEN 7.35-7.45 (SLIGHTLLY ALKALINE (BASIC) THE PH OF STOMACH ACID IS 1.5- 3.5 (ACIDIC) NORMAL VOLUME OF STOMACH FLUID IS 20-100 ML
ARTERIES carry oxygenated blood away from the heart to the tissues EXCEPT FOR
THE PULMONARY ARTERIES which carry deoxygenated blood from the RIGHT side of the heart to the lungs for oxygenation.
VEINS carry deoxygenated blood towards the heart from the tissuesEXCEPT FOR
THE PULMONARY VEINS which carry oxygenated blood to the left side of the heart.
Normal serum sodium levels range from 135 to 145 mEq/L. Water usually follows sodium so if sodium is low, it means
THERE IS TOO MUCH WATER
Normal vital signs for aged adult (65+)
Temperature 96.4-98.3 Pulse 40-100 Respirations 16-24 Blood pressure 120/80
TETANY
Tetany: A condition that is due usually to low blood calcium (hypocalcemia) and is characterized by spasms of the hands and feet, cramps, spasm of the voice box (larynx), and overactive neurological reflexes. Tetany is generally considered to result from very low calcium levels in the blood.
A nurse witnesses a traffic accident and dresses the open wounds sustained by a child. Later, in the hospital, the child develops complications from an infection in the wound. The family holds the nurse responsible for the complications and attempts to file a lawsuit. Which of the following statements is true regarding the Good Samaritan law? A. The Good Samaritan law will provide legal immunity to the nurse. B. The Good Samaritan law will not protect the nurse because she did not accept compensation. C. The Good Samaritan law is not applicable to health care workers. D. The Good Samaritan law will provide absolute exemption from prosecution.
The Good Samaritan law will provide legal immunity to the nurse.
IV
YOU HAVE TO REASSESS IN 15 MINUTES
tetany
a condition marked by intermittent/random muscular spasms, caused by malfunction of the parathyroid glands and a consequent deficiency of calcium.
A family that consists of two homosexual parents and three children living in the same house is an example of which type of family? a) Blended. b) Nuclear. c) Single-parent. d) Extended
b) Nuclear: The nuclear family is also known as the traditional family and is composed of two parents and their children. The parents might be heterosexual or homosexual, are often married or in a committed relationship, and all members of the family live in the same house until the children leave home as young adults.
A registered nurse enters a client's room and observes the unlicensed assistive personnel (UAP) pushing a client down on the bed. The client starts crying and informs the UAP that he needs to go to the bathroom. The UAP holds the client down and tells him he was just in the bathroom. The nurse observing this incident is aware that the UAP's action is an example of: A. battery. B. assault. C. fraud. D. defamation of character.
battery
The nurse is reviewing theories of illness. The germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions, is a basic belief of which theory of illness?
biomedical
The nurse documents a 2+ radial pulse. What assessment data indicated this result?
brisk, expected (normal) pulse A +2 pulse is a normal pulse.
13. When assessing a client's deep tendon reflexes, which technique would be most appropriate for the nurse to use? A) Use the blunt end of the reflex hammer to strike a smaller area. B) Strike the area slowly and methodically. C) Hold the reflex hammer between the thumb and index finger. D) Percuss the area of the tendon to be struck for the reflex.
c
8. Which of the following tests would be most appropriate for the nurse to use when assessing motor function of a client's trigeminal nerve? A) Ask client to differentiate sharp and dull sensations on the face. B) Have the client smile, frown, and wrinkle the forehead. C) Palpate temporal and masseter muscles while client clenches the teeth. D) Assess dilatation of the client's pupils with direct light.
c
Cation
cation: ion that carries a positive electric charge.
A patient repeats, I feel hot. Hot, cot, rot, tot, got. Im a spot. The nurse documents this as an illustration of:
clanging
During an interview, the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. This behavior is an example of:
compulsive disorder
osmolarity:
concentration of particles in a solution, or a solution's pulling power
Which example of client care is not the responsibility of the nurse? monitoring for changes in health status promoting safety and preventing harm; detecting and controlling risks tailoring treatment and medication regimens for each individual confirming a medical diagnosis
confirming a medical diagnosis
Anthropometric measurements provide
critical information about state of health and a child's growth pattern.
The emergency department (ED) nurse is caring for a client who recently immigrated from China and was injured in a motor vehicle collision (MVC). The nurse should implement interventions aimed at addressing which issue? A. cultural shock B. ethnocentrism C. generalization D. ageism
cultural shock
General survey begins
during interview phase of health assessment
LEFT VENTRICLE
ejects blood through aortic valve into aorta to body
percussion Diaphragmatic excursion
evaluates diaphragm movement during inspiration (descends) and expiration (elevates). Normal 2-4" (5-10cm)
Hyperkalemia
excess of potassium in the extracellular fluid
Hyperatremia
excess of sodium in the extracellular fluid
Antigen
foreign material capable of inducing a specific immune response
The nurse discovers speech problems in a patient during an assessment. The patient has spontaneous speech, but it is mostly absent or is reduced to a few stereotypical words or sounds. This finding reflects which type of aphasia?
global
Any deviations from normal ranges for a balanced water intake and output should alert the nurse to potential
imbalances
Intracellular Fluid (ICF)
intracellular fluid (ICF): fluid within the cell; synonym for cellular fluid
Illness is considered part of lifes rhythmic course and is an outward sign of disharmony within. This statement most accurately reflects the views about illness from which theory?
naturalistic
Potassium is essential for
normal cardiac, neural, and muscle function and contractility of all muscles
Manifestations of hypocalcemia include
numbness and tingling of fingers, mouth, or feet; tetany; muscle cramps; and seizures.
JVP
The jugular venous pressure (JVP, sometimes referred to as jugular venous pulse) is the indirectly observed pressure over the venous system via visualization of the internal jugular vein. It can be useful in the differentiation of different forms of heart and lung disease.
what do the kidneys do in the carbonic acid sodium bicarbonate buffer system
The kidneys assist the bicarbonate system by regulating the production of bicarbonate, (hco3-)
The nurse is reviewing the hot/cold theory of health and illness. Which statement best describes the basic tenets of this theory?
The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors of the body
When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources? A. Noted anatomists B. The underlying bones C. Their anatomical positions D. The underlying vascular network
The underlying bones
A registered nurse wishes to work as a nurse researcher. Which of the following is true regarding nurse researchers? -They serve as liaisons between staff members and directors of nursing -They tend to work in community health centers and long-term care units -They are responsible for the continued development and advancement of nursing -They usually have a baccalaureate degree in nursing
They are responsible for the continued development and advancement of nursing
HYPERVELEMIA TRESTMENT
Treatments include medications, such as diuretics, and a low-salt diet.
Vital signs are important indicators of the patient's
physiological status and response to the environment
The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess first? A. submental B. preauricular C. supraclavicular D. superficial cervical
preauricular
When examining a 16-year-old male teenager, the nurse should:
provide feedback that his body is developing normally and discuss the wide variation among teenagers on the rate of growth and development.
The function of lungs being responsible for controlling the amount of carbon dioxide in the blood describes
respiratory compensation.
The nurse recognizes that categories such as ethnicity, gender, and religion illustrate the concept of:
subcultures
Diffusion
tendency of solutes to move freely throughout a solvent from an area of higher concentration to an area of lower concentration until equilibrium is established
A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing? A. cluster B. tension C. migraine D. hypertensive
tension
A 75-year-old woman is at the office for a preoperative interview. The nurse is aware that the interview may take longer than interviews with younger persons. What is the reason for this?
An aged person has a longer story to tell.
Atrial Fibrillation
An irregular, often rapid heart rate that commonly causes poor blood flow.
A buffer is a substance that prevents body fluids from becoming overly acidic or alkaline. Buffers combine with excess acids or bases to prevent major changes in pH, keeping the pH of body fluids as close as possible to normal (7.35-7.45). Buffers work in one of two ways....?
1. A buffer can function like a base and bind or soak up free hydrogen ions. 2. Alternately, it may function like an acid and release hydrogen ions when too few are present in a solution.
MOST COMMON SIDE EFFECTS OF NARCOTIC MEDICATION
1. CONSTIPATION. 2. RESPITORY DEPRESSION
During auscultation of a patients heart sounds, the nurse hears an unfamiliar sound. The nurse should:
Ask another nurse to double-check the finding.
CONSIDERATIONS BEFORE STARTING AN IV
1. Ensure that the prescribed solution is clear and transparent. 2. the expiration date has not elapsed, (PASSED) 3. no leaks are apparent 4. and a separate label is attached
The four broad goals of the professional nurse PPTA
1. promote health 2.prevent illness 3. treat human responses to health or illness 4. advocate for individuals, families, communities, and populations.
Magnesium (Mg2+): second most abundant ICF cation after potassium; normal serum concentration of magnesium
1.3-2.3 mEq/L
3 Types of Health Assessments
1.Emergency assessment: life-threatening situation 2. Comprehensive assessment: annually on outpatient basis 3. Focused assessment: based on patient issues
The nurse is reviewing risk factors for breast cancer. Which of these women have risk factors that place them at a higher risk for breast cancer?
65 year old whose mother had breast cancer
Chloride (Cl−): major ECF anion; normal serum level of CHLORIDE IS
97-107 mEq/L
28. The emergency department nurse's rapid assessment of a young adult client admitted unresponsive reveals fixed, constricted pupils bilaterally. The nurse should consider what possible cause for this assessment finding? A) Recent narcotic use B) Hemorrhagic stroke C) Recent seizure activity D) Cerebellar lesion
A
Which of the following clients would be a candidate for total parenteral nutrition?
A client with colitis and bloody diarrhea Total parenteral nutrition is indicated when there is interference with nutrient absorption from the gastrointestinal tract or when complete bowel rest is necessary for healing. A client with bloody diarrhea and colitis requires complete bowel rest
An elderly Cantonese-speaking client has been admitted to the emergency department after suffering a fall and suspected hip fracture in her home. Emergency medical services personnel have reported to the nurse that the client speaks no English. Who is the best person to perform translation services to the client? -A hospital translator -A trusted friend -A Cantonese-speaking hospital employee -A family member
A hospital translator
ADH (VASSOPRESSIN)
A peptide hormone Made in hypothalamus Stored in posterior pituitary and released into blood stream or brain directly. Causes moderate vasoconstriction and raises blood pressure Causes water reabsorption of water in distal convoluted tubules and collecting duct of the kidney, and producing concentrated urine Released when body is dehydrated
The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a background of skills and experience from which to draw, are more likely to make their decisions using:
A set of rules.
What is the Nursing Process?
A systematic problem-solving approach to identify and treat human responses to actual or potential health problems.
Pain Assessment should be included when
Assessing vital signs - important to ask the patient regularly.
24. The nurse is conducting a focused neurological assessment of an 81-year-old client. When analyzing the assessment data, the nurse should be aware of what age-related neurological change? A) Impaired judgment B) Tremors accompanying intentional movements C) Loss of remote memory D) Loss of sensation in distal extremities
B
hypokalemia symptoms (alkolosis)
Abdominal distention, vomiting, and paralytic ileus would reflect hypokalemia.
GASTROINTESTINAL TRACT GI TRACT
Absorbs water and nutrients that enter the body through this route.
A mother brings her baby to the pediatric clinic for a 1-year-old wellness check. At birth the baby measured 22 inches and weighed 8 lbs. The nurse would expect to find which of the following when assessing the baby?
Baby measures 33 inches and weighs 24 lbs. When assessing normal growth and development, the pattern expected for the infant to 1 year old is to increase the height by one and one-half times the birth length and to triple the birth weight by age 1 year. Therefore, the nurse would expect this child to be 33 inches and weigh 24 lbs. (less)
The nurse assesses all assigned patients and sits in the nursing station to document assessment data for all patients. This is an example of:
Batch charting Batch charting occurs at the end of the shift or until all patients have been assessed to document. Point-of-care documentation occurs when nurses document assessment information as they gather it. The nurse uses a logical, organized approach and accurately describes all assessment data as precisely as possible when documenting patient information. (less)
General Survey BEGINS
Begins with the first moment of the encounter with the patient and continues throughout the health history Is the first component of the assessment Helps to form a global impression of the person Note physical appearance, body structure,mobility, and behavior
Which of the following reflects the traditional health and illness beliefs and practices of those of African heritage? Health is:
Being in harmony with nature
A nurse is working in a health care facility that is using charting by exception. Which of the following would the nurse expect to document?
Aching, burning pain in lower back With charting by exception, only abnormal findings are documented. The only abnormal finding listed is the aching burning pain in lower back.
Which of the dimensions of pain listed is being assessed by the question "How does the pain treatment you are getting affect your overall mood?"
Affective. The affective dimension concerns feelings, sentiments, and emotions related to the pain experience. The pain can affect the emotions and the emotions can affect the perception of pain. (less)
Many Asians believe in the yin/yang theory, which is rooted in the ancient Chinese philosophy of Tao. Which statement most accurately reflects health in an Asian with this belief?
All aspects of the person are in perfect balance
A client has sustained an injury to the cerebellum. Which area would be the primary area for assessment? A. Vital signs B. Neurologic system C. Cardiac function D. Coordination
Coordination
21. The nurse is assessing a 39-year-old woman who has a 20 pack-year history of cigarette smoking. When reviewing the client's current medication administration record, what drug would the nurse identify as increasing the woman's risk of stroke? A) Acetaminophen B) A beta-adrenergic blocker C) ASA D) An oral contraceptive
D
TRACHYPNEA
RAPID RESPIRATION RATE ( GREATER THAN 20 IN A MINUTE)
Which of the following levels of basic human needs is most basic? a) physiologic b) safety and security c) love and belonging d) self-actualization
a) physiologic Physiologic needs are the most basic and must be met at least minimally to sustain life.
14. When preparing to test a client for meningeal irritation, which of the following would be most important for the nurse to do first? A) Check for evidence of fever and chills. B) Ensure there is no injury to the cervical spine. C) Position the client prone. D) Check for a Babinski reflex.
b
Practicing careful hand hygiene and using sterile techniques are ways in which nurses meet which basic human need? a) physiologic b) safety and security c) self-esteem d) love and belonging
b) safety and security By carrying out careful hand hygiene and using sterile technique, nurses provide safety from infection.
Capillary Filtration
capillary filtration: passage of fluid across the wall of the capillary; results from the force of blood "pushing" against the walls of the capillaries
A nurse who usually works on the surgical unit is asked to float to the oncology unit because of staffing needs. The nurse arrives on the unit and becomes disoriented and stressed. The nurse is likely experiencing: A. culture shock. B. stereotyping. C. ethnocentrism. D. racism.
culture shock.
Hypercalcemia
excess of calcium in the extracellular fluid
pH
expression of hydrogen ion concentration and resulting acidity of a substance
fat vs lean tissue water
fat contains little water lean tissue is rich in water
What task should a nurse ask a client to perform to assess the function of cranial nerve XI?
shrug shoulders against resistance The function of cranial nerve XI can be assessed by asking the client to shrug his or her shoulders against resistance. Asking the client to move the tongue from side to side assesses function of the hypoglossal nerve, Cranial nerve XII. The nurse asks the client to swallow water to assess the function of cranial nerves IX and X. Asking the client to walk in heel-to-toe fashion helps in assessment of balance. (less)
A nurse is overheard in the hospital cafeteria making false comments about a client. The nurse is guilty of: A. slander. B. libel. C. invasion of privacy. D. assault.
slander
infiltration involves manifestations such as
swelling coolness pallor (paleness) at the catheter insertion site
iv tubing change
IV tubings are generally changed every 72 hours or as per the facility's policy. Solutions are replaced when they finish infusing or every 24 hours, whichever occurs first
An HIV-positive client discovers that his name is published in a research report on HIV care prepared by his nurse. He is hurt and files a lawsuit against her. Which offense has the nurse committed? A. Unintentional tort B. Invasion of privacy C. Defamation of client D. Negligence of duty
Invasion of privacy
Fluid intake and fluid output should be approximately the same in order to maintain fluid balance. Any other amount could lead to a fluid volume excess or deficit.
TRUE
A client who works in a manufacturing plant is attending a teaching session on plant safety. Which of the following would be an important risk prevention measure to teach regarding hearing?
Wearing ear protection when in the work environment An important risk prevention strategy would be to use ear protection when working or spending time in high noise levels. Even brief exposure can have harmful effects, and cleaning ears regularly would have no effect on preventing hearing loss due to environmental exposure. (less)
A patient has had a cerebrovascular accident (stroke). He is trying very hard to communicate. He seems driven to speak and says, I buy obie get spirding and take my train. What is the best description of this patients problem?
Wernicke's aphasia
The nurse is creating a nursing care plan for a patient who has numerous needs in the various dimensions of his life. As a result, the nurse is faced with the challenge of prioritizing certain needs over others. Place the following levels of needs in the correct ascending order. a) Self-esteem needs b) Physiologic needs c) Self-actualization needs d) Love and belonging e) Safety and security needs
b) Physiologic needs e) Safety and security needs d) Love and belonging needs a) Self-esteem needs c) Self-actualization needs
The results of a client's Rinne test are as follows: bone condcution > air conduction. How should the nurse explain these findings to the client?
"You have a conductive hearing loss." The Rinne test tests for conductive hearing loss. The client's results indicate that bone conduction is greater than air conduction which indicates conductive hearing loss. Air conduction should be twice as long as bone conduction. The whisper test evaluates loss of high frequency sounds. An audiogram can reveal a nerve related or unilateral hearing loss. (less)
PEAR DI ORANGE "SKIN OF AN ORANGE"
Agressive type of breast cancer
The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write
"bilateral lung sounds clear." Use phrases instead of sentences to record data. For example, avoid recording: "The client's lung sounds were clear both in the right and left lungs." Instead record: "Bilateral lung sounds clear." (less)
In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Which of the following describes the nurses best course of action?
Explain that the condition may be the result of hormonal changes and recommend that he see his physicsan
EXAMPLES OF CHRONIC PAIN (LASTS MORE THAN 6 MONTHS)
-ARTHRITIS (OSTEOARTHRITIS) -CANCER -DIABETES MELLITUS -FIBROMYALGA -BACK PAIN -MIGRAINES -MULTIPLE SCLEROSIS -SHINGLES -NERVE DAMAGE (NEUROPOTHY)
To reduce the potential for infection, IV solutions are replaced every
24 hours even if the total volume has not been completely instilled.
A 63-year-old Chinese-American man enters the hospital with complaints of chest pain, shortness of breath, and palpitations. Which statement most accurately reflects the nurses best course of action?
It is unclear what is happening with this patient; consequently, the nurse should perform an assessment in both the physical and the psychosocial realms
Hypermagnesemia
excess of magnesium in the extracellular fluid
External factors affecting heart rate
temperature, exercise, hormones, pain, pH, & emotions.
HEART AND BLOOD VESSELES
Circulate nutrients and water throughout the body Circulate blood through the kidneys under sufficient pressure for urine to form (pumping action of the heart) React to hypovolemia by stimulating fluid retention (stretch receptors in the atria and blood vessels)
Febrile reaction
Febrile reaction to blood components can occur because of the recipient's hypersensitivity to the donor's white blood cells. In this reaction, the client develops a fever and chills and may complain of a headache and malaise. (less)
Arrhythmia
Improper beating of the heart, whether irregular, too fast, or too slow.
The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next?
Increase the amount of strength used when attempting to percuss over the abdomen.
NERVOUS SYSTEM
Inhibits and stimulates mechanisms influencing fluid balance; acts chiefly to regulate sodium and water intake and excretion Regulates oral intake by sensing intracellular dehydration, which triggers thirst (thirst center located in the hypothalamus) Neurons, called osmoreceptors, are sensitive to changes in the concentration of ECF, sending appropriate impulses to the pituitary gland to release ADH or inhibit its release to maintain ECF volume concentration.
A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse?
Instruct the client to cough forcefully When auscultating crackles in the lung fields, the nurse should instruct the client to cough forcefully in an effort to open the airways. Then the nurse should auscultate again and note any changes. Lung sounds should be listened to with the diaphragm because they are high-pitched sounds. The bell is used for low-pitched sounds such as abnormal heart sounds. Breathing through the mouth lets the air in quicker but will not clear the airways. Use of accessory muscles is seen with respiratory distress. (less)
While caring for a Hispanic client, the nurse inadvertently offends the client. What is the best action by the nurse? A. Learn from the mistake and do not repeat it. B. Ask the client why he is so mad. C. Recognize that there is a cultural bias that led to the mistake. D. Examine the interaction and focus on the majority culture.
Learn from the mistake and do not repeat it.
A class of nursing students is studying the history of nursing. Who does the class learn that the founder of public health nursing is? -Clara Barton -Linda Richards -Lillian Wald -Dorothea Dix
Lillian Wald
The Henry Street Settlement was founded by whom? -Isabel Hampton Robb -Lillian Wald -Florence Nightingale -Dorothea Dix
Lillian Wald
Which of the following individuals provided community-based care and founded public health nursing? -Adelaide Nutting -Clara Barton -Lillian Wald -Sojourner Truth
Lillian Wald
A young couple who have been married less than a year are having difficulty with adjusting to parenting. What is a contributing factor to this level of maladjustment? A. Limited time in learning to be a marital partner B. Economic difficulties associated with parenting C. Involvement from significant others D. Stress of education, job, and parenting
Limited time in learning to be a marital partner
The nurse caring for a client formulates client outcomes based on the understanding that the outcomes should be which of the following? -General in scope -Measurable -Not bound to time -Abstract in nature
Measurable
Contractibility
Myocardial contractility represents the intrinsic ability of the heart/myocardium to contract. Changes in the ability to produce force during contraction result from incremental degrees of binding between myosin (thick) and actin (thin) filaments.
PAIN IS NOT A
NORMAL CONSEQUENCE OF AGING
The nurse is discussing BSEs with a postmenopausal woman. The best time for postmenopausal women to perform BSEs is:
On the same day every month.
VISCERAL PAIN
PAIN IN THE INTERNAL ORGANS, (MORE BLOOD SUPPLY, WHICH MAKES IT MORE PAINFUL)
ALDOSTERONE IS REGULATED BY THE
RENIN-ANGIOTENSIN SYSTEM enin is secreted from the kidneys in response to variations in blood pressure and volume and plasma sodium and potassium levels. If decreased blood pressure is detected, the adrenal gland is stimulated by these stretch receptors to release aldosterone, which increases sodium reabsorption from the urine, sweat, and the gut. This causes increased osmolarity in the extracellular fluid, which will eventually return blood pressure toward normal.
REGION OF BREAST MOST AFFECCTED BY BREAST CANCER, WHY?
RIGHT UPPER QUADRANT BECAUSE IT HAS THE MOST LYMPH NODES
When assessing aging adults, the nurse knows that one of the first things that should be assessed before making judgments about their mental status is:
Sensory perceptive abilities
A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved? A. Sternocleidomastoid B. Trapezius C. Masseter D. Temporalis
Sternocleidomastoid
4. MODULATION
The fourth phase is modulation or inhibition of painful or nociceptive stimuli. In the modulation phase, neurons descending from the brain release substances that inhibit the transmission of painful impulses. Analgesic drugs work at different steps of these processes to relieve pain.
GATE CONTROL THEORY OF PAIN
The gate control theory of pain asserts that non-painful input closes the "gates" to painful input, which prevents pain sensation from traveling to the central nervous system. Therefore, stimulation by non-noxious input is able to suppress pain. The gate control theory suggests that the signals encounter 'nerve gates' at the level of the spinal cord and they need to get cleared through these gates to reach the brain.
3. TRANSMISSION
The third phase, perception, is the conscious awareness of pain.
The nurse tests the six cardinal directions to test extraocular movement of the eye.
True
Similarly, the decreasing percentage of body fluid in older people is related to an increase in fat cells. In addition, older adults lose muscle mass as a part of aging. The combined increase of fat and loss of muscle results in reduced total body water; after the age of 60, total body water is about 45% of a person's body weight. This decrease in water increases the risk for
fluid imbalance in order adults
diuresis
increased or excessive production of urine.
The function of kidneys influencing the maintenance of the normal acid-base balance describes
renal compensation
In comparison with licensure, which measures entry-level competence, what does certification validate? A. innocence of any disciplinary violation B. specialty knowledge and clinical judgment C. more than 10 years of nursing practice D. ability to practice in more than one area
specialty knowledge and clinical judgment
A client has an edematous face, hands, and legs. Which health problem should the nurse suspect this client is experiencing? scleroderma hypothyroidism hyperthyroidism Cushing's syndrome
hypothyroidism
Kussmaul's Respiration (RD REGISTERED DIETICIAN)
Kussmaul's respiration. Increased rate and depth of breathing over a prolonged period of time. In response to metabolic acidosis, the body's attempt to blow off CO2 to buffer a fixed acid such as ketones. Ketoacidosis is seen in diabetics.
THORACIC CAVITY COVERS
LUNGS CHEST WALL MEDIASTINAL SPACE/CAVITY
During the examination, offering some brief teaching about the patients body or the examiners findings is often appropriate. Which one of these statements by the nurse is most appropriate?
"Your pulse is 80 beats per minute, which is within the normal range."
The body has three buffer systems:
(1) the carbonic acid-sodium bicarbonate buffer system, (2) the phosphate buffer system, and (3) the protein buffer system.
A normal pulse pressure range for an adult client is typically
30 to 50 mm Hg. A normal pulse pressure is 30 to 50 mmHg. Pulse pressure is the difference between the systolic and diastolic pressure reading
The nurse is conducting a class on alcohol and the effects of alcohol on the body. How many standard drinks (each containing 14 grams of alcohol) per day in men are associated with increased deaths from cirrhosis, cancers of the mouth, esophagus, and injuries?
4
CNS (INCLUDES BRAIN AND SPINAL CORD) GATE CONTROL THEORY OF PAIN
Central nervous system Gate Control Theory - most widely accepted Steps for transmission Gate opens Pain stimulus passes from peripheral to central nervous system at synaptic junction in lateral spinothalamic tracts Goes to limbic system and cerebral cortex In cerebral cortex pain response created, passes down efferent path, and response to pain.
A finding on palpation that suggests venous insufficiency is:
Diminished dorsalis pedis pulse in an edematous foot Venous insufficiency is associated with significant edema, and possibly diminished pedal pulses as a result. Ulceration, if present, tends to be on the sides of the foot and temperature is usually normal. Sensation does not tend to diminish. (less)
A group of students is reviewing information about the different types of murmurs. Which of the following would they identify as examples of midsystolic murmurs?
Innocent An innocent murmur is an example of a midsystolic murmur. Murmurs of mitral regurgitation and ventricular septal defect are examples of pansystolic murmurs. Murmur of mitral stenosis is an example of a diastolic murmur. (less)
A 17-year-old single mother is describing how difficult it is to raise a 3-year-old child by herself. During the course of the interview she states, I cant believe my boyfriend left me to do this by myself! What a terrible thing to do to me! Which of these responses by the nurse uses empathy?
It must be so hard to face this all alone.
The nurse is preparing to complete a health assessment on a 16-year-old girl whose parents have brought her to the clinic. Which instruction would be appropriate for the parents before the interview begins?
While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires?
Which tests are appropriate for a nurse to perform to test the cranial nerve VIII? A. Gag reflex, rise of the uvula, ability to swallow B. Clench the teeth, light touch, sharp/dull discrimination C. Smile, frown, show teeth, and puff out cheeks D. Whisper test, Rinne, and Weber
Whisper test, Rinne, and Weber
7. A nurse is having difficulty eliciting a patellar reflex during a client's neurological assessment. Which of the following would be most appropriate for the nurse to have the client do? A) Lock the fingers together and pull against each other. B) Clench the jaw tightly. C) Squeeze a thigh with the opposite hand. D) Stretch the arms over head.
a
Complications associated to respiratory failure include
a disruption of acid-base balance and a disruption in this organ's ability to excrete carbon dioxide; this causes the pH of the person's blood to fal
A young toddler is brought to the emergency room by his parents. The mother states that the child was playing on the floor with toys and suddenly began to wheeze. The mother reports no recent illnesses. The nurse suspects that the most likely cause of the wheezing is
a foreign body obstruction
The nurse has tested an adult client's visual fields and determined that the temporal field is 90 degrees in both eyes. The nurse should
document the findings in the client's records. Validate the eye assessment data that you have collected. This is necessary to verify that the data are reliable and accurate. Document the assessment data following the health care facility or agency policy. (less)
If the nurse makes an error while documenting findings on a client's record, the nurse should
draw a line through the error, writing "error" and initialing. Errors in documentation are usually corrected by drawing one line through the entry, writing "error," and initialing the entry. Never obliterate the error with white paint or tape, an eraser, or a marking pen. Keep in mind that the health record is a legal document. (less)
non-elecctrolytes are
chemical compounds that remain bound together when dissolved in a solution.
FINE-HEARD AT END EXPIRATION
discontinuous), do not clear with coughing, are high pitched pops/snaps. (simulate by rolling hair near ear or stethoscope).
The nurse has tested an adult client's visual fields and determined that the temporal field is 90 degrees in both eyes. The nurse should refer the client for further evaluation. examine the client for other signs of glaucoma. ask the client if there is a genetic history of blindness. document the findings in the client's records.
document the findings in the client's records.
What is the rate of administration for packed red blood cells?
1 unit over 2 to 3 hours, no longer than 4 hours Explanation: Packed red blood cells are administered 1 unit over 2 to 3 hours for no longer than 4 hours.
Normal ECF has a ratio of
20 parts bicarbonate to 1 part carbonic acid. (to be continued, 20 to 1)
A patient is reporting pain and informs the nurse that it has become unbearable. The first thing the nurse should do is what?
Assess the site and intensity of the pain. When a patient reports pain, the nurse must do an immediate pain assessment. Such an assessment is the first step of the nursing process. The complete pain assessment will cover different characteristics of the pain; however, the very first aspect is to ask about the location and intensity of the pain. Checking for the patient's allergies and what medication is ordered will follow after the assessment. The nurse would not call the physician at this point. (less)
26. The nurse has placed her hands behind the client's head and flexed the client's neck forward as far as the client can tolerate. During the test, the client experiences leg pain and bends his knees. This assessment finding is suggestive of what health problem? A) Ischemic stroke B) Meningitis C) Bell's palsy D) Brain stem lesion
B
When providing chemotherapeutic agents, which catheter is accessed with a noncoring needle?
Implanted venous access Correct Explanation: Implanted venous access catheters are accessed with a noncoring needle such as a Huber point needle.
a systemic infection includes manifestations such as
chills fever tacycardia hypotension
Hypokalemia
refers to a potassium deficit in the ECF.
When assessing the intensity of a patients pain, which question by the nurse is appropriate?
"How much pain do you have now?"
The nurse manager should provide further teaching to a new staff nurse on the pediatric unit when the staff nurse makes which statement?
"Physical growth in children takes place in an expected, steady pace." Physical growth takes place in an expected pattern, but at a variable pace. Cognitive development includes sensorimotor, preoperational, concrete operational, and formal operational stages. Development refers to changes in motor, language, psychosocial, and cognitive developments. Motor development follows a pattern, but individuals develop at variable rates. (less)
3 TYPES OF PAIN (ADD EXAMPLES HILLARY)
1. acute pain 2. chronic pain 3. neuropathic pain
Purpose of Pleurae & Pleural Space:
1. to maintain lungs in an expanded state EVEN at breathing rest. Ie. Prevents the lungs from collapsing
Bicarbonate (HCO3−): an anion that is the major chemical base buffer within the body; found in both ECF and ICF; normal serum bicarbonate
25-29 mEq/L
ARTERIAL BLOOD PH =
7.41
DYSPENEA
DIFFICULT OR LABORED BREATHING
The nurse is preparing to test a client's eyes for accommodation. The nurse would have the client focus on an object in which sequence for this test?
Far, then near When testing accommodation, the nurse would ask the client to focus on a distant object such as a finger or pencil and to remain focused on that object as the nurse moves it closer to the eyes. (less)
The nurse is preparing to assess a client's apical impulse. The nurse should palpate at which location?
Fifth intercostal space, left midclavicular line The apical impulse is palpated at the fourth or fifth intercostal space at the left midclavicular line.
A nurse auscultates a very loud murmur that occurs throughout systole and can be heard with the stethoscope partly off the chest. How should the nurse grade this murmur?
Grade 5 A very loud murmur that can be heard with the stethoscope partly off the chest is graded as Grade 5. A Grade 1 is very faint and a Grade 6 can be heard with the stethoscope entirely off the chest. A Grade 2 is quiet but heard immediately on placing the stethoscope on the chest. (less)
HEMOGLOBIN A1C TEST
Hemoglobin A1c, often abbreviated HbA1c, is a form of hemoglobin (a blood pigment that carries oxygen) that is bound to glucose. The blood test for HbA1c level is routinely performed in people with type 1 and type 2 diabetes mellitus test is limited to a three-month average because the lifespan of a red blood cell is three months
During a mental status examination, the nurse wants to assess a patients affect. The nurse should ask the patient which question?
How do you feel today?
A nurse is preparing a presentation for a local community group about coronary artery disease and culture. Which information would the nurse include?
Hypertension is more prevalent in African Americans. Ethnicity plays a role in developing coronary heart disease. African Americans, Mexican Americans, American Indians, native Hawaiians, and some Asian Americans have a higher risk of heart disease thought to be due to more severe hypertension and higher rates of obesity and diabetes in these populations (less)
A client presents to the emergency department after being hit in the head with a baseball bat during a game. The nurse should assess for which condition? Hyphema Blepharitis Chalazion Iris nevus
Hyphema
During a prenatal check, a patient begins to cry as the nurse asks her about previous pregnancies. She states that she is remembering her last pregnancy, which ended in miscarriage. The nurses best response to her crying would be:
I can see that you are sad remembering this. It is all right to cry.
body weight percetage in adult women
INTRAVASCULAR- 5% INTERSTITIAL -10% INTRACELLULAR- 35% TOTAL = 50% WATER
The client is having a Weber test. During a Weber test, where should the tuning fork be placed?
In the midline of the client's skull or in the center of the forehead. The Weber test is performed by striking the tuning fork and placing its stem in the midline of the client's skull or in the center of the forehead. In the Rinne test, the tuning fork is struck and placed on the mastoid process behind the ear. The tuning fork is not placed near the external meatus of each ear or under the bridge of the nose. (less)
A nurse assesses a client who presents to the health care clinic with suspected Bell's palsy. What finding should the nurse anticipate on examination?
Inability to wrinkle the forehead Bell's palsy is a peripheral injury to cranial nerve VII (facial) that causes the inability to close the eyes, wrinkle the forehead, or raise the forehead, along with paralysis of the lower part of the face. Drooping of the eyelids (ptosis) is seen with weak eye muscles such as in myasthenia gravis. Limited lateral gaze of the eyes may indicate increased intracranial pressure. Paralysis of the lower lip is not seen in any common disorder of cranial nerve function. (less)
BREAST DENSITY
Individualized and BRCA1 and BRCA2 screening Mammography Clinical Breast Examination Breast Self-Examination Magnetic Resonance Imaging (MRI) Chemoprevention
A middle-aged client reports difficulty in reading. Which action by the nurse is appropriate to test near visual acuity using a Jaeger reading card?
Instruct the client hold the chart 14 inches from the eyes To test near visual acuity, the nurse should have the client hold the chart 14 inches from the eyes. The Snellen chart should be kept at eye level, 20 feet away on the wall when testing for distant vision. An arm's length is an arbitrary length depending on the size of the client and is not an accurate method for testing. The chart should not be placed on a table 17 inches away from the client. (less)
Molecules in the body that remain intact, without a charge, are called
NONELECTROLYTES
RESPITORY RATE (THE NUMBER OF BREATHS YOU TAKE PER MINUTE)
NORMAL RR FOR ADULT = 12-20 INFANTS LESS THAN A YEAR = 30-60 CHILD = 20-30 ANYTHING OVER 25 FOR ADULT IS ABNORMAL
adults nay have a risk for hypertension and their HR MAY
NOT BE FAST. HYPERTENSION IS A SILNT KILLER! HYPERTENSION DIET INCLUDES LOW CARBS, HIGH PROTEIN, AND HIGH IN VEGETABLES.
Which client has more extracellular fluid?Which client has more extracellular fluid?
Newborn Explanation: Newborns have more extracellular fluid than intracellular fluid.
Therapeutic Communication
Nonjudgmental actions to address patient concerns and facilitate achievement of patient outcomes. Process requires caring, empathy and self-reflection by the nurse. Effective communication skills encourage a trusting relationship between the nurse and patient
The nurse is assessing the breasts of a 68-year-old woman and discovers a mass in the upper outer quadrant of the left breast. When assessing this mass, the nurse is aware that characteristics of a cancerous mass include which of the following? Select all that apply
Nontender mass Hard, dense, and immobile Iregular, poorly delineated border
If palpable, superficial inguinal nodes are expected to be:
Nontender, mobile, and 1 cm in diameter Healthy lymph nodes are nontender and mobile. Inguinal lymph nodes can be 1 to 2 cm in diameter.
Barriers to incorporating EBP include:
Nurses lack of research skills in evaluating the quality if research studies
ARTERIES CARRY WHAT KIND OF BLOOD
OXYGENATED BLOOD EXCEPT FOR PULMONARY ARTERIES
Which of these individuals would the nurse consider at highest risk for a suicide attempt?
Older adult man who tells the nurse that he is going to join his wife in heaven tomorrow and plans to use a gun
parenteral nutrition
Parenteral nutrition (PN) is the feeding of a person intravenously, bypassing the usual process of eating and digestion. The person receives nutritional formulae that contain nutrients such as glucose, amino acids, lipids and added vitamins and dietary minerals.
In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate?
Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat
Patients with Special Considerations
Patients unable to report pain Patients with opioid tolerance
While examining a 75-year-old woman, the nurse notices that the skin over her right breast is thickened and the hair follicles are exaggerated. This condition is known as:
Peau dorange.
While providing client care, a nurse determines that a client adheres to the health belief model. Which of the following would the nurse need to assess as a factor possibly affecting the client's response to illness? -Stress management -Nutritional awareness -Environmental sensitivity -Personality characteristics
Personality characteristics
After teaching a group of students about blood pressure and Korotkoff's sounds, the instructor determines that the teaching was successful when the students identify which of the following?
Phase II sounds appear muffled and swishing. Phase II sounds are typically muffled or swishing and occur after Phase I sounds, which are faint, clear, repetitive tapping sounds indicating the systolic pressure. Phase IV sounds are muffled, less distinct, and softer (with a blowing quality) and are followed by Phase V, which is characterized by all sound disappearing completely. The last sound heard before continuous silence signals the onset of Phase V and is commonly considered the diastolic pressure. (less)
A 23-year-old patient in the clinic appears anxious. Her speech is rapid, and she is fidgety and in constant motion. Which of these questions or statements would be most appropriate for the nurse to use in this situation to assess attention span?
Pick up the pencil in your left hand, move it to your right hand, and place it on the table.
Which action by a nurse demonstrates proper technique for assessment of chest expansion?
Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath The correct technique for assessment of chest expansion is for the examiner to place the hands on the posterior chest wall with thumbs at the level of T9 or T110 and pressing together a small skin fold. Ask the client to take a deep breath and observe the movement of the thumbs. Using the ball of the hand to feel vibration tests for tactile fremitus. Percussion of the posterior chest wall assesses for tone. The use of a stethoscope is auscultation and this technique assesses for adventitious sounds within the lungs. (less)
A client with renal disease requires IV fluids. It is important for the nurse to
Place the fluids on an electronic device IV electronic infusion device usefully and accurately regulates the infusion rate
PNEUMOTHORAX/ SPONTANEOUS PNEUMOTHORAX
Pneumothorax is a collection of free air in the chest cavity (thoracic cavity) that causes the lung to collapse. Pneumothorax may occur on its own in the absence of underlying disease; this is termed spontaneous pneumothorax.
MODIFIABLE RISK FACTORS FOR BREAST CANCER
Postmenopausal obesity Use of HRT ( Hormone replacement therapy) Alcohol use Physical inactivity
The nurse observes a middle-aged colleague fully extending her arm to read the label on a vial of medication. Which of the following age-related changes is the nurse likely to have observed? Presbyopia Cataract formation Loss of convergence Macular degeneration
Presbyopia
A group of nurses is planning to investigate the effectiveness of turning immobilized stroke clients more frequently in order to prevent skin breakdown. The team has begun by formulating a PICO question. Which of the following will the "O" in the team's PICO question refer to? -The currently-used turning schedule -Clients who have experienced a stroke -Turning clients more frequently -Preventing skin breakdown
Preventing skin breakdown
When the nurse is evaluating the reliability of a patients responses, which of these statements would be correct? The patient:
Provided consistent information and therefore is reliable
The nurse researcher would like to gather data on the attitudes of young adults on spirituality and health care. What is the most effective form of research on this topic? -A Delphi study -Methodologic survey -Quantitative research -Qualitative research
Qualitative research
HOW MANY LOBES IN EACH LUNG, AND WHY?
RIGHT LUNG HAS 3 LOBES LEFT LOBE HAS FOUR LOBES (TO LEAVE SPACE FOR YOUR HEART)
When assessing a client's pulse, the nurse should be alert to which of the following characteristics?
Rate, rhythm, amplitude and contour, and elasticity. Several characteristics should be assessed when measuring the radial pulse: rate, rhythm, amplitude and contour, and elasticity.
The nurse makes which adjustment in the physical environment to promote the success of an interview?
Reduces noise by turning off televisions and radios
Vital Signs REFLECT
Reflect health status, cardiopulmonary function, and overall body function Need to assess patient medications first Frequency Baseline
ADRENAL GLANDS DECREASE AND INCREASE OF ALDOSTERONE
Regulate blood volume and sodium and potassium balance by secreting aldosterone, a mineral corticoid secreted by the adrenal cortex The primary regulator of aldosterone appears to be angiotensin II, which is produced by the renin-angiotensin system. A decrease in blood volume triggers this system and increases aldosterone secretion, which causes sodium retention (and thus water retention) and potassium loss. Decreased secretion of aldosterone causes sodium and water loss and potassium retention. Cortisol, another adrenocortical hormone, has only a fraction of the potency of aldosterone. However, secretion of cortisol in large quantities can produce sodium and water retention and potassium deficit.
Which of the following is an example of tertiary health promotion? -Family counseling -Water treatment -Rehabilitation -Pap tests
Rehabilitation
A nurse is assigned the care of a client who speaks only French. The nurse does not know the language. What action is appropriate for the nurse in this case? -Ask another nurse to take care of the client -Request a professional interpreter -Communicate with the client non-verbally -Refuse to take charge of the client
Request a professional interpreter
When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields?
Resonance Normal lung tissue elicits a resonance tone when percussed. Hyperresonance is elicited in cases of trapped air such as in emphysema or pneumothorax. Dullness may characterize areas of increased density such as consolidation, pleural effusion, or tumor. Tympany is elicited over air filled spaces such as puffed out check or stomach bubble. (less)
Which of the following Standards of Professional Performance, as defined by the ANA, has the nurse considering factors related to safety, effectiveness, cost, and the impact on practice in the planning and delivery of nursing services? -Leadership -Practice Evaluation -Quality of Practice -Resource Utilization
Resource Utilization
HYPOTONIC SOLUTION HAS A LOWER OSMALARITY, AND CAUSES CELLS TO FLUID MOVES OUT OF THE INTRAVASCULAR SPACE AND INTO THE INTRACELLULAR FLUID, CAUSING THE CELLS TO
SWELL, AND POSSIBLY BURST
The nurse performs an assessment of the client and the family to have a better understanding of client and family needs. Which of the following is an individual need? A. Safety B. Education C. Socialization D. Political
Safety
The nurse assists a postoperative client with ambulation. The nurse recognizes that assisting the client when performing this skill meets which of Maslow's basic human needs? -Love and belonging -Self-actualization -Self-esteem -Safety and security
Safety and security
A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true? A. She obtains a 20% correct score at 100 feet. B. She can accurately name 20% of the letters at 20 feet. C. She can see at 20 feet what a normal person could see at 100 feet. D. She can see at 100 feet what a normal person could see at 20 feet.
She can see at 20 feet what a normal person could see at 100 feet.
The nurse is assessing an older adult with the Mini-Cog. The older adult is unable to recall the three unrelated words. Which type of memory is the nurse assessing?
Short-term memory One aspect of the Mini-Cog is to assess the individual's ability to recall three unrelated words after completing a task. This assesses short-term memory; things the person is presently and actively thinking about. Sensory memory is retention of a sensory image for a very brief period of time. Episodic long-term memory involves the recall of past events and personally relevant information, whereas semantic long-term memory involves the retrieval of facts, vocabulary, and general knowledge. (less)
with multiple traumas received in an A patient is brought by ambulance to the emergency department automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection?
Simultancously ask history questions while performing the examination and initiating life-saving measures
During an interview, the nurse would expect that most of the interview will take place at what distance?
Social distance
Parents raising two school-aged children incorporate their religious beliefs into the family's daily life. The family's beliefs regarding religion include dietary considerations, worship practices, attitudes, and values. This is an example of which function of the family? -Socialization -Reproductive -Physical -Affective and coping
Socialization
The nurse is assessing the communication style of the client. Communication is an example of which dimension of the individual? -Sociocultural dimension -Environmental dimension -Physical dimension -Emotional dimension
Sociocultural dimension
HOW OFTEN DO YOU REPLACE IV SOLUTIONS?
Solutions are replaced when they finish infusing or every 24 hours, whichever occurs first.
A client who suffers from arthritis complains of sharp pain in her knees and elbows. The nurse recognizes this is what type of pain?
Somatic Pain nociception has various locations. Visceral pain originates from abdominal organs; patients often describe this pain as crampy or gnawing. Somatic pain originates from skin, muscles, bones, and joints; patients usually describe somatic pain as sharp (D'Arcy, 2014). Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues. It is often burning or sharp, such as with a partial-thickness burn. Referred pain originates from a specifi c site, but the person experiencing it feels the pain at another site along the innervating spinal nerve (Fig. 6.3). (less)
PHYSICAL ASSESSMENT CCOMPONENTS (AKA REVIEW OF SYSTEMS)
Speak in lay terms not medical terms. Inform patient of each assessment PRIOR TO doing the assessment. Start with general questions as you examine each system followed by detailed questions as needed. Answer patient questions Document your findings
The nurse enters an older client's room to assess for pain and discovers the client is hard of hearing. What is the nurse's best action?
Speak to the client face to face. When assessing the older patient for pain, determine whether the patient has any auditory impairment. If so, position your face in the patient's view, speak in a slow, normal tone of voice, reduce extraneous noises, and provide written instructions. The FLACC scale is used primarily for infants. Hearing aids are expensive and suggesting to purchased one does not aid in the pain assessment at present. (less)
Which of the following is a symptom related to vertigo?
Spinning sensation Vertigo is defined as the misperception or illusion of motion of the person or the surroundings. Most people with vertigo describe a spinning sensation or say they feel although objects are moving around them. (less)
A 17-year-old high school senior presents to the clinic in acute respiratory distress. Between shallow breaths he states he was at home finishing his homework when he suddenly began having right-sided chest pain and severe shortness of breath. He denies any recent traumas or illnesses. His past medical history is unremarkable. He doesn't smoke, but drinks several beers on the weekend. He has tried marijuana several times but denies any other illegal drugs. He is an honour student and on the basketball team. His parents are both in good health. He denies any recent weight gain, weight loss, fever, or night sweats. Examination shows a tall, thin young man in obvious distress. He is diaphoretic and breathing at a rate of 35 breaths per minute. Auscultation reveals no breath sounds on the right side of his superior chest wall. On percussion he is hyperresonant over the right upper lobe. With palpation he has absent fremitus over the right upper lobe. What disorder of the thorax or lung best describes his symptoms?
Spontaneous pneumothorax Spontaneous pneumothorax occurs suddenly, causing severe dyspnea and chest pain on the affected side. It is more common in thin young males. On auscultation of the affected side there will be no breath sounds; on percussion there is hyperresonance or tympany. There will be an absence of fremitus to palpation. Given this young man's habitus and pneumothorax, you may consider looking for features of Marfan's syndrome. (less)
Which of these statements is true regarding the use of Standard Precautions in the health care setting?
Standard precautions are intended for use with all patients regardless of their risk or presumed infection status.
Start Set 1
Start Set 1
The nurse has completed an assessment on a patient who came to the clinic for a leg injury. As a result of the assessment, the nurse has determined that the patient has at-risk alcohol use. Which action by the nurse is most appropriate at this time?
State, You are drinking more than is medically safe. I strongly recommend that you quit drinking, and Im willing to help you
A mother brings her 28-month-old daughter into the clinic for a well-child visit. At the beginning of the visit, the nurse focuses attention away from the toddler, but as the interview progresses, the toddler begins to warm up and is smiling shyly at the nurse. The nurse will be most successful in interacting with the toddler if which is done next?
Stoop down to her level, and ask her about the toy she is holding.
During a blood transfusion of a client, the nurse observes the appearance of rash and flushing in the client, although the vital signs are stable. Which intervention should the nurse perform for this client first?
Stop the transfusion immediately The nurse needs to stop the transfusion immediately. The nurse should prepare to give an antihistamine because these signs and symptoms are indicative of an allergic reaction to the transfusion, infuse saline at a rapid rate, and administer oxygen if the client shows signs of incompatibility
A couple with adolescent children is most likely to focus on which of the following developmental tasks? A. Strengthening marital relationships B. Establishing a mutually satisfying marriage C. Adjusting to retirement D. Coping with loss of energy and privacy
Strengthening marital relationships
A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be
Subjective
The nurse is reviewing a SOAPIE note in the patient's medical record. The nurse recognizes that "States no longer nauseous and would like something to eat" is which part of the SOAP note.
Subjective This is an example of subjective assessment data because it contains data verbally provided by the patient. Objective data are data cues the nurse can observe. Analysis involves the identification of patient problems based on the subjective and objective data. The plan outlines the course of action taken to address the problem. Evaluation involves a determination of whether the plan and attainment of expected patient outcomes. (less)
individual who takes the magicoreligious perspective of illness and disease is likely to believe that his or her illness was caused by:
Supernatural forces
The nurse is palpating a female patients breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation?
Supine with the arms raised over her head
As a mandatory reporter of elder abuse, which must be present before a nurse should notify the authorities?
Suspicion of elder abuse and/or neglect
A nurse is working with a client who is victim of a gun shooting. The client has an increased pulse rate and pupil dilation and is clearly in stress. The nurse recognizes the "fight-or-flight" response in this client and understands that this represents an activation of which of the following?
Sympathetic nervous system The sympathetic nervous system ("fight-or-flight" system) is activated during stress and elicits responses such as decreased gastric secretions, bronchiole dilatation, increased pulse rate, and pupil dilatation. The parasympathetic nervous system functions to restore and maintain normal body functions, for example, by decreasing heart rate. The somatic nervous system mediates conscious, or voluntary, activities, whereas the autonomic nervous system (comprising the sympathetic and parasympathetic systems) mediates unconscious, or involuntary, activities. The central nervous system (CNS) encompasses the brain and spinal cord, which are covered by meninges, three layers of connective tissue that protect and nourish the CNS. (less)
SYSTEMIC CIRCULATION
Systemic circulation is the part of the cardiovascular system which carries oxygenated blood away from the heart to the body, and returns deoxygenated blood back to the heart Systemic circulation, the larger loop of the figure eight, involves blood flow from the heart to the body cells and back again
FOR ADULTS WITH PAIN WE USE
THE NUMERIC SCALE TO ASSESS PAIN.
WHO IS CONSIDERED THE PRIMARY DATA SOURCE?
THE PATIENT is considered the Primary Data Source - provides their perspective of past & current problems. This is called Subjective Data. - is evaluated by the nurse as either a Reliable or Unreliable Historian.
PULMONAARY EMBOLISM PATIENT TILT (trendelenburg position feet higher than head 15-30 degrees
THEM TO THE LEFT SIDE TO try and trap the embolism into the roght atrium. *USE APPROPRIATELY SIZED COMPRESSION STOCKINGS, BUT DON'T LET THE PT SLEEP WITH THEM ON! f you've got some kind of embolus (air, is the more likely candidate) and you want to prevent it from getting into the general body circulation, the best way you can prevent this is to: (1) get the patient into a trendelenberg position. this is where the patient's head is lower than their feet. what does that do? it now makes the left ventricle of the heart (it's apex) the highest part of the heart if you consider it's relation to the horizon. (2) turn the patient to their left side. the aortic valve and the aorta are the last places the blood travels as it makes it way out of the heart and it's your last chance to prevent an air embolism from escaping into the general circulation. any air is either going to float to the top of the highest point of the structure it is in (not a danger in the atrium, goes to the apex of the heart if it's in the ventricle). meanwhile, the liquid blood continues to be pumped around normally.
Diminished cognitive ability and hypertension may result from hyperchloremia
TRUE
b) Insulin promotes the transfer of potassium from the extracellular fluid into skeletal muscle and liver cells.
TRUE
b) Sodium is regulated by the renin-angiotensin-aldosterone system.
TRUE
During an examination, the nurse notes that a patient is exhibiting flight of ideas. Which statement by the patient is an example of flight of ideas?
Take this pill? The pill is red. I see red. Red velvet is soft, soft as a babys bottom.
The pulse pressure is calculated by subtracting the diastolic pressure from the systolic pressure. In other words, it is the change in pressure from the diastolic level to the systolic level. It is determined by two factors, the stroke volume and the compliance of the arterial system. The stroke volume, of course, is the amount of the blood injected into arteries by each heart beat. The compliance is determined by the elasticity of the arterial system. Flexible arteries that expand easily have a high compliance. Stiff arteries have a low compliance.
Teach patients Educate about the risks of hypertension Vital signs monitor Doppler technique FOR DETERMINING THE POINT OF SYSTOLIC AND DIASTOLIC BLOOD PRESSURES
A nurse is caring for a female client age 17 years whose left leg was amputated after being crushed in a motor vehicle accident. Which of the following interventions might the nurse perform to accommodate the client's intellectual dimension? -Encouraging friends and relatives to visit often and bring games to distract her -Considering the client's developmental stage when planning nursing care -Providing the opportunity for a counselor to come in and talk to her about her loss -Teaching her how to care for the stump and explaining the rehabilitation program
Teaching her how to care for the stump and explaining the rehabilitation program
The staff educator from the hospital's respiratory unit is providing a public educational event. The educator is talking about health promotion activities for people with respiratory diseases or those who are at high risk for respiratory complications. What would the educator include in the presentation?
Teaching strategies to reduce complications of existing diagnoses Health promotion activities focus on preventing disease from developing (primary prevention), screening to identify conditions at an early curable stage (secondary prevention), and reducing complications of existing or established medical diagnoses (tertiary prevention)
During an interview, a woman has answered yes to two of the Abuse Assessment Screen questions. What should the nurse say next?
Tell me about this abuse in your relationships
During a mental status assessment, which question by the nurse would best assess a persons judgment?
Tell me what you plan to do once you are discharged from the hospital.
The nurse is preparing to assess a client's vital signs. Which vital sign should the nurse assess first?
Temperature The client's temperature is measured first. Doing so puts the client at ease and causes him or her to remain still for several minutes. This is important because pulse, respiration, and blood pressure are influenced by activity and anxiety. (less)
In which order should a nurse assess a client's vital signs?
Temperature, pulse, respiration, and blood pressure When assessing the vital signs of the client, the nurse should begin by measuring the client's temperature, to put the client at ease and to quiet the client for better assessment of the remaining vital signs. Pulse, respiration, and blood pressure can be altered by anxiety and activity. (less)
When assessing the client's ear, which finding should the nurse identify as indicating a need for further assessment and possible treatment?
Tender tragus A tender tragus is associated with otitis externa or a postauricular cyst. Darwin's tubercle is a clinically insignificant finding. Normally, cerumen may be yellow, orange, red, brown, gray, or black and soft, moist, dry, flaky, or even hard. A pearly gray tympanic membrane is a normal finding. (less)
A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis? A. Tension B. Migraine C. Cluster D. Analgesic rebound
Tension
A client comes to the trauma unit in respiratory distress following a motor vehicle accident. On examination, the nurse notices that the trachea is deviated from the midline. What does this finding indicate? Tension pneumothorax Cardiac tamponade Flail chest Severe neck fracture
Tension pneumothorax
Which model is most useful in examining the cause of disease in an individual, based upon external factors? -The Health-Illness Continuum -The High-Level Wellness Model -The Health Belief Model -The Agent-Host Environment Model
The Agent-Host Environment Model
A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which of the following observations can be made by the nurse and athletes by measuring the blood pressure?
The ability of the arteries to stretch Measuring the blood pressure helps to assess the efficiency of the client's circulatory system. Blood pressure measurements reflect the ability of the arteries to stretch, the volume of circulating blood, and the amount of resistance the heart must overcome when it pumps blood. Measuring the blood pressure does not help in assessing the thickness of blood, oxygen level in the blood, or the volume of air entering the lungs. (less)
As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure?
The blood pressure increases. The elasticity and resistance of the walls of the arterioles help to maintain normal blood pressure. With aging, the walls of arterioles become less elastic, which interferes with their ability to stretch and dilate, contributing to a rising pressure within the vascular system that is reflected in an increased blood pressure. (less)
acid base compensation
The body compensates for the metabolic acidosis by increasing ventilation through the lungs, thus increasing the rate of carbonic acid excretion, resulting in a fall in PaCO2. To compensate for respiratory alkalosis, the kidneys increase the excretion of HCO to the urine. Kidneys compensate for respiratory acidosis by increasing the excretion of H ion into the urine. The kidneys respond to metabolic alkalosis by retaining acid and excreting HCO.
The nurse is completing a client's ear assessment. What assessment finding would indicate the need to perform Weber's test?
The client has unilateral hearing loss. Unilateral hearing loss is the major indication for Weber's test, which helps distinguish between conductive hearing and sensorineural hearing. Older age, infection, and a history of stroke are not specific indications for this test. (less)
Who is the authority on the presence and extent of pain experienced by a patient?
The patient The only one who can be a real authority on whether, and how, an individual is experiencing pain is that individual.
FOR IV THERAPY, THE PRIMARY AND SECONDARY TUBING SHOULD BE
The primary tubing should be approximately 110 inches (2.8 m) long and the secondary tubing should be about 37 inches (94 cm) long.
The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present?
The renal system retains more water. When antidiuretic hormone is present, the distal tubule of the nephron becomes more permeable to water. This causes the renal system to retain more water. A lack of antidiuretic hormone causes increased production of dilute urine. Antidiuretic hormone does not cause thirst.
Which vessels return the lymph fluid to circulation?
The thoracic ducts at the junctions of the subclavian and internal jugular veins return the lymph fluid to the circulation. There are no internal jugular, epitrochlear, or infraclavicular ducts. (less)
Which statement demonstrates the safest way to document assessment findings of drainage noted in both eyes of a client? A. Thick, purulent drainage is noted at inner corner of OD. B. Thick, purulent drainage is noted at inner corner of OS. C. Thick, purulent drainage is noted at inner corner of OU. D. Thick, purulent drainage is noted at inner corner of both eyes.
Thick, purulent drainage is noted at inner corner of both eyes.
BOTH NEWBORNS AND ELDERLY ARE
UNDERTREATED FOR PAIN
AB BLOOD TYPE IS
UNIVERSAL RECIPIENTS (LACK OF AGGULTIN/CLOTTING Agglutination (clumping
2 EXAMPLES OF NONELECTROLYTES IN THE
UREA AND GLUCOSE
NONELECTROLYTES HAVE NO CHARGE 2 EXAMPLES (UR GAY)
UREA AND GLUCOSE
During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss his sons treatment, however, he suddenly crosses his arms against his chest and crosses his legs. This changed posture would suggest that the parent is:
Uncomfortable talking about his sons treatment.
VASCULAR NETWORK
Vascular NetworKTransports oxygenated blood throughout the body and returns deoxygenated blood to heart and lungs for reoxygenation.
Venous System
Veins, venules & connecting veins (perforators) collect unoxygenated blood from the body and return it to the heart.Venous walls are a thin-walled, low-pressure system - rely on other body systems for venous return.
vesicular breath sounds
Vesicular breath sounds are heard across the lung surface. They are lower-pitched, rustling sounds with higher intensity during inspiration. During expiration, sound intensity can quickly fade. Inspiration is normally 2-3 times the length of expiration.
PRIMARY BODY FLUID IS
WATER
In response to a question about stress, a 39-year-old woman tells the nurse that her husband and mother both died in the past year. Which response by the nurse is most appropriate?
What did you do to cope with the loss of both your husband and mother?
The nurse is assessing a new patient who has recently immigrated to the United States. Which question is appropriate to add to the health history?
When did you come to the United States, and from what country?
During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is most accurate?
Whether the inversion is a recent change should be determined.
electrolytes
are substances that are capable of breaking into particles called ions
ION
atom or molecule carrying an electric charge in solution
When assessing the client for pain, the nurse should
believe the client when he or she claims to be in pain. "Pain is whatever the person says it is." It is important to remember this definition when assessing and treating pain.
normal heart rate
between 60-100 beats per minute. Athletes may have a resting HR as low as 40 bpm.
4. A client complains of headaches each morning that resolve after getting out of bed. Which of the following would be most appropriate for the nurse to do? A) Assess the client's level of consciousness. B) Assess the client's deep tendon reflexes. C) Refer the client for immediate medical follow-up. D) Refer the client for physical therapy and occupational therapy.
c
most common acid in body? most common base in body?
carbonic acid (H2CO3), bicarbonate hco3-
Upon examination of the ear with an otoscope, the nurse documents the skin of the ear canal as thickened, red, and itchy. The nurse would expect this finding with a diagnosis of
chronic otitis media
The nurse has tested the near visual acuity of a 45-year-old client. The nurse explains to the client that the client has impaired near vision and discusses a possible reason for the condition. The nurse determines that the client has understood the instructions when the client says that presbyopia is usually due to congenital cataracts. decreased accommodation. muscle weakness. constant misalignment of the eyes.
decreased accommodation.
A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?
distended neck veins Flid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended
Hydrostatic Pressure
force exerted by a fluid against the container wall
The nurse reviews the laboratory test results of a client and notes that the client's potassium level is elevated. What would the nurse expect to find when assessing the client's gastrointestinal system?
high potassium= diarrhea
Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as:
hyponatremia. Hyponatremia refers to a sodium deficit in the extracellular fluid caused by a loss of sodium or a gain of wate
aldosterone and adh hormone both
incerase blood pressure and blood voolume
Because ECF is more easily lost from the body than ICF,
infants are more prone to fluid volume deficits.
3 types of solutions
isotonic solution = normal rbc hypotonic solution = dilute swollen red blood cell hyperrtonic solution= concentrated/shrunken/creneted blood cell
When evaluating a patients pain, the nurse knows that an example of acute pain would be:
kidney stones
Osteoporotic thinning and collapse of the vertebrae secondary to bone loss in an elderly client may result in
kyphosis (hunchback) ABNORMALLY CURVED SPINE In older adults, osteoporotic thinning and collapse of the vertebrae secondary to bone loss may result in kyphosis.
An adult client visits the clinic and tells the nurse that he has had excessive tearing in his left eye. The nurse should assess the client's eye for A. viral infection. B. double vision. C. allergic reactions. D. lacrimal obstruction.
lacrimal obstruction.
In order to palpate an apical pulse when performing a cardiac assessment, where should the nurse place the fingers?
left midclavicular line at the fifth intercostal space The apical pulse is the point of maximal impulse and is located in the fifth intercostal space at the left midclavicular line when the client is placed in a sitting position. The apical impulse is palpated in the mitral area and therefore cannot be palpated at the left midclavicular line at the third intercostal space, at right of the midclavicular line at the third intercostal space and at right of the midclavicular line at the fifth intercostal space. (less)
PLEURAL FRICTION RUB
loud, coarse low pitched grating, scratching, or squeaking sound (continuous). Indicates inflammed pleurae rubbing together. Not cleared by coughing.
An older client asks why vision is not as sharp as it used to be when the eyes are focused forward. What should the nurse realize this client is describing? A. cataracts B. glaucoma C. detached retina D. macular degeneration
macular degeneration
The nurse assesses a client with noisy breathing including a gasping sound with respiration. The nurse notes tracheal deviation from the usual midline position. Which conditions should the nurse assess for further? Select all that apply. mediastinal mass atelectasis pneumothorax goiter inflammation of preauricular node
mediastinal mass atelectasis pneumothorax goiter
The nurse is reviewing the principles of pain. Which type of pain is due to an abnormal processing of the pain impulse through the peripheral or central nervous system?
neuropathic
Nociceptors are
sensory receptors located throughout the body and detect painful stimuli They are free nerve endings Can produce pain resulting from heat, pressure, or noxious chemicals, e.g. those found in inflammatory process.
solutes
substance dissolved in a solution
Aldosterone enhances renal excretion of potassium.
true
ELECTROLYTES IN THE INTRACELLULAR FLUID (ICF)
POTASSIUM+ PHOSPHORUS MAGNUESIUM+
KNEE-CHEST POSITION
PT KNEELS ON EXAM TABLE, BUTTOCKS RAISED WHILE HEAD AND CHEST REMAIN FLAT ON THE TABLE (CHILDS POSE)
Normal serum sodium levels range from 145 to 155 mEq/L.
FALSE, 135- 145
A patient in the clinic where you work is considered legally blind. The nurse knows that this means the vision in his better eye, corrected by glasses, is what? A. 20/100 or less B. 20/200 or less C. 20/300 or less D. 20/400 or less
20/200 or less
"Acute Pain related to instillation of peritoneal dialysate as evidenced by client wincing and grimacing during procedure, client description of experience as 'stabbing'" is an example of which type of nursing diagnosis? Actual diagnosis Risk diagnosis Wellness diagnosis Potential diagnosis
Actual diagnosis
A nurse is applying the nursing process and is in the diagnosis phase. With which activities would the nurse be involved? Select all that apply. Collecting subjective and objective data Organizing data Analyzing data Identifying patterns Identifying indicators of potential dysfunction
Analyzing data Identifying patterns Identifying indicators of potential dysfunction
The brain is a network of interconnecting neurons that control and integrate the body's activities. What components make up these neurons? Select all that apply.
Axon • Dendrite • Cell body Each neuron contains a cell body , which serves as the control center; smaller receiving fibers called dendrites; and a connecting long fiber called an axon. Axons are white because they are covered with a myelin sheath that speeds up impulse conduction. Cell bodies are on the outside of the brain (gray matter or cerebral cortex), while axons that connect to other parts of the nervous system are directed toward the center of the brain.
What muscles control the eye movement and hold the eye in place in the socket? A. Extraocular B. Oculomotor C. Trochlear D. Abducens
Extraocular
A client with diabetes mellitus has been admitted to the intensive care unit with a serum glucose reading of 400 mg/dL (22.20 mmol/L). Because the care for this client will involve multiple disciplines, which diagnostic statement would be most appropriate for the nurse to select? Risk for unstable blood glucose related to diabetes PC: Hyperglycemia related to uncontrolled serum glucose Diabetes mellitus as evidenced by serum glucose of 400 mg/dL (22.20 mmol/L) Need for glucose control as evidenced by hyperglycemia
PC: Hyperglycemia related to uncontrolled serum glucose
Normal vital signs for adults
Temperature 96.4-99.5 Pulse 60-100 Respirations 12-20 Blood-pressure 120/80
Which statement by the nurse demonstrates ethnocentrism? A. "That client is too old to learn how to eat gluten free." B. "That client needs to learn that pain is best managed with traditional medications like morphine." C. "That client is so whiny. I am so tired of hearing him complain about pain." D. "That client is unlike any other Muslim client I have had in the past."
"That client needs to learn that pain is best managed with traditional medications like morphine."
The nurse assesses a client's carotid pulse and finds it to be of normal amplitude. The nurse would document this as which of the following?
2+ A normal pulse amplitude would be recorded as 2+. A weak pulse amplitude would be documented as 1+; increased as 3+; bounding as 4+.
S2
2nd heart sound is produced by closure of the aortic and pulmonic valves
hypotonic
: having a lesser concentration than the solution with which it is being compared
The nurse knows that which statement is true regarding the pain experienced by infants?
A procedure that induces pain in adults will also induce pain in the infant.
The nurse recognizes that working with children with a different cultural perspective may be especially difficult because:
Children have spiritual needs that are influenced by their stages of development
Which is not a primary intracellular electrolyte?
Chloride Chloride, along with sodium and bicarbonate, are the primary ECF electrolytes.
During a discussion about BSEs with a 30-year-old woman, which of these statements by the nurse is most appropriate?
Examine your breasts shortly after your menstrual period each month
HYPERTENSIVE CRISIS (EMERGENCY CARE NEEDED)
HIGHER THAN 180/HIGHER THAN 110
What is a state of complete, physical, mental, and social well-being, not merely the absence of disease or infirmity? -Holism -Wellness -Host -Health
Health
A mother brings her 6-month-old to the clinic for a well-baby checkup. She tells the nurse that she is concerned that her baby is not crawling yet. What would be important for the nurse to explain to this mother?
Individuals develop at different rates. Motor development also follows a pattern, but individuals develop at variable rates.
SUBJECTIVE DATA COLLECTION OF PAIN INCLUDES
Location Duration Intensity Quality/description Alleviating/aggravating factors Pain management goal Functional goal
EUPENEA
NORMAL RESPIRATION RATE
After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be:
Objective.
A patient comes to the clinic and reports pain when he touches his ear. With what is this finding most consistent?
Otitis externa Pain with auricle movement or tragus palpation indicates otitis externa or furuncle.
Pain that is felt in a part of the body that has been removed is called:
Phantom pain. Phantom pain can be perceived in nerves left by a missing, amputated, or paralyzed body part.
What part of the eye receives and transmits visual stimuli to the brain for processing? Retina Optic disc Posterior chamber Vitreous chamber
Retina
DYSPNEA
SHORTNESS OF BREATHE, DIFFICULT OR LABORED RESPIRATION
A client is admitted to the health care facility after sustaining a crushing injury to the right eye. The nurse should anticipate abnormal results for which vision test? A. Accommodation B. Six cardinal positions of gaze C. Pupillary reaction to light D. Position and alignment of the eyeballs
Six cardinal positions of gaze
The nurse has palpated a lump in a female patients right breast. The nurse documents this as a small, round, firm, distinct, lump located at 2 oclock, 2 cm from the nipple. It is nontender and fixed. No associated retraction of the skin or nipple, no erythema, and no axillary lymphadenopathy are observed. What information is missing from the documentation?
Size of the lump
Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium?
Sodium is regulated by the renin-angiotensin-aldosterone system.
When a breastfeeding mother is diagnosed with a breast abscess, which of these instructions from the nurse is correct? The mother needs to:
Temperly discontinue nursing on the affected breast and manually expressed milk and discard it
4 ways fluids move to maintain homeostasis
filtration osmosis active transport diffusion
CRACKLES (RALES)
indicates air bubbling through fluid or mucous. (atelectasis, pulmonary edema, bronchitis, pneumonia, CHF)
Hyperkalemia
refers to a potassium surplus in the ECF.
The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment
the functional assessment can identify any problems with memory the individual may be experiencing
ECF includes two major areas,
the intravascular and interstitial compartments. A third, usually minor, compartment is the transcellular fluid.
According to Schuster (2008), what is the second step in developing a concept map? -Analyze and categorize data -Identify goals, outcomes, and interventions -Develop a basic skeleton diagram -Label and analyze nursing diagnoses relationships
Analyze and categorize data
What are various measurements of the human body, including height and weight, called?
Anthropometric Anthropometric measurements are the various measurements of the human body, including height and weight.
A female client is admitted to the health care facility due to reports of decreased appetite, loss of sleep, feelings of being unsafe in her own home, and inability to concentrate. She appears pale; her hair is disheveled, she is not wearing makeup, and she will not make eye contact. Based on this data, which nursing diagnosis can the nurse confirm?
Anxiety The major defining characteristics of anxiety are present: loss of sleep, feeling unsafe, inability to concentrate, and poor eye contact. There are no major characteristics for the nursing diagnosis of imbalanced nutrition: less than body requirements, risk for self-directed violence, or impaired verbal communication. (less)
A man is at the clinic for a physical examination. He states that he is very anxious about the physical examination. What steps can the nurse take to make him more comfortable?
Appear unhurried and confident when examining him.
A home care nurse is teaching a client and family about the importance of a balanced diet. The nurse determines that the education was successful when the client identifies which of the following as a rich source of potassium?
Apricots are a rich source of potassium. Dairy products are rich sources of calcium. Processed meat and bread products provide sodium.
The nurse is caring for a terminally ill patient whose family has requested to hold a spiritual ceremony, during which they will be using incense. What would be the best intervention you could make on behalf of this patient? -Refuse the ceremony because it may affect other patients in this unit -Discourage the family from performing the ceremony -Arrange for the ceremony to occur after obtaining permission from administration -Discourage the use of incense in the hospital
Arrange for the ceremony to occur after obtaining permission from administration
When examining an older adult, the nurse should use which technique?
Arrange the sequence of the examination to allow as few position changes as possible.
The nurse is aware that intimate partner violence (IPV) screening should occur with which situation?
As a routine part of each health care encounter
A nurse is preparing to examine a client from Southeast Asia who has been experiencing chronic headaches. Which of the following should the nurse do in light of this client's cultural background? A. Avoid asking the client to remove her clothes for the examination B. Have a nurse who is the same sex as the client perform the examination C. Ask permission before palpating the head and neck D. Palpate the client's feet before palpating the head
Ask permission before palpating the head and neck
A nurse is testing a client's corneal reflex but notices that the reflex appears to be reduced. The client is otherwise alert and oriented, with no signs of neurologic degeneration. What is an appropriate action by the nurse?
Ask the client about the presence of contact lenses The corneal reflex test is done to assess the sensory portion of cranial nerve V (trigeminal). If the client has an intact nervous system, the nurse should ask about the presence of contact lenses because they can cause the reflex to be absent or reduced. Touching the cornea with a small piece of cotton is how the test is performed. Blinking or rinsing the eyes is not an appropriate action.
The nurse has completed a Glasgow Coma Scale assessment and assigns the client a score of three. Which is the best way for the nurse to assess pain in this client?
Assess for nonverbal signs. The GCS is a tool for assessing a patient's response to stimuli. Scores range from 3 (deep coma) to 15 (normal). Eye opening response: Spontaneous 4 To voice 3 To pain 2 None 1 Best verbal response: Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 None 1 Best motor response: Obeys command 6 Localizes pain 5 Withdraws 4 Flexion 3 Extension 2 None 1 Total 3-15. A score of three indicates deep coma; therefore, the client is unable to verbalize pain level on numerical scale or FACES scale. A client in a coma can still experience pain. (less)
During an examination of a 7-year-old girl, the nurse notices that the girl is showing breast budding. What should the nurse do next?
Assess the girls weight and body mass index (BMI)
A 21-year-old college senior presents to the clinic reporting shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory, gastrointestinal, and urinary symptoms and says she has no chest pain. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray; she takes no other medications. She has had no surgeries. Her mother has allergies and eczema; her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and has recently started a job as a bartender in town. On examination she is in no acute distress. Temperature is 98.6, blood pressure is 120/80, pulse is 80, and respirations are 20. Head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this presentation best describe?
Asthma Asthma causes shortness of breath and a nocturnal cough. It is often associated with a history of allergies and can be exacerbated by exercise or irritants such as smoke in a bar. On auscultation there can be normal to decreased air movement. Wheezing is heard on expiration and sometimes inspiration. The duration of wheezing in expiration usually correlates with the severity of illness, so it is important to document this length (e.g., wheezes heard halfway through exhalation). In severe asthma, wheezes may not be heard because of the lack of air movement. Paradoxically, these clients may have more wheezes after treatment, which actually indicates an improvement in condition. Peak flow measurements help to discern this. (less)
A Malaysian client is admitted to the health care facility with complaints of cramping pain in the abdomen and loose stools. Where should the nurse be seated when interviewing the client? -Alongside the client -In one corner of the room -Behind the client -At more than one arm's distance
At more than one arm's distance
A client from Malaysia is admitted to the health care facility with reports of cramping pain in the abdomen and loose stools. Where should the nurse be seated when interviewing the client? A. Alongside the client B. Behind the client C. At more than one arm's distance D. In one corner of the room
At more than one arm's distance
During the physical examination of a client, a nurse notes that a client's trachea has been pushed toward the right side. The nurse recognizes that the pathophysiologic cause for this finding is related to what disease process? A. Endocarditis B. Bronchitis C. Atelectasis D. Tuberculosis
Atelectasis
During the physical examination of a client, a nurse notes that a client's trachea has been pushed toward the right side. The nurse recognizes that the pathophysiological cause for this finding is related to what disease process? A. Endocarditis B. Bronchitis C. Atelectasis D. Tuberculosis
Atelectasis
What is the lab test commonly used in the assessment and treatment of acid-base balance?
Aterial Blood Gas ABGs are used to assess acid-base balance. The pH of plasma indicates balance or impending acidosis or alkalosis. The complete blood cell count measures the components of the blood, focusing on the red and white blood cells. The urinalysis assesses the components of the urine
How may a nurse demonstrate cultural competence when responding to patients in pain?
Avoid stereotyping responses to pain by patients. Culture influences an individual's response to pain. It is particularly important to avoid stereotyping responses to pain because the nurse frequently encounters patients who are in pain or anticipating it will develop. A form of pain expression that is frowned on in one culture may be desirable in another cultural group. (less)
BREAST EXAM
BREAST SELF-EXAM= LYING SUPINE Inspection Patient sitting and disrobed to waist Skin changes, symmetry, contours, retraction Inspection Arms at side Appearance of skin Size and symmetry of breasts Contour of breasts Characteristics of nipples INSPECTION INCLUDES: ARMS OVER HEAD HANDS PRESSED AGAINST HIPS LEANING FORWARD PALPATION Palpation The nipple Elasticity Thickening The axillae (cont'd) Palpation Pectoral nodes Lateral nodes Subscapular nodes
The nurse is preparing to teach a woman about BSE. Which statement by the nurse is correct?
BSE on a monthly basis will help you become familiar with your own breasts and feel their normal variations.
A nurse performs a respiratory assessment on a client and notes the respiratory rate to be 10 breaths per minute. The nurse knows the proper term for this rate is what?
Bradypnea A respiratory rate less than 10 breaths per minute is called bradypnea. Tachypnea is a respiratory rate greater than 24 breaths per minute. Hyperventilation is used to describe respirations that are increased in rate and depth. Hypoventilation is a rate that is decreased with a decrease in depth, and with an irregular pattern. (less)
A client presents to a primary care office with a complaint of double vision (diplopia). On questioning, the client claims to have not suffered any head injuries. Which of the following underlying conditions should the nurse most suspect in this client? A. Vitamin A deficiency B. Brain tumor C. Allergies D. Viral infection
Brain tumor
A nurse exits the room of a confused client without raising the side rails on the bed. The failure to raise the side rails would constitute which element of liability related to malpractice? A. Breach of duty B. Duty C. Causation D. Damages
Breach of duty
A nurse fails to communicate a change in the client's condition to the physician. Which element related to proving malpractice has been met? A. Duty B. Breach of duty C. Proximate cause D. Damages
Breach of duty
The nurse fails to contact the physician regarding a client who had an open-reduction internal fixation of the tibia and has experienced increasing leg pain (unrelieved by pain medication) for the past 4 hours. Which element of liability has been violated? A. Breach of duty B. Causation C. Damages D. Duty
Breach of duty
While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. The nurse would document this as which of the following?
Bronchial breath sounds Harsh high pitches sounds short during inspiration and long during expiration reflect bronchial breath sounds, typically heard over the trachea. Vesicular breath sounds are low, breezy, and soft, long in inspiration and short in expiration, normally heard over the peripheral lung fields. Bronchovesicular breath sounds are moderate-pitched sounds equal during inspiration and expiration normally, heard over the major bronchi. Adventitious breath sounds are sound added or superimposed over normal breath sounds. (less)
When crackles, wheezes, or rhonchi clear with a cough, which of the following is a likely etiology?
Bronchitis Adventitious sounds that clear with cough are usually consistent with bronchitis or atelectasis. The other conditions would not have findings that cleared with a cough.
The nurse is examining a 3-year-old child who was brought to the emergency department after a fall. Which bruise, if found, would be of most concern?
Bruising on the abdomen
23. The nurse is obtaining the health history of a young adult client. During the interview, the client tells the nurse, ìI banged my head pretty good when I was snowboarding last weekend.î The client states that he did not subsequently seek care. What is the nurse's most appropriate action? A) Promptly assess the client's balance and coordination. B) Teach the client about the warning signs of increased intracranial pressure. C) Refer the client for medical assessment and possible treatment. D) Teach the client about the importance of wearing head protection during sports.
C
3. Which of the following would the nurse most likely find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident? A) Inability to hear high-pitched sounds B) Loss of tactile sensation C) Difficulty speaking D) Blurred vision
C
The nurse working in the emergency department is assessing an intoxicated driver involved in a motor vehicle crash when the client insists on ambulating to the bathroom. The nurse escorts the client and calls for help while anticipating which abnormal gait in this client that places him at risk for falls?
Cerebellar ataxia Cerebellar ataxia, a wide-based gait with staggering and lurching, is often due to alcohol intake or cerebral palsy. Spastic hemiparesis is usually caused by stroke, not alcohol intoxication. Scissors gait is spastic diplegia associated with bilateral spasticity of the legs. Sensory ataxia is due to cerebral palsy also resulting in a wide-based gait.
The husband of a 65-year-old female tells the nurse, "My wife is having trouble navigating the steps in our home and she needs my help to step down off a curb." What part of the nervous system should the nurse assess for a potential source of the problem? A. Cerebellum B. Temporal lobe C. Cranial nerves D. Deep tendon reflexes
Cerebellum
VESICULAR LUNG SOUNDS
4. VESICULAR= heard throughout lung fields, they are soft, low pitched. Inspiration time is greater than expiration time I>E
Mamogram is performmed at
40 years old, unless there is a history of breast cancer then 25 years old. if mammogram is abnormal, then order a MRI. LARGE BREASTS INCREASE YOUR RISK FOR BREASTS CANCER. EX OF DOCUMENTATION: PEASIZED NODULE FOUND ON LEFT UPPER QUADRANT BETWEEN 1:00-2:00 PM.
A nurse is assessing the pulse rate of an athletic client during a routine checkup. The nurse should anticipate the pulse rate to be in what range of beats per minute?
45 to 60 The normal pulse rate of a well-conditioned athletic client is often less than 60 beats per minute because of the conditioning of the cardiovascular system. A pulse rate ranging between 60 and 100 beats/min is normal for adults. A pulse rate of more than 100 beats/min would indicate tachycardia. (less)
How would a student nurse define a conceptual framework? -A group of interrelated objects that follow a pattern -A foundation for nursing skills and care -An explanation of nursing and nursing practice -A set of phenomena and related abstractions
A group of interrelated objects that follow a pattern
When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects?
Abnormal laboratory values
CA2+ SORCES AND LOSSES
Absorbed from foods in the presence of normal gastric acidity and vitamin D Lost via feces and urine Sources include milk, milk products, and cheese; dried beans; fortified orange juice; green, leafy vegetables; small fish with bones; and dried peas and beans
A post-operative client is observed breathing 24 breaths/minute while complaining of 10/10 abdominal pain. The client's oxygen saturation is 90% on 2 liters nasal cannula. What is the nurse's priority action?
Administer prescribed analgesia as ordered. The client is complaining of a the highest level of pain at 10/10. Therefore, the increased respirations and low oxygen saturation are likely a result of hypoventilation due to pain. Acute pain that is is not adequatley treated can impair pulmonary function. When the client is suffering from an intense amount of time, the client may not be very receptive to teaching and explanations. The client may have the desire to cough and deep breathe but is unable to due to the intensity of pain. The client can still breathe on his/her own, so an ambu bag is not needed. (less)
Common or concerning symptoms to inquire about in the general survey and vital signs include all of the following except:
Adventitious lung sounds Auscultating the lungs is more appropriate during the respiratory review of systems. Weight, temperature, and level of consciousness are all components of the general survey and vital signs. (less)
What term is used to describe the degree of vascular resistance to ventricular contraction?
Afterload Afterload refers to the degree of vascular resistance to ventricular contraction.
Afterload
Afterload is the pressure in the wall of the left ventricle during ejection. In other words, it is the end load against which the heart contracts to eject blood. Afterload is readily broken into components: one factor is the aortic pressure the left ventricular muscle must overcome to eject blood.
What do retinal abnormalities include? Age-related macular degeneration Mydriasis Argyll Robertson syndrome Horner's syndrome
Age-related macular degeneration
Definition of Pain
"An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. (American Pain Society, 2003) Pain is "whatever the experiencing person says it is, existing whenever he says it does" (McAffery & Pasero, 1990)
Which of the following commonly used intravenous solutions is hypotonic?
0.45% NaCl 0.45% NaCl is hypotonic, normal saline and Lactated Ringer's are isotonic. 5% dextrose in 0.45% NaCl is hypertonic.
In what time period did nursing care as we now know it began? -18th to 19th century -Early civilization to 16th century -Pre-civilization -16th to 17th century
18th to 19th century
Pleurae
2 Protective overlapping moist membranes or layers 1. Visceral Pleura - adheres to the lungs 2. Parietal Pleura- adheres to thoracic walls, diaphragm & mediastinum Pleural space: area between the visceral and parietal pleura containing a scant amount of fluid
fluid intake per day is how many ml how much comes from iingested water? how much comes from ingested foods? how much comes from metabolic oxidation?
2,600 ml per day 1,300 ml from ingested water 1,000 ml coming from ingested food 300 ml coming from metabolic oxidation
Phosphate (PO4−): major ICF anion; a buffer anion in both ICF and ECF; normal serum phosphate level
2.5-4.5 mg/dL
A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL?
3,000 Fluid intake and fluid output should be approximately the same in order to maintain fluid balance. Any other amount could lead to a fluid volume excess or deficit.
Which of these would be formulated by a nurse using diagnostic reasoning?
Diagnostic hypothesis
REFERRED PAIN
PAIN IN A SPECIFIC SITE, BUT YOU EXPERIENCE IT SOMEWHERE ELSE. FOR EXAMPLE: APENDESITIS AND PAIN EXPERIENCED IN THE SHOULDER AND BELLY, (AWAY FROM THE APPENDIX)
NA+ REGULATION
Transported out of the cell by the sodium-potassium pump Regulated by renin-angiotensin-aldosterone system Elimination and reabsorption regulated by the kidneys Sodium concentrations affected by salt and water intake
The nurse auscultates the apical pulse and then palpates the PMI (point of maximal impulse). To best palpate the PMI, the nurse places two fingers at the left border of the heart in the 5th intercostal space.
True
when you breathe out
When you breathe out, or exhale, your diaphragm relaxes and moves upward into the chest cavity. The intercostal muscles between the ribs also relax to reduce the space in the chest cavity.
2 types of nerve fibers
a delta fibers (myelated) faster c fibers (non-myelated) slower
Where do individuals learn their health belief's and values? a) in the family b) in school c) from school nurses d) from peers
a) in the family Healthcare activities, health beliefs, and health values are learned within one's family.
When examining an infant, the nurse should examine which area first?
abdomen
Hypernatremia
refers to a surplus of sodium in the ECF
Which of the following nursing groups provides a definition and scope of practice for nursing? -ICN -The Joint Commission -ANA -AAN
ANA
The nurse has used interpretation regarding a patients statement or actions. After using this technique, it would be best for the nurse to:
Allow time for the patient to confirm or correct the inference.
The nurse is incorporating a persons spiritual values into the health history. Which of these questions
Are you a part of any religious or spiritual congregation?
2. A client has sustained an injury to the cerebellum. Which area should be the nurse's primary focus for assessment? A) Vital signs B) Respiratory status C) Cardiac function D) Coordination
D
The nurse is caring for a 63-year-old client who can neither read nor speak English. What would be the appropriate chart to use to assess this patient's vision? A. Allen B. Snellen E C. Ishihara D. PERRLA
Snellen E
A 52-year-old patient with myopia calls the ophthalmology clinic very upset. She tells the nurse, "I keep seeing semi-clear spots floating across my vision. What is wrong with me?" What would be the most appropriate response by the nurse?
"It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'." Floaters (translucent specks that drift across the visual field) are common in people older than 40 years of age and nearsighted patients; no additional follow-up is needed.
A mother brings her 3 year old to the clinic, concerned about her daughter's growth and development. She tells the nurse that her daughter can climb stairs, dress herself, and feed herself, but she cannot draw circles or rectangles like her 5-year-old brother. What should the nurse tell this mother?
"This is normal for this age, because children do not master the fine motor skill of drawing until age 5 years." The patient is right on target for her fine and gross motor skills. Climbing stairs, feeding herself, and dressing herself are normal skills for this age group. Drawing circles and rectangles are fine motor skills that are not accomplished until age 5 years. (less)
A 6-year-old boy has come to the clinic with his mother because of recent eye redness and discharge. The nurse's assessment has suggested a diagnosis of conjunctivitis. What should the nurse tell the mother about her son's eye?
"This might have been the result of an allergy, but most likely it was caused by a bacteria or virus." Conjunctivitis usually has an infectious etiology. Severe pain and vision damage are not common consequences.
4 NORMAL BREATH SOUNDS tbbv
1. TRACHEAL 2. BRONCHIAL 3.BRONCHIVESICULAR 4.VESIVCULAR
The nurse understands the importance of performing an accurate pain assessment. In addition to having the patient rate the pain on a pain scale, other things to assess are the following: (Check all that apply.)
-Location and duration -Quality and description -Alleviating and aggravating factors In a pain assessment. the nurse asks the patient to use a pain scale to rate the intensity of the pain. Other areas to assess are location and duration, quality and description, and any alleviating or aggravating factors. Although the nurse would want to assess the patient's allergies before giving pain medications, diet is not included, nor is urinary output or oxygenation. (less)
A client enters the emergency department moaning and complaining of severe pain in his lower back. Which of the following clinical manifestations should the nurse expect to see in this client as a physiologic response to pain? Select all that apply.
-Perspiration - Increased heart rate -Sleeplessness Sleeplessness, perspiration, and increased heart rate are physiologic responses to pain. Pain elicits a stress response in the human body that triggers the sympathetic nervous system. Hyperglycemia, not hypoglycemia, and decreased, not increased, intestinal motility are physiologic responses to pain. (less)
BREAST EXAM ASSESSMENT USING FOUR QUADRANTS AND A CLOCK FOR LOCATION (RUP,LUQ,LLQ,RLQ)
-START UNDER THE ARM/AXILLARY REGION (LYMPH NODES ARE PRESENT) -USE A ROLLING MOTION -PRESS DOWN ON NIPPLE TO ASSURE THERE IS NO DISCHARGE -SYMMETRY (CHECK TO MAKE SURE BREASTS ARE EVEN)
UPPER AIRWAY "CONDUCTING AIRWAY" INCLUDES
1. MOUTH 2. PHARYNX 3. LARYNX (VOICE BOX) 4. NOSE 5. BRONCHI 6. BRONCHIOLES
9 organs/body systems related to the regulation of fluid and electrolyte imbalance
1.KIDENYS 2. HEART/BLOOD VESSELS 3. LUNGS 4. ADRENAL GLANDS 5. PITUITARY GLAND 6. THYROID GLAND 7. NERVOUS SYSTEM 8. GASTROINTESTINAL TRACT 9. PARATHYROID GLANDS
the adult heart contracts at a rate of ---- beats per minute
60 beats
the heart pumps an average of --- of blood per minutew
5 gallons
37 degrees Celsius is
98.6 degrees FAHRENHEIT °C x 9/5 + 32 = °F (°F - 32) x 5/9 = °C
Hypocalcemia
: insufficient amount of calcium in the extracellular fluid
As a nurse is adjusting a client's hospital bed, the nurse accidently pinches a finger between the bed and the wall. Which of the following components is involved in the transduction of the pain the nurse feels?
A-delta fibers Nociceptors are located at the peripheral ends of both myelinated nerve endings of type A fibers and unmyelinated type C fibers, and there are three types that are stimulated by different stimuli: mechanosensitive nociceptors (of A-delta fibers), sensitive to intense mechanical stimulation (e.g., pliers pinching skin); temperature-sensitive (thermosensitive) nociceptors (of A-delta fibers), sensitive to intense heat and cold; and polymodal nociceptors (of C fibers), sensitive to noxious stimuli of a mechanical, thermal, or chemical nature. There are no "K-fibers" or "L-beta fibers." (less) PAIN FIBERS
Major control over the extracellular concentration of potassium within the human body is exerted by:
ALDOSTERONE Aldosterone exerts major control over the extracellular concentration of potassium. It also enhances renal secretion of potassium.
The nurse is assessing the mental status of a child. Which statement about children and mental status istrue?
All aspects of mental status in children are interdependent.
A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition? A. Surgery B. Daily use of eye drops C. Corrective lenses D. No night driving
Corrective lenses
Which of these responses might the nurse expect during a functional assessment of a patient whose leg is in a cast?
I'm able to transfer myself from the wheelchair to the bed without help
Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as
Intuition
The nurse is assessing bruising on an injured patient. Which color indicates a new bruise that is less than 2 hours old?
Red
e water from food and oxidation is balanced by
Water loss through the feces, the skin, and the respiratory process
The nurse recognizes that an example of a person who isheriage consistent would be :
Woman who follows the traditions that her mother followed regarding meals.
The nurse is assisting with a BSE clinic. Which of these women reflect abnormal findings during the inspection phase of breast examination?
Woman whose nipples are in different planes (deviated).
The oncoming nurse is assigned to the following clients. Which client should the nurse assess first?
a newly admitted 88-year-old with a 2-day history of vomiting and loose stools Young children, older adults, and people who are ill are especially at risk for hypovolemia. Fluid volume deficit can rapidly result in a weight loss of 5% in adults and 10% in infants. A 5% weight loss is considered a pronounced fluid deficit; an 8% loss or more is considered severe. A 15% weight loss caused by fluid deficiency usually is life threatening
A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but then laughs loudly at the content. This behavior is a display of:
inappropriate affect
A nurse working with patients in the community is aware that which of the following is a true statement related to environmental factors in a community? a) Barriers to accessing healthcare within a community may include lack of transportation. b) Lack of health insurance is a negative environmental factor affecting one's access to healthcare. c) The quality of air and water are relatively consistent when comparing urban and rural environments. d) Environmental factors focus on the harmful effects on an individual's health.
a) Barriers to accessing healthcare within a community may include lack of transportation: Environmental barriers to accessing healthcare within a community include lack of transportation, distance to services, and location of services.
Which of the following family structures is presently most common in the United States? a) Households with two parents, each of whom works outside the home b) Single-parent households headed by a woman c) Traditional nuclear families with one wage earner d) Blended families in which one or both partners bring children to the relationship
a) Households with two parents, each of whom works outside the home The family is an institution that has undergone significant change in recent decades. Currently, two-career families, in which both parents work outside the home, are the norm.
HYPERPNEA
abnormally rapid or deep brething
The nurse applies antiseptic and a dressing to an IV site in the event of
an infection
The apex of each lung is located at the
area slightly above the clavicle. The apex of each lung extends slightly above the clavicle.
ion
atom or molecule carrying an electrical charge.
Family assessment of a father, mother and four children has suggested the presence of several risk factors. Which of the following aspects of the family's structure and function would be considered a psychosocial risk factor? a) The family's electricity has been cut off at various times due to nonpayment. b) The mother has a history of heavy alcohol use. c) The parents have a tumultuous relationship with frequent separations in the past. d) The family lives in a small apartment in a poor neighborhood with high crime rates.
c) The parents have a tumultuous relationship with frequent separations in the past. Conflict is an example of a psychosocial risk factor. Chemical dependency is considered a lifestyle risk factor while a lack of adequate housing is an environmental risk factor.
The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland?
calcium and phisphorus The parathyroid gland secretes parathyroid hormone, which regulates the level of calcium and phosphorus. Removal of the parathyroid gland will cause calcium and phosphorus imbalances
when phosphate is hgh,
calcium is low
A client's most recent blood work indicates a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?
cardiac irregularities Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias
An adult client tells the nurse that his eyes are painful because he left his contact lenses in too long the day before yesterday. The nurse should instruct the client that prolonged wearing of contact lenses can lead to A. retinal damage. B. cataracts. C. myopia. D. corneal damage.
corneal damage.
An adult client tells the nurse that his eyes are painful because he left his contact lenses in too long the day before yesterday. The nurse should instruct the client that prolonged wearing of contact lenses can lead to
corneal damage. Improper cleaning or prolonged wearing of contact lenses can lead to infection and corneal damage.
Of all the physiologic needs, which one is the most essential? a) food b) water c) elimination d) oxygen
d) oxygen Oxygen is the most essential of all needs because all body cells require oxygen for survival.
ANION
ion that carries a negative electric charge
Endocrine disorders and ingestion of large amounts of antacids cause metabolic alkalosis.
true
The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? The nurse:
organizes the assessment so that the patient does not change positions too often.
Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient?
palpation
The thin double-layered serous membrane that lines the chest cavity is termed
parietal pleura. The parietal pleura line the chest cavity.
In caring for a patient, the nurse recognizes which of the following as the primary educational and support structure for an individual? -Clergy -Peers -Teachers and coaches -Family members
Family members
A community health nurse is providing care to several farming families in a rural community. Which of the following would be most important for the nurse to integrate into the plans of care for these families? A. The traditional nuclear family structure is the current norm. B. Family structures may change over time. C. All family types have similar problems regardless of their structure. D. The extended family structure has fewer issues that impact family functions.
Family structures may change over time.
During a client's vascular assessment, the nurse is palpating the pulse just under the client's inguinal ligament. The nurse is assessing which pulse?
Femoral The femoral pulse is palpated in the groin (inguinal area) by compressing the femoral artery between skin and bone. The temporal pulse is located on the head. The brachial pulse is palpated medial to the biceps tendon in and above the bend in the elbow. The popliteal pulse is palpated behind the knee. (less)
FIBROADENOMAS (CYST, NOT BREAST CANCER)
Fibroadenomas (fy-broe-ad-uh-NO-muhz) are solid, noncancerous breast tumors that occur most often in adolescent girls and women under the age of 30. You might describe a fibroadenoma as firm, smooth, rubbery or hard with a well-defined shape. Usually painless, a fibroadenoma might feel like a marble in your breast, moving easily under your skin when touched. Fibroadenomas vary in size, and they can get bigger or even shrink on their own. Fibroadenomas are among the most common breast lumps in young women. Treatment may include monitoring to detect changes in the size or feel of the fibroadenoma, a biopsy to evaluate the lump, or surgery to remove it.
Which of the following statements is true regarding the internal structures of the breast? The breast is made up of
Fibrous, glandular, and adipose tissues.
The nurse is preparing to assess a client's apical impulse. The nurse would palpate at which location?
Fifth intercostal space, left midclavicular line The apical impulse is palpated at the fourth or fifth intercostal space at the left midclavicular line.
How do people of Canadian Indian descent prefer to be identified? A. Indians B. Americans C. Canadians D. First Nations
First Nations
A woman is discussing the problems she is having with her 2-year-old son. She says, He wont go to sleep at night, and during the day he has several fits. I get so upset when that happens. The nurses best verbal response would be:
Fits? Tell me what you mean by this.
A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider? A. Mobile from side to side B. Soft consistency C. Fixed to underlying tissue D. Round and 8mm in size
Fixed to underlying tissue
A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider? A. Mobile from side to side B. Soft in consistency C. Fixed to underlying tissue D. Round and 8 mm in size
Fixed to underlying tissue
A client with dehydration or volume depletion has barely visible neck veins, even when lying flat. These are described as what?
Flat neck veins A client with dehydration or volume depletion have barely visible neck veins, even when lying flat. These are described as flat neck veins. Distended neck veins are used to describe engorged neck veins found in clients with fluid volume overload. Round and invisible neck veins are distracters to the question. (less)
Who is considered to be the first nursing researcher? -Dorothea Dix -Clara Barton -Lillian Wald -Florence Nightingale
Florence Nightingale
Who of the following is considered to be the first nursing theories who conceptualized nursing in terms of manipulating the environment? -Florence Nightingale -Dorothea Orem -Lydia Hall -Sister Callista Roy
Florence Nightingale
What action on the part of a middle-aged client would best exemplify Erikson's concept of generativity?
Guiding and mentoring individuals who are younger Generativity implies mentoring and giving to future generations. It is a broad concept, but it does not necessarily involve increasing one's income or emphasizing one's own knowledge and ideas over those of others. (less)
A patient describes feeling an unreasonable, irrational fear of snakes. His fear is so persistent that he can no longer comfortably look at even pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them. The nurse recognizes that he:
Has a snake phobia.
A patient has had arthritic pain in her hips for several years since a hip fracture. She is able to move around in her room and has not offered any complaints so far this morning. However, when asked, she states that her pain is bad this morning and rates it at an 8 on a 1-to-10 scale. What does the nurse suspect? The patient:
Has experienced chronic pain for years and has adapted to it.
How does the nurse differentiate a pleural friction rub from a pericardial friction rub?
Have the client hold his or her breath; if the rub persists, it is pericardial Pericardial friction rubs can be differentiated from pleural friction rubs by having the client hold the breath. If present without breathing, the rub is pericardial. Turning the client to the right side and auscultating either the base of the heart or the upper back do not differentiate between pericardial and pleural friction rubs. (less)
A nurse begins the eye examination on a client who presents to the health care clinic for a routine examination. What is the correct action by the nurse to perform the test for near visual acuity?
Have the client hold the Jaeger card 14 inches from the face & read with one eye at a time Near vision is tested with a Jaeger card, Snellen card, or comparable card), held 14 inches from the face. Have the client cover one eye with an opaque card before reading from top to bottom. Sitting the client in front of the examiner, extending one arm, and slowly move one finger upward until it is seen by both the client and the examiner is a test for gross peripheral vision. If the client wears glasses, they should be left on for the test. Placing the client 20 feet from the chart and record the smallest line the client can read is the test for distant acuity. (less)
A nurse begins the eye examination on a client who presents to the health care clinic for a routine examination. What is the correct action by the nurse to perform the test for near visual acuity? A. Have the client hold the Jaeger card 14 inches from the face and read with one eye at a time B. Sit the client in front of the examiner, extend one arm, and slowly move one finger upward C. Tell the client to remove glasses, if present, and read the Snellen card using both eyes D. Place the client 20 feet from the Snellen chart and record the smallest line the client can read
Have the client hold the Jaeger card 14 inches from the face and read with one eye at a time
A client complains of pain in several areas of the body. How should the nurse assess this client's pain?
Have the client rate each location separately. When assessing pain location, ask the patient to point to the painful area. If more than one area is painful, have the patient rate each one separately, and note which area is the most painful. Marking each site is not necessary practice for assessing pain. Pain is a subjective sensation for the client. Radiating pain is notable, because such radation may affect treatment choices. (less)
When assessing a client for possible varicose veins, which of the following would the nurse do?
Have the client stand for the exam When assessing for varicose veins, the nurse should have the client stand because the varicose veins may not be visible when the client is supine and not as pronounced when the client is sitting. Raising the client's leg would be inappropriate because this would promote venous return and emptying of the veins. Dorsiflexing the foot is used to assess the Homans' sign. The ankle-brachial index is used if the client has symptoms of arterial occlusion. (less)
When assessing a client for possible varicose veins, the nurse should do which of the following actions?
Have the client stand for the exam. When assessing for varicose veins, the nurse should have the client stand because the varicose veins may not be visible when the client is supine and not as pronounced when the client is sitting. Raising the client's leg would be inappropriate because this would promote venous return and emptying of the veins. Dorsiflexing the foot is not part of this assessment. The ankle-brachial index is used if the client has symptoms of arterial occlusion. (less)
According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, patients:
Have the right to copy their health records. HIPAA affords patients the right to see and copy their health records, update their health records, and get a list of disclosures a healthcare institution has made for the purposes of treatment, payment, and healthcare operations. Patients have the right to request a restriction on certain uses or disclosures and choose how to receive this health information. HIPAA includes punishments for anyone caught violating patient privacy, but these punishments are not directed at the patient because HIPAA was implemented to protect the privacy of an individual's health information. (less)
When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L; potassium, 4.1 mEq/L; calcium 7.9 mg/dL, and magnesium 1.9 mg/dL; the nurse should notify the physician of the client's:
Low Calcium Normal total serum calcium levels range between 8.9 and 10.1 mg/dL.
In obtaining a review of systems on a healthy 7-year-old girl, the health care provider knows that it would be important to include the:
Limitations related to her involvement in sports activities.
A young couple who have been married less than a year are having difficulty with adjusting to parenting. What is a contributing factor to this level of maladjustment? -Involvement from significant others -Limited time in learning to be a marital partner -Economic difficulties associated with parenting -Stress of education, job, and parenting
Limited time in learning to be a marital partner
The nurse is caring for a Jewish adolescent who is anxious to enter adulthood. The nurse suggests which activity to achieve adulthood status?
Living independently In the United States, living independently and becoming economically independent are two determinants of adulthood. Defining adulthood may differ in various cultures. A bar mitzvah, confirmation ceremony, and graduation do not necessarily ensure independence. (less)
During your physical examination of the patient you note an enlarged tender tonsillar lymph node. What would you do? A. Assess for meningitis B. Look for involvement of other regions of the body C. Look for a source such as infection in the area that it drains D. Assess for dietary changes
Look for a source such as infection in the area that it drains
HCOS- SOURCES AND LOSSES
Losses possible via diarrhea, diuretics, and early renal insufficiency Excess possible via overingestion of acid neutralizers, such as sodium bicarbonate
A female patient tells the nurse that she has had six pregnancies, with four live births at term and two spontaneous abortions. Her four children are still living. How would the nurse record this information?
Grav 6, Term 4, (S)Ab-2, Living 4
Percussion NORMAL LUNG FINDINGS
Lungs should be filled with air which produces resonance sounds is loud, low pitched, & hollow (like a drum) . It is normal to have a dull (muffled) sound over the heart & liver.
The client has a history of breast cancer with reconstructive surgery. The nurse should assess the client for what potential complication?
Lymphedema Lymphedema can be a result of scarring injury, removal of lymph nodes, radiation or chronic infection. Peripheral arterial disease is caused by decreased arterial blood supply. Venous stasis is due to blood not moving which puts the client at risk for varicose veins. (less)
As part of the health history of a 6-year-old boy at a clinic for a sports physical examination, the nurse reviews his immunization record and notes that his last measles-mumps-rubella (MMR) vaccination was at 15 months of age. What recommendation should the nurse make?
MMR vaccination needs to be repeated at 4 to 6 years of age.
4 steps involved in nociception (PROCESS) (sensory nerve that responds to harmful stimuli) TOO CUTE TO MAKE PAIN
1. Transduction, 2) Conduction, 3) Transmission, 4) Modulation, 5) Perception.
cc
CHEIF COMPLAINT
3 EXAMPLES OF ANIONS (CLUBBY BAKES PIES)
CHLORIDE- BICARBONATE- PHOSPHATE-
WHAT ARE THE 3 PRIMARY ECF ELECTROLYTES (CAN SHE BAKE?)
CL- CHLORIDE NA+ SODDIUM HCO3- BICARBONATE
Which of the following theories supports the developmental framework of family assessment? -Duvall -Bowen -Satir -Minuchin
Duvall
Which of the following theorists supports the developmental framework of family assessment? A. Minuchin B. Duvall C. Satir D. Bowen
Duvall
BRONCHOPHONY
"SAY 99"
7 Adventitious (ABNORMAL) BREATH SOUNDS
1. RHONICHI 2. WHEEZING 3. STRIDOR 4. PLEURAL FRICTION RUB 5. CRACKLES (RALES) 6. FINE-HEARD AT END EXPIRATION 7.COARSE
extracellular fluid is
15-20% of body fluid
low blood pressure
90/60
hyponatremia
: insufficient amount of sodium in the extracellular fluid
c) Sodium is not regulated by natriuretic peptides.
FALSE, SODIUM IS REGULATED BY NATRIURETIC PEPTIDES
what does the phosphate buffer system do?
It converts alkaline sodium phosphate (Na2HPO4), a weak base, to acid-sodium phosphate (NaH2PO4) in the kidneys.
The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the _______diagnosis
Nursing
ADH (VASOPRESSIN) IS RELEASED IN THE BODY WHEN
THE BODY IS DEHYRATED/ HYPOTHALMUS/ PITUITARY GLAND---KIDNEYS
PO FOR PAIN
YOU HAVE TO REASSESS IN 30 MINUTES
Hypervolemia
excess of plasma
When reviewing the demographics of ethnic groups in the United States, the nurse recalls that the largest and fastest growing population is:
Hispanic.
After educating a group of students on the different types of nursing diagnoses, the instructor determines that the education was successful when the students identify wellness diagnoses statements as consisting of how many parts? 1 2 3 4
1
The milliequivalent (mEq) is the unit of measure that describes the chemical activity of electrolytes. One milliequivalent of either a cation or an anion is chemically equivalent to the activity of
1 MG OF HYDROGEN
A 55-year-old client is being evaluated for a hearing impairment. Which question would be most appropriate to provide the most useful information?
"Are you having difficulty hearing high-frequency sounds?" Asking the client about changes in hearing ability with different frequency sounds would be most appropriate because the client is over age 50 and may be experiencing presbycusis, a loss of ability to hear high-frequency sounds. Asking about drainage would provide information about a possible infection; asking about pain would provide information about possible ear infection, cerumen blockage, sinus infections, or teeth and gum problems. Asking about a popping sensation may be appropriate if otitis media and perforation are suspected. (less)
The nurse is caring for a client who is having nothing by mouth (NPO) on the first postoperative day. The client's blood pressure was 120/80 mm Hg approximately 4 hours ago, but it is now 140/88 mm Hg. The nurse should ask the client which of the following questions?
"Are you having pain from your surgery?" Explanation: A client's blood pressure will normally vary throughout the day due to external influences. This includes pain.
A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough?
"Are you taking any medications on a regular basis?" A persistent cough without any other respiratory symptoms could be related to new medications, especially beta blockers or angiotensin converting enzyme (ACE) inhibitors, which are prescribed for hypertension. A change in diet and exercise are healthy behaviors that would not cause a persistent cough. Stress often causes shortness of breath. (less)
The nurse is documenting client care. Which nursing assessment note would be most appropriate?
"Client voices concerns about being able to change abdominal dressings at home." Documentation of data needs to be clear, concise and nonjudgmental. The documentation note "Client voices concerns about being able to change abdominal dressings at home." is clear and identifies the client's concerns. All other documentation notes are judgmental and not data based. (less)
What is the rate of administration for packed red blood cells?
1 unit over 2 to 3 hours, no longer than 4 hours
THE SOLUTES INCLUDE
ELECTROLYTES AND NONELECTROLYTES
When planning a cultural assessment, the nurse should include which component?
Health-related beliefs
When assessing the quality of a patients pain, the nurse should ask which question?
"What does your pain feel like?"
VENOUS THROMBOEMBOLISM
Together, DVT and pulmonary embolism constitute a single disease process known as venous thromboembolism
LYMPHATIC SYSTEM COLLECTS EXTRA FLUID FROM THE
VASCULAR SYSTEM
AUTOMATICITY
WHEN THE CELLS IN THE SA NODE PROCESS AUTOMATICALLY. THE CARDIAC CELLS GENERATE THEIR OWN IMPULSE.
Peripheral IV devices:
are cannula/catheter inserted into a small peripheral vein for therapeutic purposes such as administration of medications, fluids and/or blood products.
hypophosphatemia
below-normal serum concentration of inorganic phosphorus
EXAMPLES OF ACUTE PAIN (LASTS LESS THAN 6 MONTHS)
burning your finger on the stove, labor pains, papercut, needleprick, stubbing your toe, breaking a bone, one-time headache, flu, asthma attack
A client is concerned about tripping when walking and feeling uncoordinated. Which part of the brain might be causing this client's symptoms? A. brainstem B. cerebellum C. frontal lobe D. parietal lobe
cerebellum
Dehydration
decreased water volume in body tissue
A patient has been admitted to the hospital with vertebral fractures related to osteoporosis. She is in extreme pain. This type of pain would be classified as:
deep somatic
One of the body's normal physiologic responses to pain is
diaphoresis. Diaphoresis is associated with acute pain.
A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of:
electrolytes (lytes) The nurse knows that the client's electrolytes need to be restored. Rehydration after exercise can only be achieved if the electrolytes lost in sweat, as well as the lost water, are replaced. The client does not need to have non-electrolytes, colloid solution, or interstitial fluid restore
The nurse observes an inward turning of the lower lid in a 77-year-old patient. The nurse documents A. entropion B. ectropion C. ptosis D. exophthalmos
entropion
Extracellular Fluid (ECF)
fluid outside the cells; includes intravascular and interstitial fluids
During an assessment of a patients family history, the nurse constructs a genogram. Which statement best describes a genogram?
graphic family tree that uses symbols to depict the gender, relationship and age of immediate family members
The nurse is planning to assess a client's near vision. Which technique should be used? shine a light on the bridge of the nose have the client read newspaper print held 14 inches from the eyes ask the client to move the eyes in the direction of a moving finger have the client stand 20 feet from a wall chart and read the letters after covering one eye
have the client read newspaper print held 14 inches from the eyes
The nurse is assessing a patient who has been admitted for cirrhosis of the liver, secondary to chronic alcohol use. During the physical assessment, the nurse looks for cardiac problems that are associated with chronic use of alcohol, such as:
hypertension
Hypokalemia
hypokalemia: insufficient amount of potassium in the extracellular fluid
Fluid intake is regulated primarily by the thirst mechanism. Located within the hypothalamus, the thirst control center is stimulated by
intracellular dehydration (the loss of or deprivation of water from the body or tissues) and decreased blood volume.
The nursing student is working with an experienced nurse in ICU. As the nursing student enters the room of the client diagnosed with a cerebral hemorrhage, the experienced nurse immediately says, "This patient is getting worse." This is an example of the experienced nurse using... -intuitive problem identification -illogical thinking -acute observation ability -an assumption to guide practice
intuitive problem identification
While riding in the elevator, a nurse discusses the HIV-positive status of a client with other colleagues. The nurse's action reflects: A. invasion of privacy. B. defamation of character. C. professional negligence. D. false imprisonment.
invasion of privacy.
cation give 5 examples
ions develop a positive charge and are called mAJOR CATIONS FOUND IN BODY FLUIDS ARE SODIUM POTASSIUM CALCIUM HYDROGEN MAGNESIUM
ANIONS GIVE 3 EXAMPLES
ions that develop a negative charge and are called MAJOR ANIONS IN THE BODY FLUID ARE CHLORIDE BICARBONATE POSPHATE
EXTRACELLULAR FLUID (ECF)
is all the fluid outside the cells, accounting for about 30% of the total body water or 20% of the adult's body weight.
INTRACELLULAR FLUID (ICF)
is the fluid within cells, constituting about 70% of the total body water or 40% of the adult's body weight.
When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L; potassium, 4.1 mEq/L; calcium 7.9 mg/dL, and magnesium 1.9 mg/dL; the nurse should notify the physician of the client's:
low calcium. Normal total serum calcium levels range between 8.9 and 10.1 mg/dL.
Resonant sounds are
low pitched, hollow sounds heard over normal lung tissue.
otonic solution is generally administered to
maintain fluid balance in clients who may not be able to eat or drink for a short period.
The nursing instructor is discussing fluid and electrolyte balance with a group of students. One of the students asks the instructor how fluids move to maintain homeostasis. The instructor formulates her response based on her knowledge that fluid homeostasis can be maintained by which of the following? Select all that apply.
oh f did angelica trip? Osmosis Filtration Diffusion Active transport Acid-base balance concerns chemical reactions in the body that influence metabolism.
During an interview, the nurse states, You mentioned having shortness of breath. Tell me more about that. Which verbal skill is used with this statement?
open-ended question
The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should
position the client 609.6 cm (20 ft) away from the chart. Used to test distant visual acuity, the Snellen chart consists of lines of different letters stacked one above the other. The letters are large at the top and decrease in size from top to bottom. The chart is placed on a wall or door at eye level in a well-lighted area. The client stands 20 feet from the chart and covers one eye with an opaque card (which prevents the client from peeking through the fingers). Then the client reads each line of letters until he or she can no longer distinguish them. (less)
colloid solutions are used to
replace circulating blood volume because the suspended molecules pull fluid from other compartments.
BLOOD PRESSURE
the pressure exerted by the blood on the inner walls of the arteries, being relative to the elasticity and diameter of the vessels and the force of the heartbeat
The most important step that the nurse can take to prevent the transmission of microorganisms in the hospital setting is to:
wash hands before and after contact with each patient.
An infant is brought to the emergency room with dehydration due to vomiting. After several failed attempts to start an IV, the nurse observes a scalp vein. When accessing the scalp vein, the nurse should use a(an)
winged infusion needle Winged infusion needles are short, beveled needles with plastic flaps or wings. They may be used for short-term therapy or when therapy is given to a child or infant.
The nurse is teaching about sources of calcium for a client newly diagnosed with lactose intolerance. The client would require further teaching if which food is chosen? A. green, leafy vegetables B. prunes C. egg yolks D. yogurt
yogurt
HYPERTENSION STAGE 2
160 OR HIGHER/100 OR HIGHER
S1
2nd heart sound is produced by closure of the aortic and pulmonic valves
atelectasis
Complete or partial collapse of a lung or a section (lobe) of a lung.
lithotomy POSITION
FOR PELVIC EXAMINATION, PAP SMEARS PT IS POSITIONED IN DORSAL RECUMBENT POSITION WITH FEET ON CORNERS OF TABLE
SOLVENTS ARE
LIQUIDS THAT HOLD A SUBSTANCE IN SOLUTION
What is the nurse's best defense if a patient alleges nursing negligence?
Patient's record
When documenting IPV and elder abuse, the nurse should include:
Photographic documentation of the injuries.
The nurse recognizes that the concept of prevention in describing health is essential because:
Prevention places the emphasis on the link between health and personal behavior.
During an examination, the nurse notices a patterned injury on a patients back. Which of these would cause such an injury?
Whipping from an extension cord
The nurse is reviewing the principles of nociception. During which phase of nociception does the conscious awareness of a painful sensation occur?
perception
PRECORDIUM
the region or the thorax immediately in front of the heart. (THE CHEST WALL)
The nursing instructor is teaching students about growth and development during a pediatric clinical rotation. The instructor knows that one of the students needs more information when the student states:
"Growth and development is a simple process." Growth and development is a complex process with many contributing variables, including culture, genetics, environment, and health. Developmental changes are not easily measured with universal tools. (less)
The nursing students asks the instructor to explain what a community is. Which statement by the instructor would be inappropriate? -"A community is a group of individuals who live in the same geographic area." -"The members of a community share some characteristic in common, such as cultural values." -"Communities have few effects on the health of the individuals that live there." -"A community provides resources and serves that help to keep its members healthy."
"Communities have few effects on the health of the individuals that live there." -"A community provides resources
During an eye assessment, the nurse is testing a client's visual acuity using a Snellen chart. In order to prepare the client for this component of assessment, what instruction should the nurse provide?
"Cover one of your eyes and then read out the letters on the chart, starting from the top." Using a Snellen chart requires that the client stand a specific distance from the chart, usually 20 feet. The client does not move, and each eye is assessed individually.
A nurse is interviewing a client as part of a routine examination of his ears and hearing. The nurse notes that this client has high blood pressure. Which of the following questions regarding his hearing should the nurse ask that is associated with his high blood pressure?
"Do you experience any ringing, roaring, or crackling in your ears?" Ringing in the ears (tinnitus) may be associated with excessive ear wax buildup, high blood pressure, or certain ototoxic medications. None of the other questions pertains to conditions related to high blood pressure. Ear pain is associated with ear infections, cerumen blockage, sinus infections, teeth and gum problems, and swimmer's ear. Drainage usually indicates infection. Hearing loss may be related to any number of causes but is not associated with high blood pressure. (less)
Which question asked by the nurse is assessing problems with tinnitus?
"Do you experience buzzing in your ears?" The nurse assesses tinnitus by asking, "Do you experience buzzing in your ears?" Problems with balance occur with vertigo. Drainage from the ear(s) occurs with otalgia. The question, "In what situations is it hard for you to hear?" assesses for general hearing loss. (less)
A nurse is caring for a female patient of Hawaiian descent. Which interview question would be appropriate based on the cultural beliefs of Hawaiians? A. "Do you base your diet on eating a balance of hot and cold foods?" B. "Do you use any medicinal plants or minerals?" C. "Do you ever use fad diets to lose weight?" D. "Do you have a preference for the gender of the nurse caring for you?"
"Do you use any medicinal plants or minerals?"
The nurse is interviewing a client who is Native American/First Nations. What question would be best to ask this client? A. "Do you use herbal or medicinal plants?" B. "When you consume dairy products, do you have any gastrointestinal discomfort?" C. "Is your diet based on using hot/cold foods to treat illness?" D. "Will you require a kosher meal?"
"Do you use herbal or medicinal plants?"
A nursing instructor realizes that a student needs further teaching concerning growth and development when the student states the following:
"Erikson's theory states a person cannot advance to the next stage if the previous task is not completed." Erikson's theory covers the lifespan and is divided into eight stages. Piaget's theory deals with cognitive development. In Erikson's theory, a person can advance to the next stage even if the previous task has not been completed. (less)
The nurse just attended a seminar on cultural diversity. Which statement by the nurse would require further education? A. "Ethnicity begins at birth or through adoption of characteristics." B. "People of the same ethnicity share many of the same cultural and social beliefs." C. "Ethnicity can often determine dialect and political interests." D. "Ethnicity and race are the same thing and are affected by cultural practice."
"Ethnicity and race are the same thing and are affected by cultural practice."
A nurse is planning education on self-administration of insulin to the client and his family members. The client asks the nurse why the family members are also included in the teaching. What should the nurse's response be? -"Family members are a point of contact and are able to check on your progress." -"Family members are at risk of developing diabetes mellitus in future." -"Family members can take you to the hospital if any emergency occurs." -"Family members are equally involved in planning and implementation of care."
"Family members are equally involved in planning and implementation of care."
The mother of a 7 month old attempts to scoop cereal with his palm and reach his mouth, but drops several pieces of cereal on the floor. His mother asks if this feeding behavior is normal. What is the nurse's best response?
"Fine grasp is just now starting to develop at this age." At age 7-13 months, an infant uses pincer grasp to pick up objects. A child is not expected to feed himself with a spoon and cup until age 10-14 months.
The nurse is assessing cranial nerves III, IV, and VI. Which instructions should the nurse provide to the client in order to perform this assessment?
"Follow my finger with only your eyes." Testing cranial nerves III, IV, and VI also tests the movement of the eye muscles by asking the client to move the eyes in different directions. Turning the head assesses neck range of motion and mobility. Shrugging shoulder against resistance assesses a different cranial nerve. Asking the client to stand still with the eyes closed is known as the Romberg's test to test balance. (less)
A nurse notes that the pulse rate of a client is less than 60 beats per minute. Which question is appropriate for the nurse to ask the client in regards to this finding?
"Have you been sitting for a long time?" Sitting or standing for too long may cause the blood to pool and decrease the pulse rate. Fever and stress cause the pulse rate to increase, not decrease. Vitamin supplements do not affect the pulse rate. (less)
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?
"How do you usually go about making difficult decisions?" Piaget's concept of formal operations focuses primarily on thinking patterns and decision making. Intelligence and relationships are not central focuses.
A medical surgical client is in the radiology department. The client's cousin arrives on the medical surgical unit and asks to speak with the nurse caring for his cousin. The visitor asks the nurse to provide a brief outline of the client's illness. Which response, if given by the nurse, would demonstrate application of legal safeguard in her practice? A. "I will call the client and ask his permission." B. "I cannot give you that information due to client confidentiality." C. "Do you have any identification proving you are related to the client?" D. "I'm busy right now, but can talk later."
"I cannot give you that information due to client confidentiality."
During an assessment, the nurse asks a female patient, How many alcoholic drinks do you have a week? Which answer by the patient would indicate at-risk drinking?
"I have seven or eight drinks a week, but I never get drunk."
What statement by a middle-aged adult would most clearly suggest successful achievement of Erikson's central task during this stage of development?
"I'm doing a lot of volunteering in order to give back to the community." Erikson identified the main task of middle adulthood as generativity versus stagnation. "Giving back" is a tangible indicator of generativity. Each of the other listed statements is positive, but none directly exemplifies this developmental task. (less)
The nurse educator is presenting an in-service on nursing and malpractice. Which statements, made by the nursing staff, would indicate to the educator that further teaching is required? Select all that apply. A. "If I make a mistake, I will not tell anyone" B. "When I document, I make sure it is factual, accurate, complete, and timely." C. "I will have the supervisor fill out the incident report when I make an error." D. "I am accountable for any task that I delegate." E. "The nursing plan of care must be accurate and be followed. It is part of the client's permanent record."
"If I make a mistake, I will not tell anyone" "I will have the supervisor fill out the incident report when I make an error."
Which statement by the nurse is a culturally appropriate reaction to a client's perception of pain? A. "Asian clients have a high pain tolerance." B. "Some procedures hurt more and should have more pain reaction." C. "If a client needs to yell in pain, that is their right." D. "Males tend to overreact to pain for sympathy."
"If a client needs to yell in pain, that is their right."
A client has questioned why the nurse asked him how his family members usually treat their pain. Which of the following would be the most appropriate response by the nurse?
"It helps me to determine how the family understands and perceives pain." Asking about family experiences and pain will help assess possible family-related perceptions of pain or any past experiences with persons in pain. How people respond to pain varies with the meaning placed on pain and the response expected from pain in the culture in which the person is raised. (less)
The patient asks the nurse why the nurse put the tuning fork on the bone behind the ear. Which is the best response by the nurse?
"It identifies a problem with the normal pathways for sound to travel to your inner ear." Placing the tuning fork on the mastoid bone is one part of the Rinne's test, which assesses the normal pathways for sound to travel to the inner ear. Equilibrium is assessed with the Romberg test. Multiple sources of assessment data are used to determine whether hearing loss is caused by degeneration of nerves in the inner ear or repeated ear infections. (less)
A 52-year-old patient with myopia calls the ophthalmology clinic very upset. She tells the nurse, "I keep seeing semi-clear spots floating across my vision. What is wrong with me?" What would be the most appropriate response by the nurse? A. "It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'." B. "Please come into the clinic right away so we can see what is wrong." C. "Because it is almost 5 o'clock, please go to the emergency department right away. This sounds very serious." D. "I have an opening tomorrow at 2 in the afternoon. Can you come in then?"
"It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'."
The nursing student is applying Erikson's theory to the young adult patient she is caring for on the medical unit. The instructor knows that the student needs further instruction when she states:
"My patient is not in a sexual relationship; therefore, she has not accomplished Erikson's task of intimacy." In his theory, Erikson did not indicate that intimacy is achieved only through a sexual union but also through close friendships and physcal expressions. The young adult would have achieved trust during her infant years and would have become autonomous when she was a toddler learning how to make choices. (less)
A woman who has just discovered that she is pregnant is in the clinic for her first obstetric visit. She asks the nurse, How many drinks a day is safe for my baby? The nurses best response is:
"No amount of alcohol has been determined to be safe during pregnancy."
The nurse is participating in a discussion about controlled substances. Which statement, made by the nurse, indicates the nurse is aware of laws governing the distribution of controlled substances? A. "When a nurse abuses controlled substances in the workplace and gets help, she will not be charged with a criminal act." B. "Nurses are responsible for adhering to specific documentation about controlled substances." C. "An impaired nurse is promptly punished by being terminated and having his or her license suspended." D. "The nurse is only at risk if she diverts medication from the client; using personal drugs decrease your risk."
"Nurses are responsible for adhering to specific documentation about controlled substances."
PAIN ASSESMENT MNEMONIC
"OLD CARTS" 1. Onset- when did the pain start? 2. Location- where is the pain? 3. Duration- how long have you been having this pain? 4. Characteristic- what TYPE of pain are you experiencing? (sharp, dull, needle-like) 5. Allieviating Factors- What makes the pain feel better? Have you taken any medications for it? 6. Timing- Is the pain better/worse during the night/day? 7. Severity- Use a numeric scale, ask the patient to rate the pain. 0 being no pain, and 10 being the worst pain you could possibly experience.
Which statement indicates that the nurse understands the pain experienced by an older adult?
"Pain indicates a pathologic condition or an injury and is not a normal process of aging."
A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's following statements would appear at the beginning of a charting entry?
"Patient complaining of abdominal pain rated 8/10." The SOAP method of charting (Subjective data, Objective data, Assessment, Plan) begins with the information provided by the patient, such as a complaint of pain. The nurse's objective observations and assessments follow, with interventions, actions, and plans later in the charting entry. (less)
The nurse is providing care for a 61-year-old female smoker who is 30 kg overweight and was diagnosed with type 2 diabetes several years prior. Which of the following teaching points regarding the prevention of peripheral artery disease (PAD) is most accurate?
"Quitting smoking and keeping good control of your blood sugar levels are important." Smoking cessation and adequate glycemic control should be prioritized when teaching this client. Ankle edema should be assessed and followed up, but would not likely necessitate emergency care. Clients are not normally taught self-assessment of pulses, and quitting smoking and controlling blood glucose are more important than screening tests. (less)
EGGOPHONY
"SAY E-E-E".... IF THE PT SAID "A" IT WOULD BE A SIGN OF CONSOLIDATION WITHIN THE LUNGS, EITHER PNEMONIA, OR CHF!
A client being discharged from the hospital asks the nurse, "When I go visit my family out of state, should I take my living will with me, or do I need a new one for that state?" What is the most appropriate response made by the nurse? A. "A living will can only be used in the state it was created in." B. "Take it with you. It is recognized universally in the United States." C. "As long as your family knows your medical wishes, you will not need it." D. "We have it on file here, so any hospital can call and get a copy."
"Take it with you. It is recognized universally in the United States."
A nurse hired to work in an ambulatory setting attends new employee orientation. The nurse never worked in ambulatory before and is concerned about the Scope and Standards of Practice for Professional Ambulatory Care Nursing. Which response, given by the nurse educator, would further explain the Scope and Standards of Practice for Professional Care Nursing to the new nurse? A. "The Scope and Standards of Practice for Professional Ambulatory Care Nursing takes precedent over the facility's policies and procedures." B. "The Scope and Standards of Practice for Professional Ambulatory Care Nursing sets the standards for the nursing supervisor to assess a nurse." C. "The Scope and Standards of Practice for Professional Ambulatory Care Nursing determines if a nurse is minimally competent to receive a license to practice as a nurse." D. "The Scope and Standards of Practice for Professional Ambulatory Care Nursing deal with the professional obligations of a nurse working in the ambulatory setting."
"The Scope and Standards of Practice for Professional Ambulatory Care Nursing deal with the professional obligations of a nurse working in the ambulatory setting."
A 90-year-old patient is crying and states to the nurse, "I've had such a wasted life." The most appropriate response from the nurse will be
"You are feeling like you have had a wasted life...?" The central task for the older adult is ego integrity vs. despair. Unsuccessfully completing this task can lead to regret, discontent, and pessimism.
The nurse is caring for a client who practices Catholicism and was newly diagnosed with cancer. The client states, "God is punishing me for my past sins." How should the nurse respond? A. "You sound upset, would like you to talk about it?" B. "Why do you think God is punishing you?" C. "Would you like me to get someone from your church to visit you?" D. "You didn't get cancer as punishment."
"You sound upset, would like you to talk about it?"
Recently, lung cancer has metastasized to the bones of a 68-year-old client, precipitating a sudden increase in his pain. The client's wife and daughter are concerned about the consequent increase in the amount of hydromorphone the client requires, citing the risk of addiction. How can the nurse best respond to the family's concern?
"There's a very minimal risk of addiction, and controlling his pain is our first concern." Concerns about addiction are normally unfounded. Nonetheless, it is inaccurate to characterize the possibility of addiction as a myth, on one hand, or a very real risk, on the other. Tolerance would not necessitate discontinuation. (less)
A 6-year-old boy has come to the clinic with his mother because of recent eye redness and discharge. The nurse's assessment has suggested a diagnosis of conjunctivitis. What should the nurse tell the mother about her son's eye? "In children, this problem is usually caused by an increase in pressure within the eye." "I'll prescribe some analgesics because your son is likely to have quite severe pain while his eye heals." "Antibiotics will clear this up, but you need to make sure he gets them as ordered to avoid vision damage." "This might have been the result of an allergy, but most likely it was caused by a bacteria or virus."
"This might have been the result of an allergy, but most likely it was caused by a bacteria or virus."
A Hispanic client has been hospitalized for 6 days for postoperative infection. The client's weight is decreasing each day, and the nutritional intake is declining. Which nutritional assessment question is most appropriate? A. "Why aren't you eating your food?" B. "Are you aware that you are losing weight?" C. "What type of food do you eat at home?" D. "Don't you like what is on your food tray?"
"What type of food do you eat at home?"
Which question would be most appropriate to ask a client when the goal is to identify precipitating factors that might have exacerbated the pain?"
"What were you doing when the pain first stated? Exacerbation means something that could make the pain more intense or worse than previously experienced. Asking when the client was doing when the pain started might identify that type of factor. Asking about concurrent symptoms provides information about the possible source of the pain. Asking when the pain started provides information about the onset and duration of the pain. Asking if the pain is continuous or intermittent helps to identify the nature of the pain. (less)
The nurse is assessing a client's pain. Which question would be most appropriate to ask the client when the goal is to identify precipitating factors that might have exacerbated the pain?
"What were you doing when the pain first stated?" Asking what the client was doing when the pain started might identify a precipitating factor. Asking about concurrent symptoms provides information about the possible source of the pain. Asking when the pain started provides information about the onset and duration of the pain. Asking if the pain is continuous or intermittent helps to identify the nature of the pain. (less)
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?
"What would you describe as your main strengths and weaknesses?" Asking a client about his or her strengths and weaknesses can elicit insights into self-concept or self-image. Asking about religion or self-improvement is unlikely to elicit these data. A person may give insights into his or her self-image when asked about meaningful activities, but this is less direct than asking about strengths and weaknesses. (less)
The nurse is asking an adolescent about illicit substance abuse. The adolescent answers, Yes, Ive used marijuana at parties with my friends. What is the next question the nurse should ask?
"When was the last time you used marijuana?"
An Asian American client is admitted to the health care facility with hypoglycemia. After the client is stable, the nurse discovers that the client has not had his prescribed medicines. The client believes that eating saffron will keep his blood sugar under control. What is the most appropriate response by the nurse? -"Saffron does not have nay effect on blood sugar level." -"Let me inform the physician that you are not taking your medicines." -"Why don't you take the medicines, too, and benefit from both?" -"Yes, I agree that you should continue taking saffron for diabetes."
"Why don't you take the medicines, too, and benefit from both?"
CRACKLES/RALES (SMALL CLICKIN, BUBBLING, OR RATTLING SOUNDS)HEARD IN THE LUNGS
---> CHF, PNEAMONIA
A nurse assesses a female client's core body temperature and finds that she has a slightly elevated temperature. Which of the following factors could explain this finding? Select all that apply.
-client just finished exercising. - The client is ovulating. -The client is stressed. Several factors may cause normal variations in the core body temperature. Strenuous exercise, stress, and ovulation can raise temperature. Body temperature is lowest early in the morning (4:00 to 6:00 AM) and highest late in the evening (8:00 PM to midnight). Hypothermia (lower than 36.5°C or 96.0°F) may be seen in prolonged exposure to the cold, hypoglycemia, hypothyroidism, or starvation. Hyperthermia (higher than 38.0°C or 100°F) may be seen in viral or bacterial infections; malignancies; trauma; and various blood, endocrine, and immune disorders.
When to assess vital signs
-on admission to any health care agency or institution. -based on agency or institutional policy and procedures -Anytime there's a change in the patient's condition -anytime there is a loss of consciousness -before and after any surgical or invasive diagnostic procedure -before administering medications that affect cardiovascular and respiratory function
Calcium (Ca2+): most abundant electrolyte in the body; 99% of body calcium is stored in bone; 1% inside cells; NORMAL SERUM LEVELS ARE
0.1% in ECF; normal total serum calcium level: 8.6-10.2 mg/dL; normal ionized serum calcium level:`
Which is a common anion?
Chloride Correct Explanation: Chloride is a common anion, which is a negatively charged ion. Magnesium, potassium, and calcium are cations, or positively charged ion
The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade?
1+ The edema in the client should be graded as 1+, which means that the edema is just perceptible and of 2 mm dimension. A measurement of 2+ or 3+ indicates moderate edema of 4 to 6 mm. A measurement of 4+ indicates severe edema of 8 mm or more. (less)
The desirable amount of fluid intake and loss in adults ranges from
1,500 to 3,500 mL each 24 hours, with most people averaging 2,500 to 2,600 mL per day
Threee major types of blood vessels
1. Arteries- carry blood away from the heart 2. capillaries- enable the actual exchange of water and chemicals between the blood and the tissues; 3. veins- carry blood from the capillaries back toward the heart. The word vascular, meaning relating to the blood vessels, arteries and veins have three layers and cappilaries contain one layer of epitheliel cells 1. tunicca intima (thinnest layer) (only layer found in capillaries) 2. tunica media (thickest layer in arteries) 3. tunica adventita- (thickest layer in veins)
3 MAJOR NECK VESSELS (VESSEL=ANY CHAMBER THAT CARRIES FLUID)
1. CARATID ARTERIES-The carotid arteries are major blood vessels in the neck that supply blood to the brain, neck, and face. 2. INTERNAL JUGULAR VEIN- is the major venous return from the brain, upper face and neck. ... 3. EXTERNAL JUGULAR VEIN-receives the greater part of the blood from the exterior of the cranium and the deep parts of the face,
3 ARTERIAL GREAT VESSALS cap
1. CARATID ARTERY- The carotid arteries are major blood vessels in the neck that supply blood to the brain, neck, and face. There are two carotid arteries, one on the right and one on the left. In the neck, each carotid artery branches into two divisions: The internal carotid artery supplies blood to the brain. 2. Aorta-the main artery of the body, supplying oxygenated blood to the circulatory system. In humans it passes over the heart from the left ventricle and runs down in front of the backbone. 3. PULMONART VEINS-The pulmonary veins are large blood vessels that receive oxygenated blood from the lungs and drain into the left atrium of the heart. There are four pulmonary veins, two from each lung. The pulmonary veins are among the few veins that carry oxygenated blood.
hypervolemia symptoms
1. EDEMA, (SWELLING, PARTICUARLLY IN FEET AND ANKLES) 2. ORTHOPNEA, DIFFICULTY BREATHING WHILE LYING DOWN 3. CRACKLES/RALES HEARD ON AUSCULTATION 4. HIGH BLOOD PRESSURE 5. INCREASED RR 6. ASCITES (EXCESS FLUID IN THE ABDOMEN) 7. STRONG, RAPID PULSE 8. JUGULAR VEIN DISTENTION 9. PRESENCE OF EXTRA HEART SOUNDS S3 10. LOW HEMOGLOBIN OR HEMOCRIT LEVELS 11. INCREASED PAP (PULMONARY ARTERY PRESSURE) 12. ELEVATED CVP (CENTRAL VENOUS PRESSURE) 13. WEIGHT GAIN 14. SHORTNESS OF BREATH/ INCREASED RR (BOTH DUE TO DECREASED RED BLOOD CELLS) DILUTION OF BLOOD CCELLS PRODUCES A COMPENSATORY INCREASE IN RESPIRATION TO IMPROVE OXYGENATION. 15. dyspnea, and orthopnea (difficulty breathing lyinig down) 16. paroxysmal noctural dypnea (PDN) severe attacks of shortness of breath and coughing that occur at night. 17. cough 18. X RAY RESULTS SHOW PULMONARY EDEMA 19. OLIGURIA, ( PRODUCTION OF ABNORMALLY SMALL AMOUNTS OF URINE) 20. SPECIFIC GRAVITY CHANGES IN URINE (NORMAL = 1.000-1.030) 21. INTAKE IS GREATER THAN OUTPUT 22. AZOTEMIA (MEDICAL CONDITION ASSOCIATED WITH HIGH LEVELS OF NITROGEN CCONTAINING COMPOUNDS, SUCH AS UREA, CREATINE, AND OTHER BODY WASTE IN THE BLOOD. 23. NEUROLOGICAL CHANGES INCLUDING, MENTAL STATUS CHANGES LIKE. CONFUSION, AND LETHARGY 24. ANXIETY, AND RESTLESSNESS
NAME 3 COMMON BREAST MASSES
1. FIBROADENOMA-A noncancerous breast tumor that most often occurs in young women. 2. CYSTS-Search Results Cysts: Cysts are abnormal, closed sac-like structures within a tissue that contain a liquid, gaseous, or semisolid substance. Cysts can occur anywhere in the body and can vary in size. The outer, or capsular, portion of a cyst is termed the cyst wall. most are harmless, but should be removed when possible because they occasionally may change into malignant growths, become infected, or obstruct a gland. 3. CANCER-the disease caused by an uncontrolled division of abnormal cells in a part of the body. Cancer is not just one disease, but a large group of almost 100 diseases. Its two main characteristics are uncontrolled growth of the cells in the human body and the ability of these cells to migrate from the original site and spread to distant sites. If the spread is not controlled, cancer can result in death. One out of every four deaths in the United States is from cancer. It is second only to heart disease as a cause of death in the states.
Frameworks for Health Assessment
1. Functional assessment Focuses on the functional patterns that all humans share 2. Head-to-toe assessment Most organized 3. Body systems approach Promotes critical thinking
PERCUSSION FUNCTION AND TECHNIQUE
1. Generates sounds and assesses if underlying tissues are air filled, fluid filled or solid-always compare bilaterally in the intercostal spaces 2. Technique: Position only your pleximeter finger (middle finger of your non-dominant hand)) on the chest wall and apply a quick, sharp tap to the distal interphalangeal joint (1st one after the nail bed) with your partially flexed plexor fingertip (middle finger of your dominant hand).
The nurse is administering 1,000 mL 0.9 normal saline over 10 hours (set delivers 60 gtt/1 mL). Using the formula below, the flow rate would be:
100 gtt/min 100gtt/min is the correct rate. 1000 mL divided by10 hours= 100 mL per hour x 60 gtt/minute, divided by 60 minutes.
1. VENOUS GREAT VESSELS (JESSICA SIMPSON IS PREGNANT)
1. Jugular veins- The jugular veins are veins that bring deoxygenated blood from the head back to the heart via the superior vena cava. any of several large veins in the neck, carrying blood from the head and face. 2. Superior Vena Cava- a large vein carrying deoxygenated blood into the heart : A large vein that receives blood from the head, neck, upper extremities, and thorax and delivers it to the right atrium of the heart. 3. Inferior Vena Cava- a large vein carrying deoxygenated blood from the lower and middle body into the right atrium of the heart. The inferior vena cava is the largest vein in the human body. It collects blood from veins serving the tissues inferior to the heart and returns this blood to the right atrium of the heart. Although the vena cava is very large in diameter, its walls are incredibly thin due to the low pressure exerted by venous blood. 4. Pulmonary Artery- the artery carrying blood from the right ventricle of the heart to the lungs for oxygenation. ONE OF THE ONLY ARTERIES THAT CARRY DEOXYGENATED BLOOD
LOWER AIRWAY "RESPIRATION AIRWAY" INCLUDES
1. LUNGS 2. ALVEOLI ( SMALL, BALLON LIKE STRUCTURES ATTACHED TO THE BRANCHES OF THE BRONCHIAL PASSAGES,) WHERE GAS EXCHANGE OF OXYGEN AND CARBON DIOXIDE OCCURS IN THE ALVEOLI.
PALPATION TECHNIQUE
1. Lightly touch the chest using your fingertips: a. always compare bilaterally b. determine tender areas & abnormalities in skin, muscles, tracheal position & ribs 2. Determine chest expansion: a. posterior position, thumbs at 10th rib, fingers parallel to lateral rib cage. b. Slide hands toward spine (medially) to raise a loose fold of skin on each side between your thumbs and the patient's spine. c. have the patient inhale deeply. Feel for range of movement & symmetry of rib cage- your thumbs should move apart equally. 3. Feel for tactile fremitus (vibrations) transmitted to the chest wall when the patient speaks. a. use the ball of your hand(bony part of the palm at the base of the fingers. b. have the patient state "ninety-nine". You should feel the vibrations through your hands in a healthy patient with a normal voice-more intense at scapula, less intense at lung bases
4 Phases of the Interview Process
1. Preinteraction Phase: gathering and interpreting patient data prior to meeting the patient 2. Beginning Phase: Introduction, verification of correct patient, purpose of meeting 3. Working Phase: collect patient subjective data using closed & open ended questions 4. Closing Phase: conclusion of the interview process by summarizing problems and offering strategies for management of problems
What are the 3 Prevention Levels to promote health
1. Primary prevention 2.Secondary Prevention 3.Tertiary prevention: existing disease Rx to prevent complications and promote health at patient's optimal level
what are the SEVEN rights to administering medication? PMDRTDR
1. RIGHT PATIENT 2. RIGHT MEDICATION 3. RIGHT DOSAGE 4. RIGHT ROUTE 5. RIGHT TIME 6. RIGHT DOCUMENTATION 7. RIGHT TO REFUSE TREATMENT/MEDICATION
WHAT ARE THE 9 ARTERIAL PULSE POINTS WITHIN THE HUMAN BODY?
1. SUPERFICIAL TEMPORAL ARTERY 2. FACIAL ARTERY 3. COMMON CAROTID ARTERY 4.BRACHIAL ARTERY 5.RADIAL ARTERY 6. FEMORAL ARTERY 7. POPLITEAL ARTERY 8. POSTERIOR TIBIAL ARTERY 9. DORSALIS PEDIS ARTERY
Five great vessels enter and leave the heart: SIPPA
1. Superior vena cava 2. Inferior vena cava 3. pulmanry artery 4. pulmonary vein 5. aorta
what are the body's three buffer systems
1. THE CARBONIC ACID-SODIUM BICARBONATE BUFFER SYSTEM 2. THE PHOSPHATE BUFFER SYSTEM 3. THE PROTEIN BUFFER SYSTEM
TRACHEAL LUNG SOUNDS
1. TRACHEAL=heard over the trachea in the neck, very loud, high pitched. Inspiratory & expiratory time is equal I=E
Muscles utilized for inspiration
1. diaphragm- primary muscle of respiration increases superior-inferior (top to bottom) thoracic cavity, elevates lower ribs & moves abdominal contents downward 2. external intercostals increases anterior-posterior (front to back) thoracic cavity 3. accessory muscles (Scalene & Sternocleidomastoid) contract when there is an increased inspiratory effort to increase the anterior-posterior thoracic cavity
What is a health assessment?
1. gathering information about the patient's health status 2. analyzing and synthesizing collected data 3. determining nursing interventions based on the collected data 4. evaluating patient care outcomes of implemented nursing interventions
Muscles utilized for expiration
1. relaxation of inspiratory muscles 2. internal intercostals-used for forceful expiration decreasing anterior-posterior (front to back) thoracic cavity 3. abdominal muscles-(obliques, rectus & abdominus) -used for increased expiratory effort decreasing superior-inferior (top to bottom) thoracic cavity
Outcomes are measurable and specific criteria on what the nurse and patient agree upon. All Outcomes have 3 components (Page 7 Lab Packet) 3 COMPONENTS OF OUTCOMES
1.Action Verb 2.Measurable Behavior 3. Realistic Timeframe i.e. The patient will perform (action verb) isometric exercises (measurable behavior) twice a day (realistic timeframe)
BLOOD FLOW THROUGH THE HHEART
1.Blood that has circulated through the body, which has lost its oxygen and collected carbon dioxide, enters through the vena cava into the right atrium of the heart. 2.The right atrium contracts and pumps the blood through the tricuspid valve and into the right ventricle. 3.The right ventricle then pumps blood through the pulmonary artery into the lungs. 4.In the lungs, tiny blood vessels called capillaries absorb carbon dioxide from the blood and replace it with oxygen. 5.Oxygenated blood then flows through the pulmonary vein and into the left atrium 6.Oxygenated blood then pumps through the mitral valve and into the left ventricle. 7.The left side of the heart contracts the strongest to send blood out the left ventricle and through the aortic arch on its way to all parts of the body. At this point, there are a few options for the blood flow: blood can be pumped • through the carotid artery and into the brain. • through the auxiliary arteries and into the arms. • through the aorta and into the torso and legs. 8.Blood will then move through the arteries, then through capillaries, and then return through the veins. 9.Deoxygenated blood (blood without oxygen) will then return to the heart. 10.The cycle repeats
Barriers to Pain Assessment
1.Reluctance to report pain/take medications 2. Fear that pain indicates disease progression 3. Fear of being called a "complainer" 4.Concern about adverse drug effects 5. Concern about tolerance or addiction 6. Concern over cost of medication
Which ribs are considered "floating ribs"?
11th and 12th Note that the costal cartilages of the first seven ribs articulate with the sternum; the cartilages of the 8th, 9th, and 10th ribs articulate with the costal cartilages just above them. The 11th and 12th ribs, the "floating ribs," have no anterior attachments. The cartilaginous tip of the 11th rib usually can be felt laterally, and the 12th rib may be felt posteriorly. On palpation, costal cartilages and ribs feel identical. (less)
A nurse is assessing the central venous pressure of a client who has a fluid imbalance. Which reading would the nurse interpret as suggesting an ECF volume deficit?
12 cm H2O Explanation: The normal pressure is approximately 4 to 11 cm H2O. An increase in the pressure, such as a reading of 12 cm H2O may indicate an ECF volume excess or heart failure. A decrease in pressure, such as 3.5 cm H2O, may indicate an ECF volume deficit. (less)
A drop of 20 mmHg or more form the recorded sitting blood pressure may indicate orthostatic hypotension. Therefore, a change in blood pressure from 122/72 mmHg to 98/52 mmHg fits this criteria. The other blood pressure readings, although lower than the sitting blood pressure would not reflect orthostatic hypotension. (less)
120/55 mm Hg A drop in both the systolic and diastolic readings of 20 mm Hg or more from the sitting position to the standing position indicates orthostatic hypotension. A drop of less than 20 mm Hg from the sitting position is considered normal. An elevation is not called hypotension but hypertension. (less)
A nurse has an order to obtain orthostatic blood pressure readings on a client admitted with dehydration. The sitting blood pressure is 140/75mmHg. Which blood pressure reading with the client standing should the nurse recognize as orthostatic hypotension?
120/55 mmHg A drop in both the systolic and diastolic readings of 20 mmHg and more indicates orthostatic hypotension. A drop of less than 20 mmHg from the sitting position is considered normal. An elevation is not called hypotension but hypertension. (less)
A nurse is assessing the respiratory rate of an elderly client. Which of the following findings in breaths per minute would indicate a normal respiratory rate in this client?
18 A respiratory rate of 18 breaths/min would be normal for this client. In older adults, the normal respiratory rate would range between 15 and 22 breaths/min. Respiratory rates of fewer than 15 breaths/min or more than 22 breaths/min would be an abnormal respiratory rate for this client. (less)
THERE ARE FOUR VALVES OF THE HEART (2 AV VALVES AND TWO SEMI-LUNAR VALVES)
2 ATRIOVENTRICULAR VALVES ARE THE MITRAL VALVE (BICUSPIC) AND THE TRICUSPID VALVE 1. MITRAL (BICUSPID VALVE)= . It lies between the left atrium and the left ventricle. The mitral valve opens to increased pressure as the left atrium fills with blood. Closes off the upper left chamber (or left atrium) collecting the oxygen-rich blood coming in from the lungs.Opens to allow blood to pass from the upper left side to the lower left side (or from the left atrium to the left ventricle). 2. TRICUSPID VALVE=The tricuspid valve, or right atrioventricular valve, is on the right dorsal side of the mammalian heart, between the right atrium and the right ventricle. The function of the valve is to prevent back flow of blood into the right atrium. 2 SEMILUNAR VALVES ARE THE AORTIC VALVE AND THE PULMONARY VALVE 1. AORTIC VALVE= The aortic valve is located between the aorta and the heart's left ventricle. Closes off the lower left chamber that holds the oxygen-rich blood before it is pumped out to the body. Opens to allow blood to leave the heart (from the left ventricle to the aorta and on to the body). 2. PULMONARY VALVE= : located between the right ventricle and the pulmonary artery. Closes off the lower right chamber (or right ventricle). Opens to allow blood to be pumped from the heart to the lungs (through the pulmonary artery) where it will receive oxygen.
2 Types of Data and 2 Types of Sources
2 Types: Subjective Data: Non-measurable, it is what the patient states Objective Data: Measurable, it is what you find performing inspection, palpation, percussion and auscultation 2 Sources: Primary: from patient Secondary: from family and medical records
In what years of life does Jean Piaget's second stage, preoperational, take place?
2 to 7 years The second stage of Jean Piaget's cognitive model is preoperational, which lasts from approximately ages 2 to 7 years.
BRONCHIAL LUNG SOUNDS
2.BRONCHIAL= heard over the trachea & larynx, they are loud, high pitched. Inspiration time is less than expiration time I<E
Which vision acuity reading indicates blindness?
20/200 The reading of 20/200 on a vision acuity test indicates blindness. The reading of 20/20 is considered normal vision. This means that the client being tested can distinguish what a person with normal vision can distinguish from 20 feet away. The top or first number is always 20, indicating the distance from the client to the chart. The bottom or second number refers to the last full line the client could read. The higher the second number, the poorer the vision. 20/40 and 20/100 also denote poor vision. (less)
The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the:
25 cm scar on the right lower forearm.
BRONCHIVESICULAR LUNG SOUNDS
3. BRONCHOVESICULAR= heard over major bronchi (1st & 2nd ICS & between the scapula), they are medium in intensity and pitch. Inspiratory & expiratory time is equal I=E
FOODS HIGH IN POTASSIUM AND NORMAL LEVELS
3.5-5.0 mEq/L 1. POTATOES 2. SUN DRIED TOMATOES 3. BANNANAS 4. KIDNEY BEANS 5.DRIED FRUITS (APRICOTS, PEACHES, FIGS) 6. AVACADO 7.FISH (SALMON, TUNA) 8. ACORN SQUASH 9. MILK 10. DARK LEAFY GREENS
cell fluid is
35-40% of body weight
Breast cancer PERCENTAGES AND SYMPTOMS
4% with breast complaints 5% with nipple discharge 11% with lump or mass All breast masses require careful assessment Second leading cause of cancer death Declines in new cases of invasive breast cancer Earlier and more advanced breast cancer in African American women
A nurse is assessing the pulse rate of an athletic client during a routine checkup. The nurse should anticipate the pulse rate to be in what range of beats per minute?
40-60 The normal pulse rate of a well-conditioned athletic client is often less than 60 beats per minute because of the conditioning of the cardiovascular system. A pulse rate ranging between 60 and 100 beats/min is normal for adults. A pulse rate of more than 100 beats/min would indicate tachycardia. (less)
Smoking can cause vasoconstricion, hypertension and peripheral vascular disease, not vasodilation and hypotension.
48 mmHg The pulse pressure is the difference between the systolic and diastolic pressures. For this client, the pulse pressure would be 48 mmHg.
Which fluid should be administered slowly to prevent circulatory overload?
5% NaCl When a hypertonic solution is infused, it raises serum osmolarity, pulling fluid from the cells and the interstitial tissues into the vascular space. Examples of hypertonic solutions include 3% NaCl and 5% NaCl
plasma is
5% of body weight
WHen should you do a self-breast exam?
5-7 days after your mences due to breast changes during your period
Which child would the nurse expect to draw a circle and triangle?
5-year-old Brian The nurse would expect 5-year-old Brian to draw a circle and triangle.
A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate?
50 gtt/min Explanation: The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes.
A nurse is caring for a 22-year-old man and a 75-year-old man. If the nurse gave both patients the same simple comparison task, how much faster would the nurse expect the 22-year-old to finish it than the 75-year-old?
50% Numerous studies have examined the speed of cognition in older adults, and the results have shown that older adults take about 50% longer than younger adults to do a simple comparison task. (less)
By what percent can clients reduce their risk of cardiac events the first year after quitting smoking?
50% Correct Explanation: Nurses should ask clients who smoke about their willingness to quit at every visit. Clients who quit reduce their risk of cardiac events by 50% after the first year. Nurses can give clients choices about tools to help them quit, such as referrals to behavioral therapy, information about support groups, or medication. (less)
total body fluid is
50-60% of body weight
A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing?
60 drops/mL Microdrip tubing, regardless of manufacturer, delivers a standard volume of 60 drops/mL. Macrodrip tubing manufacturers, however, have not been consistent in designing the size of the opening. Therefore, the nurse must read the package label to determine the drop factor (number of drops/mL)
Parents of 13-year-old Kara express concern about whether Kara will always be short. Her mother is 5 feet, 2 inches and her father is 5 feet, 8 inches. In inches, what would be an accurate estimate of potential adult height for Kara?
62.5 Kara's estimated adult height would be 62.5 inches. (68 + 62 - 5 inches)/2
VENOUS BLOOD PH
7.36
Due to a change in the client's status, a nurse is now assessing a client's temperature by the axillary route. Previously, the client had an oral temperature of 98.4oF. Which finding would the nurse interpret as within the range of the client's previous temperature?
97.4oF An axillary temperature is 1oF lower than the oral temperature. In this case, the axillary temperature that is within the client's oral temperature range would be 97.4o F. Rectal temperature is between 0.7oF and 1oF higher than the normal oral temperature. (less)
Due to a change in the client's level of consciousness, a nurse is now assessing a client's temperature by the axillary route. Previously, the client had an oral temperature of 98.4ºF. Which finding would the nurse interpret as corresponding most closely to the client's previous temperature?
97.4ºF Explanation: An axillary temperature is 1ºF lower than the oral temperature. In this case, the axillary temperature that is within the client's oral temperature range would be 97.4ºF. Rectal temperature is between 0.7ºF and 1ºF higher than the normal oral temperature.
The nurse obtains a client's blood pressure when standing and compares it to the measurement obtained while the client was sitting. The client's blood pressure when sitting was 122/72 mmHg. Which finding would suggest to the nurse that the client is experiencing orthostatic hypotension?
98/52 mmHg A drop of 20 mmHg or more form the recorded sitting blood pressure may indicate orthostatic hypotension. Therefore, a change in blood pressure from 122/72 mmHg to 98/52 mmHg fits this criteria. The other blood pressure readings, although lower than the sitting blood pressure would not reflect orthostatic hypotension. (less)
The nurse obtains a client's blood pressure when standing and compares it to the measurement obtained while the client was sitting. The client's blood pressure when sitting was 122/72 mmHg. Which finding would suggest to the nurse that the client is experiencing orthostatic hypotension?
98/52 mmHg A drop of 20 mmHg or more form the recorded sitting blood pressure may indicate orthostatic hypotension. Therefore, a change in blood pressure from 122/72 mmHg to 98/52 mmHg fits this criteria. The other blood pressure readings, although lower than the sitting blood pressure would not reflect orthostatic hypotension. (less)
HYPOVENTILATION
: deficient ventilation of the lungs that results in reduction in the oxygen content or increase in the carbon dioxide content of the blood or both
HYPERVENTILLATION
: excessive rate and depth of respiration leading to abnormal loss of carbon dioxide from the blood
22. An adult client has asked the nurse about actions that she can take to reduce her future risk of stroke. What health promotion activity should the nurse prioritize? A) Smoking cessation B) Annual MRI screening C) Nutritional supplementation D) Improved coping skills
A
27. The nurse is performing the Romberg test as part of a client's focused neurological assessment. What finding would constitute a positive Romberg test? A) The client moves her feet apart to prevent herself from falling. B) The client is unable to consistently touch her finger to her nose while her eyes are close. C) The client experiences pain during neck flexion and extension. D) The client experiences pain when clenching her teeth.
A
A patient with type AB blood has experienced a precipitous drop in his hemoglobin levels due to a gastrointestinal bleed and now requires a blood transfusion. Which of the following blood types may this patient safely receive? Select all that apply.
A • B • AB • O Explanation: Persons with type AB blood are often called universal recipients, a fact that is rooted in their lack of agglutinins for either A or B antigens.
A nurse is receiving report from the night shift about four clients. Which client would the nurse see first?
A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min Decreased level of consciousness, respiratory rate above 30 breaths/min, cyanosis, retractions, and use of accessory muscles may indicate hypoxia (a medical emergency). The only scenario in line with these criteria is the man with COPD. (less)
BRCA TESTING
A breast cancer (BRCA) gene test is a blood test to check for specific changes (mutations) in genes that help control normal cell growth. Finding changes in these genes, called BRCA1 and BRCA2, can help determine your chance of developing breast cancer and ovarian cancer.
Which of the following clients would be a candidate for total parenteral nutrition?
A client with colitis and bloody diarrhea Correct Explanation: Total parenteral nutrition is indicated when there is interference with nutrient absorption from the gastrointestinal tract or when complete bowel rest is necessary for healing. A client with bloody diarrhea and colitis requires complete bowel rest
Which of the following assessment findings suggests a problem with the client's cranial nerves? A. A client states that he has recently begun seeing lights flashing in his field of vision. B. A client's extraocular movements are asymmetrical and she complains of diplopia. C. Fundoscopic examination reveals intraocular bleeding. D. A client's lens appears cloudy and she claims that her visual acuity has recently declined.
A client's extraocular movements are asymmetrical and she complains of diplopia.
Which of the following assessment findings suggests a problem with the client's cranial nerves?
A client's extraocular movements are asymmetrical and she complains of diplopia. Deficits in cranial nerves III, IV, and VI can manifest as impaired extraocular movements or diplopia. Flashes of light are associated with retinal detachment, while intraocular bleeding and cataracts do not have a neurological etiology. (less)
CREPITUS
A clinical sign in medicine that is characterized by a peculiar crackling, crinkly, or grating feeling or sound under the skin, around the lungs, or in the joints. (AIR TRAPPED UNDER THE SKIN)
A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collect in this setting
A complete health data base because of the nurses primary responsibility for monitoring the patients health
HYPERVOLEMIA is what? signs/symptoms
A condition in which the liquid portion of the blood (plasma) is too high. HTN (HYPERTENSION) WEIGHT LOSS TENTED, DRY SKIN (SKIN TURGOR)\ INCREASED RR INCREASED PR COOL SKIN FLAT NECK VEINS OLIGURIA, VERY SMALL AMTS OF URINE Lethargy, no energy
What is Communication?
A dynamic system of sending and receiving messages (information exchange) between individuals (a sender and a receiver). Comprised of Verbal (speech) and Non-Verbal (body language) Messages Message interpretation (decoding) is affected by many variables and determines subsequent feedback and further information exchange
The nurse notes a tophus of the ear of an older adult. Which assessment data is consistent with a tophus?
A hard nodule composed of uric acid crystals A tophus is a hard nodule composed of uric acid crystals. A cyst on the ear would present as a fluid-filled sac. Redness and bulging of the eardrum is characteristic of otitis media with effusion. Scarring of the tympanic membrane occurs with repeated ear infections with perforation of the tympanic membrane (less)
A nurse is palpating a Caucasian client's chest as part of a routine assessment. Which of the following findings would the nurse expect in this client because of his race?
A larger thorax and greater lung capacity The size of the thorax, which affects pulmonary function, differs by race. Compared with African Americans, Asians, and Native Americans, adult Caucasians have a larger thorax and greater lung capacity. A costal angle greater than 90 degrees is an indicator of long-standing hyperinflation of the lungs, as in emphysema. Pectus carinatum is a forward protrusion of the sternum causing the adjacent ribs to slope backward (often referred to as pigeon chest). Barrel-chest configuration results in a more horizontal position of the ribs and costal angle of more than 90 degrees. This often results from long-standing emphysema. (less)
You are assessing visual fields on a patient newly admitted for eye surgery. The patient's left eye repeatedly does not see your fingers until they have crossed the line of gaze. You would document that the patient has what? A. A left temporal hemianopsia B. A homonymous hemianopsia C. A bitemporal hemianopsia D. A quadrantic defect
A left temporal hemianopsia
You are assessing visual fields on a patient newly admitted for eye surgery. The patient's left eye repeatedly does not see your fingers until they have crossed the line of gaze. You would document that the patient has what?
A left temporal hemianopsia When the patient's left eye repeatedly does not see your fingers until they have crossed the line of gaze, a left temporal hemianopsia is present.
The client being admitted to the oncology unit conveys his wishes regarding resuscitation in the event of cardiopulmonary arrest. The nurse advises the client that it would be in his best interest to obtain which document? A. A will B. A living will C. Proof of health care power of attorney D. A proxy directive
A living will
Susan, a 6-month-old, is hospitalized for a respiratory illness. Which activity would be appropriate for the nurse to provide for Susan?
A mobile A mobile would be most appropriate for a 6-month-old child. This child would not be walking but would experiment with kicking a mobile to see it move. Pull toys are appropriate for toddlers (12- to 18-month-olds). The child 12- to 18-months-old would be capable of staking cubes or blocks. A coloring book and crayons would be appropriate for an older child, 4 years and older. (less)
PULSE RATE
A normal resting heart rate for adults ranges from 60 to 100 beats a minute. Generally, a lower heart rate at rest implies more efficient heart function and better cardiovascular fitness. For example, a well-trained athlete might have a normal resting heart rate closer to 40 beats a minute.
Once physiologic needs are met, nurses can concentrate on meeting self-actualization needs of patients. What are examples of self- actualization needs according to Maslow's hierarchy of needs? (Select all that apply.) A. A nurse attains a master's degree in nursing by going to school in the evening. B. A nurse refers a patient's spouse to an Al- Anon group meeting. C. A student nurse takes a course in communication to improve her ability to relate to patients. D. A nurse raises the side rails on the bed of a patient at risk for falls. E .A nurse administers insulin to a diabetic patient. F. A nurse subscribes to several nursing journals to stay abreast of developments in the profession.
A nurse attains a master's degree in nursing by going to school in the evening. A student nurse takes a course in communication to improve her ability to relate to patients. A nurse subscribes to several nursing journals to stay abreast of developments in the profession.
The nursing faculty is lecturing on unintentional and intentional torts. The faculty asks a nursing student to provide an example of an unintentional tort. Which example, if provided by the student, would indicate the student has a clear understanding of torts? A. Nurses are in the elevator discussing a client's laboratory values. B. A nurse is telling a client he cannot leave the hospital until he pays his bill. C. A nurse is threatening to restrain a client if he does not stop talking. D. A nurse gives a medication and client has an adverse reaction.
A nurse gives a medication and client has an adverse reaction.
Which of the following is an example of certification? A. A nurse who demonstrates advanced expertise in a content area of nursing through special testing. B. A graduate of a nursing education program who passes NCLEX-RN. C. An education program that meets standards of the National League for Nursing. D. A hospital that meets the standards of the Joint Commission.
A nurse who demonstrates advanced expertise in a content area of nursing through special testing.
Which of the following is an example of certification? A. A nurse who demonstrates advanced expertise in a content area of nursing through special testing. B. A hospital meets the standards of the Joint Commission. C. An education program that meets standards of the National League for Nursing. D. A graduate of a nursing education program who passes NCLEX-RN.
A nurse who demonstrates advanced expertise in a content area of nursing through special testing.
Which nursing student would most likely be held liable for negligence? A. A nursing student performs a dressing change using sterile technique and documents the presence of necrotic tissue in the wound. B. A nursing student reports that insulin was not administered to the client by the nurse on the previous shift. C. A nursing student administers medication to a resident, while working as an unlicensed assistive personnel (UAP) at a local nursing home. D. A nursing student completes an incident report after administering a medication to a client, who then experienced an adverse reaction to the medication.
A nursing student administers medication to a resident, while working as an unlicensed assistive personnel (UAP) at a local nursing home.
Which of the following wounds is most likely attributable to neuropathy?
A painless wound on the sole of the client's foot, which is surrounded by calloused skin Neuropathic ulcers tend to develop on pressure points, such as the sole of the foot, and are often free of pain. Painful wounds surrounded by healthy skin are associated with arterial insufficiency and moderately painful ankle wounds surrounded by pigmented skin are often associated with venous ulcers. (less)
Which of these clinical situations would the nurse consider to be outside normal limits?
A patient has had two pregnancies, and she breastfed both of her children. Her youngest child is now 10 years old. Her breast examination reveals breast tissue that is somewhat soft, and she has a small amount of thick yellow discharge from both nipples
Which of the following is an example of a characteristic of Stage 2 of illness? -A person tells his family that he is sick and allows them to take care of him -A person experiences a headache and sore throat and takes an aspirin -A person visits a physician to receive treatment for symptoms of an infection -A person begins rehabilitation following a stroke that left him paralyzed on one side
A person tells his family that he is sick and allows them to take care of him
An adolescent confides in the school nurse that she is arguing daily with her mother, and she often wonders if her mother loves her. The school nurse recognizes that the student faces which of the following risk factors for altered family health? -A psychosocial risk factor -A lifestyle risk factor -A developmental risk factor -A biologic risk factor
A psychosocial risk factor
A Catholic priest baptizes a stillborn baby of a Catholic family. What type of practice is this considered? A. Necessary B. Expected C. A ritual D. A birth rite
A ritual
The nurse notes a cyst on the ear of an older adult. Which assessment data is consistent with a cyst?
A sac with a membranous lining filled with fluid A cyst on the ear would present as a fluid-filled sac. A tophus is a hard nodule composed of uric acid crystals. Redness and bulging of the eardrum is characteristic of otitis media with effusion. Swelling of the external ear canal with inflammation or infection would be referred to as an edematous ear. (less)
To best enhance the quality of life for senior citizens, which of the following should a community sponsor? -Home health visits -Transportation to physicians -Church groups -A senior center
A senior center
Which of the following is an example of sociocultural dimension influencing a person's health-illness status? -A teenager who is worried about his scars from an automobile accident -A father who is a practicing Jehovah's Witness refusing a blood transfusion for his son -A family living in a city with high air pollution -A single mother of two applies for food stamps in order to feed her family
A single mother of two applies for food stamps in order to feed her family
A 55-year-old male client has just been diagnosed with presbycusis. In the interview with the client, the nurse should most expect the client to complain of having trouble hearing which of the following in the initial stages of this condition?
A story his wife is telling him Presbycusis often begins with a loss of high-frequency sounds (woman's voice) followed later by the loss of low-frequency sounds. The bass speakers, his son's voice, and the engine starting would all have lower-frequency sounds than his wife's voice. (less)
A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice?
A trained interpreter.
Which of the following clients is most likely to be diagnosed with migraine headaches? A. A woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room B. A woman who complains of recurrent headaches near the end of her workday spent at a computer station C. A man who has sought care for treatment of his episodic headaches that occur several times each day D. A man whose headaches are accompanied by severe light sensitivity but an absence of nausea
A woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room
Assess for and report signs and symptoms of fluid volume deficit (9 things
A. decreased skin turgor (skin elasticity) B. Sudden weight loss of 2% or greater C. Dry mucous membranes, thirst D. ORTHOSTATIC HYPERTENSION/POSTURAL HYPOTENSION (LOW BP WHILE STANDING) AND LOW B.P E. WEAK, RAPID PULSE F. NECK VEINS ARE FLAT WHEN CLIENT IS SUPINE (LYING DOWN) G. CHANGE IN MENTAL STATUS I. ELEVATED BUN (Blood Urea Nitrogen) and Hct (Hematocrit) bun normal levels=
KNOW NORMAL BREATHE SOUNDS VS
ABNORMAL BREATHE SOUNDS AND USE THE LADDER PATTERN TO DETECT/CHECK FOR SYMMETRY WITHIN THE LUNGS
Dyspnea, an uncomfortable awareness of breathing that is inappropriate to the level of exertion, is what?
AIR HUNGER Dyspnea is air hunger, a nonpainful but uncomfortable awareness of breathing that is inappropriate to the level of exertion, commonly termed shortness of breath.
Hives, itching, and anaphylaxis occur in
ALLERRGIC REACTIONS
Arterial and venous blood must maintain a slightly alkaline pH: arterial blood pH = 7.41 and venous blood pH = 7.36. Because the normal pH of arterial blood is 7.41, a person is considered to have acidosis when the pH of blood falls below this value and to have alkalosis when the pH rises above 7.41.
ARTERIES eat more veins eat less
SITTING POSITION
ASCULATION OF HEART AND LOUNGS HEAD, EARS, NOSE, AND THROAT, AND PARTS OF THE NEUROLOGICAL EXAM.
A nurse palpates the presence of an enlarged inguinal lymph node. Which area of the client's body should the nurse thoroughly examine to assess for the source of this finding?
Abdomen, noting any organ enlargement or tenderness Inflammation or infection in the abdomen would drain into the inguinal nodes located in the groin area. The epitrochlear nodes are located in the upper inside of the arm. Enlargement of these nodes may indicate infection in the hand or forearm or they may occur with generalized lymphadenopathy. Cervical lymph nodes are part of the system that drains the head and neck, and enlargement would be due to a recent ear infection, sore throat, or other upper respiratory tract infection. (less)
The nurse is caring for 6-year-old Abigail. Which activity would the nurse expect Abigail to perform?
Abigail draws a picture of her family. Abigail is in Erikson's stage of industry versus inferiority. She would be expected to plan and complete an activity, such as drawing a picture of her family. As an infant in the stage of trust versus mistrust, Abigail would learn to calm herself by sucking her thumb. Adolescents achieve identity (versus role confusion) by establishing their own opinions, views, and ideas separate from parent, peers, and others. Middle-aged adults demonstrate generativity (versus stagnation) by sharing their knowledge with younger generations. (less)
percussion ABNORMAL LUNG FINDINGS
Abnormal Lung findings: a. Lungs filled with fluid or exudate (high concentrations of protein, cells or solid debris produce dullness (muffled thud). Sound is medium in intensity & pitch & less hollow because of less air. b. Lungs hyperinflated (COPD, emphysema) produce hyperresonance. Sound is very loud in intensity, low pitch & long duration because of more air.
Where is the temporal artery palpated? A. Above the cheek bone near the scalp line B. Just left of midline at the base of the neck C. Between the mandibular joint and the base of the ear D. Just left or right of the spine at the base of the skull
Above the cheek bone near the scalp line
A 7-year-old boy is performing poorly in school. His teacher is frustrated because he is frequently seen "staring off into space" and not paying attention. If this is a seizure, it most likely represents which type? A. Pseudoseizure B. Tonic-clonic C. Absence D. Myoclonus
Absence
A nursing student is reading a research article form a nursing journal. The student is aware that the opening paragraph summarizing the article (and the findings of the research) is a good place to start. What part of the article is the nursing student reading? -Conclusions -Results -Review of the literature -Abstract
Abstract
When auscultating the heart sounds of a client, a nurse notes that the S2 is louder than the S1. How should the nurse describe S2?
Accentuated An accentuated S2 means that the S2 is louder than the S1. This occurs in conditions in which the aortic or pulmonic valve has a higher closing pressure. A diminished S2 means that the S2 is softer than the S1. This occurs in conditions in which the aortic or pulmonic valves have decreased mobility. Normal split S2 can be heard over the second or third left intercostal space; it is usually heard best during inspiration and disappears during expiration. Wide split S2 is an increase in the usual splitting that persists throughout the entire respiratory cycle, and widens on expiration. (less)
Nursing, as a profession, has long held the belief that providing nursing care to an individual patient means providing nursing care to the entire family. What does this mean when put into a holistic framework of patient care? A. Families are caretakers even when the patient is not acutely ill. B. It is necessary for the nurse, patient and the patient's family to integrate the physical and emotional environment of the patient. C. Active participation by individuals and families in health promotion is integral to this framework of patient care. D. This model is congruent with the philosophy of traditional patriarchal medicine.
Active participation by individuals and families in health promotion is integral to this framework of patient care.
A client comes to the emergency room complaint of abdominal pain, fever, chills, and nausea. Upon further examination the client is diagnosed with appendicitis. What type of illness does the nurse identify this client to have? -Contagious -Chronic -Acute -Tertiary
Acute
A client presents to the ED with pain in the upper right quadrant that worsens after eating. The client describes the pain as sharp, stabbing, and at times very intense. This is a description of which type of pain?
Acute Acute pain results from tissue damage, whether through injury or surgery. Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues. Phantom pain is pain in an extremity or body part that is no longer there. Cutaneous pain and phantom pain are not described as above. Chronic pain, also known as persistent pain, is a description of a pain that is present for more than six months, and can be described in many different terms, not just as above. (less)
Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning?
Acute Confusion related to cerebral edema Edema in and around the brain increases intracranial pressure, leading to the likelihood of confusion. Constipation related to immobility, Pain related to surgical incision, Risk for Infection related to inadequate personal hygiene are nursing diagnoses that have no connection to fluid and electrolyte imbalance
Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning?
Acute Confusion related to cerebral edema Explanation: Edema in and around the brain increases intracranial pressure, leading to the likelihood of confusion.
A client presents to the health care clinic with reports of 20day history of sore throat pain, ear pressure, fever, and stiff neck. The client states they have taken Tylenol and lozenges without relief. Which nursing diagnosis can be confirmed by this data?
Acute Pain related to sore throat The client describes pain on 2 day duration which is within the definition for acute pain. The client did not describe or display any major defining characteristics of anxiety such as restlessness, concern about lifestyle changes, sleep disturbances. The stiff neck was not confirmed by objective data collected by the nurse. No evidence exists for the client to have risk for fluid volume deficit. (less)
Upon examination of the head and neck of a client, a nurse notes that the submandibular nodes are tender and enlarged. The nurse should assess the client for further findings related to what condition? A. Metastatic disease B. Chronic infection C. Acute infection D. Cushing's disease
Acute infection
9. A client has presented with signs and symptoms that are suggestive of Bell's palsy. What assessment finding is most consistent with this diagnosis? A) Inability to detect sharp and dull stimuli B) Inability to wrinkle the forehead C) Closure of the affected eye from swelling D) Muscle spasm of the lower face on the affected side
B
Otoscopic examination of a 69-year-old client's tympanic membrane reveals that it is red, bulging, and distorted. The nurse also notes a diminished light reflex. To what should the nurse most likely attribute this assessment finding?
Acute otitis media A red, bulging eardrum coupled with distorted, diminished, or absent light reflex is associated with acute otitis media. Repeated ear infections usually cause the formation of white scar tissue. Trauma causes the accumulation of blood behind the eardrum, which appears blue or dark red. (less)
A nurse is caring for a client diagnosed with pancreatitis. Which of the following is a priority need for nursing management? -Depression due to recurrent symptoms -Acute pain in the abdomen -Inability to take care of family -Lack of self-confidence
Acute pain in the abdomen
ACUTE PAIN <LESS THA N 6 MONTHS
Acute pain is a type of pain that typically lasts less than 6 months, or pain that is directly related to soft tissue damage such as a sprained ankle or a paper cut. Acute pain is of short duration but it gradually resolves as the injured tissues heal.
The nurse is explaining the expected developmental tasks of a typical family with adolescents. Which of the following would be incorrect for the nurse to include? A. Adjustment to retirement B. open communication C. Strengthen the marital relationship D. Maintain a supportive home environment
Adjustment to retirement
A client suffering from a headache complains of throbbing, severe, unilateral pain that feels worse when exposed to bright lights. The client also complains of nausea and vomiting. What is the nurse's best action? Administer narcotic pain medication Administer migraine medication Administer medication for common cold Prepare the client for a spinal tap
Administer migraine medication
A patient is complaining of severe knee pain after twisting it during a basketball game and is requesting pain medication. Which action by the nurse is appropriate?
Administer pain medication and then proceed with the assessment.
Which age group is at risk for fluid and electrolyte imbalances resulting from fad dieting?
Adolescents Fad diets or purging to lose weight can cause severe fluid and electrolyte imbalances.
The nurse is determining the number of annual influenza inoculations that will need to be provided to a group of community members. Which members would benefit from receiving this vaccination? (Select all that apply.)
Adult patient caring for children under age 5 • Older adult attending adult day care • Adult patient with chronic obstructive pulmonary disease The Centers for Disease Control and Prevention recommend the annual influenza vaccination for any adult with a chronic pulmonary condition, any adult who attends a chronic care facility, and caregivers of children younger than 5 years. The Centers for Disease Control and Prevention do not specifically identify the populations that include a young adult patient who lives alone or the adolescent patient being home schooled for the annual influenza vaccination, although all people wishing to reduce the risk of infection should be vaccinated. (less)
You are studying the peripheral vascular system so you would know that the vasa vasorum is found where?
Adventitia of the artery The outer layer of the artery is the adventitia, connective tissue containing nerve fibers and the vasa vasorum.
A client admitted to the telemetry floor informs the nurse that he has an advance directive and does not wish to be resuscitated if his heart stops beating. The client takes a copy of the advance directive from his wallet and hands it to the nurse. The nurse documents on the electronic chart that the client has an advance directive, makes a copy of the advance directive, and immediately informs the patient's physician. In this situation, what is the nursing role demonstrated by the nurse? -Counselor -Researcher -Advocate -Leader
Advocate
During an examination of a patients abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drumlike quality of the sounds across the quadrants. This type of sound indicates:
Air-filled areas
In response to a question regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing this information?
Alcohol can interact with all medications and can make some diseases worse.
A nurse notes that a client looks much older than his chronologic age. Which of the following conditions would most likely contribute to this appearance?
Alcoholism A client may appear older than actual chronologic age due to a hard life, manual labor, chronic illness, alcoholism, or smoking. Parkinson's disease is associated with stiff, rigid movements. Marfan's syndrome is associated with arm span being greater than height and pubis to sole measurement exceeding pubis to crown measurement. Cushing's syndrome is associated with central body weight gain with excessive cervical obesity (Buffalo's hump). (less)
ALDOSTERONE
Aldosterone is a steroid hormone. Its main role is to regulate salt and water in the body, thus having an effect on blood pressure.
All lung tissue is expected to be WHAT on percussion
All lung tissue is expected to be RESONANT (HOLLOW-SOUNDING) on percussion Resonant sounds are low pitched, hollow sounds heard over normal lung tissue.
A student nurse is assisting an elderly patient to ambulate following hip replacement surgery, and the patient falls and reinjures the hip. Who is potentially responsible for the injury to this patient? A. The student nurse B. The nurse instructor C. The hospital D. All of the above
All of the above
A 2-year-old child has been brought to the clinic for a well-child checkup. The best way for the nurse to begin the assessment is to:
Allow the child to keep a security object such as a toy or blanket during the examination.
A client has an injury that affects the posterior sensory nerve columns of the spinal cord. Which of the following will the the nurse most likely find during the examination of the sensory system? (Select all that apply.) A. Alteration in the perception of position B. Changes in the perception of vibration C. Change in pain perception D. Alteration in temperature sense E. Loss of depth perception
Alteration in the perception of position Changes in the perception of vibration
A patient co ntacts the office and tells the nurse that she is worried about her 10-year-old daughter having breast cancer. She describes a unilateral enlargement of the right breast with associated tenderness. She is worried because the left breast is not enlarged. What would be the nurses best response? Tell the mother that
Although an examination of her daughter would rule out a problem, her breast development is most likely normal.
The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use?
Although the stethoscope does not magnify sound, it does block out extraneous room noise
Which organization has established standards that help the nurse determine which clinical actions fall under the scope of nursing practice? -State Board of Nursing -International Council of Nurses -National League for Nursing -American Nurses Association
American Nurses Association
Which of the following organizations is the best source of information when a nurse wishes to determine whether an action is within the scope of nursing practice? -American Association of Colleges in Nursing (AACN) -National League for Nursing (NLN) -American Nurses Association (ANA) -International Council of Nurses (ICN)
American Nurses Association (ANA)
What is a long-term complication of peripheral vascular disease?
Amputation Diseases of the peripheral vascular system, peripheral arterial disease, venous stasis, and thromboembolic disorders can severely affect the lifestyle and quality of life of patients. Identifying modifiable risk factors and providing health promotion counseling can prevent or delay long-term complications, such as decreased mobility and amputation. (less)
BRUIT
An abnormal whooshing sound of blood through an artery that usually indicates that the artery has been narrowed, causing a turbulent flow, as in arterioscleroisis. Bruits are abnormal - if the patient is healthy and "normal," you should not hear any bruits. Bruits can be detected in the neck (carotid bruits), umbilicus (abdominal aortic bruits), kidneys (renal bruits), femoral, iliac, and temporal arteries.
A rapid onset of symptoms that lasts a relatively short time indicates what health problem? -Potential for wellness -Actual risk factor -A chronic illness -An acute illness
An acute illness
A nurse will be performing frequent assessment and reassessment of a client. Which form would be most appropriate for the nurse to use?
An assessment flow chart Flow charts help staff record and retrieve data for frequent reassessments. Flow charts help streamline documentation and prevent needless repetition of data.
A nurse is assessing the blood pressure of a client using the Korotkoff's sounds technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record?
An auscultatory gap is a period during which sound disappears. An auscultatory gap can range as much as 40 mm Hg. A widening in the diameter of the artery takes place in the phase II of the Korotkoff sound technique. An adult diastolic pressure takes place in the phase IV of the Korotkoff sound technique.
A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs?
An implanted central venous access device (CVAD) Implanted CVADs are ideal for long-term uses such as chemotherapy.
Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?
An infant age 4 months An infant has considerably more total-body fluid and extracellular fluid (ECF) than does an adult. Because ECF is more easily lost from the body than intracellular fluid, infants are more prone to fluid volume deficits
The nurse is caring for a patient who is experiencing visceral pain. What is this patient's most likely diagnosis?
Appendicitis Visceral pain originates from abdominal organs; patients often describe this pain as crampy or gnawing.
Which of the following statements most accurately describes the maintenance of normal intraocular pressure? A. The lacrimal gland produces increased fluid when intraocular pressure is low and ceases production when pressure is high. B. The eye is a closed system whose contents of aqueous humour provide consistent internal pressure. C. The muscles of the ciliary body adjust the volume of the eye in response to increased or decreased pressure. D. Aqueous humour is continuously circulating through the eye with production equalling drainage.
Aqueous humour is continuously circulating through the eye with production equalling drainage.
The nurse is inspecting the cornea and lens of an elderly client and notices a white arc around the limbus of the client's eye. The nurse recognizes this condition, common in older adults, as which of the following? A. Arcus senilis B. Presbyopia C. Ectropion D. Myopia
Arcus senilis
The nurse is inspecting the cornea and lens of an elderly client and notices a white arc around the limbus of the client's eye. The nurse recognizes this condition, common in older adults, as which of the following?
Arcus senilis Arcus senilis, a normal condition in older clients, appears as a white arc around the limbus. The condition has no effect on vision. Presbyopia, which is impaired near vision, is caused by decreased accommodation and is a common condition in clients over 45 years of age. Ectropion is when the lower eyelids evert, causing exposure and drying of the conjunctiva. This is a normal finding in the older client. Myopia is impaired far vision. (less)
The community health nurse is caring for an older patient who states that she has not been taking the postoperative pain medication that she was prescribed. What question is most likely to be relevant?
Are you able to afford the prescribed medication? If a patient continues to refuse pain medication, you may consider asking the patient they can afford the prescribed medication.
The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask?
Are you able to dress yourself?
A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self- mutilation and has a history of suicide attempts. She describes difficulty sleeping at night and has lost 10 pounds in the past month. Which of these statements or questions is the nurses best response in this situation?
Are you feeling so hopeless that you feel like hurting yourself now?
A 26-year-old woman was robbed and beaten a month ago. She is returning to the clinic today for a follow- up assessment. The nurse will want to ask her which one of these questions?
Are you having any disturbing dreams?
During a class on religion and spirituality, the nurse is asked to define spirituality. Which answer is correct? Spirituality:
Arises out of each person's unique life experience and his or her personal effort to find purpose in life."
A hospital patient who does not speak or understand English has been ordered an invasive diagnostic test. The nurse believes that the patient is highly anxious about his care and prognosis. He is accompanied by his daughter, who speaks minimal English. How should the nurse best prepare this patient for his diagnostic test? A. Describe the procedure in simple terms to the patient. B. Pull up an online video of the procedure on the nurse's smartphone in order to provide the patient with visual information. C. Describe the procedure in detail to the patient's daughter and have her explain it to her father. D. Arrange for a hospital interpreter to describe the procedure to the patient.
Arrange for a hospital interpreter to describe the procedure to the patient.
During a health visit, a client says, "I know that arteries and veins are blood vessels, but what's the difference?" Which of the following would the nurse include in the response?
Arteries have thicker walls than veins. Arteries are blood vessels that carry oxygenated, nutrient-rich blood from the heart to the capillaries via a high-pressure system. Arterial walls are thick and strong and contain elastic fibers for stretching. Veins contain nearly 70% of the body's blood volume. (less)
During a health visit, a client says, "I know that arteries and veins are both blood vessels, but what's the difference?" Which of the following would the nurse include in the response?
Arteries have thicker walls than veins. Arteries are blood vessels that carry oxygenated, nutrient-rich blood from the heart to the capillaries via a high-pressure system. Arterial walls are thick and strong and contain elastic fibers for stretching. Veins contain nearly 70% of the body's blood volume. (less)
Arterial System
Arteries, Arterioles, & Capillaries make up the vessels in the arterial system. Walls of arterial system made up of 3 layers Smooth endothelial cells - inner layer of blood vessels
A 82 year old female presents with neck pain, decreased strength and sensation of the upper extremities. The nurse identifies that this could be related to what? A. Arthritic changes of the cervical spine B. Bacterial thyroiditis C. Cranial damage D. Muscle tension
Arthritic changes of the cervical spine
An 81-year-old client complains of neck pain and demonstrates decreased range of motion on examination. Which of the following causes should the nurse most suspect in this client? A. Meningeal inflammation B. Stress C. Injury to the sternomastoid D. Arthritis
Arthritis
Which abnormal skin color should a nurse anticipate assessing on a dark-skinned client?
Ashen gray The skin of a dark-skinned client with cyanosis would be ashen gray. The skin tone would appear yellowish in a light-skinned client if the client had jaundice. A beige-pink skin tone would be a normal finding for the light-skinned client. (less)
The nurse is assessing the skin condition and color of an African-American client. Which of the following would the nurse document as an abnormal finding?
Ashen gray skin color In dark-skinned individuals, loss of red tones and ashen gray color (suggesting cyanosis) would be considered abnormal. Normally, skin color is evenly distributed; pores may or may not be clearly visible. Color typically ranges from light tan to dark brown or olive in dark-skinned clients. (less)
A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN I. Which of the following would the nurse do?
Ask a client to identify scents. Cranial nerve I is the olfactory nerve, which would be tested by having the client occlude one nostril and identify a scent. Using the Snellen chart tests CN II, the optic nerve. Testing extraocular eye movements evaluates tests CN III (oculomotor), CN IV (trochlear), and CN VI (abducens). The Weber test evaluates CN VIII (acoustic/vestibulocochlear). (less)
A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN I. Which of the following would the nurse do?
Ask a client to identify scents. Cranial nerve I is the olfactory nerve, which would be tested by having the client occlude one nostril and identify a scent. Using the Snellen chart tests CN II, the optic nerve. Testing extraocular eye movements evaluates tests CN III (oculomotor), CN IV (trochlear), and CN VI (abducens). The Weber test evaluates CN VIII (acoustic/vestibulocochlear).
A male client comes to the clinic complaining of a persistent cough. Further questioning reveals that he was just recently diagnosed with hypertension. Which of the following would the nurse do next?
Ask about any medications being used for hypertension. The nurse needs to ask the client about medications being used to treat his hypertension. Side effects of certain antihypertensive medications include persistent cough, which is of no consequence except for its annoying nature. Once this information is obtained then the nurse can gather additional information and complete the assessment to ensure that the findings are related to the medication and not another problem (less)
A nurse assesses a client's pupils for the reaction to light and observes that the pupils are of unequal size. What should the nurse do next in relation to this finding?
Ask the client about previous trauma to the eyes Unequal pupil size is termed anisocoria. Often it is a normal finding but it can indicate trauma to the parasympathetic nerve supply to the iris. The nurse should ask the client about previous trauma to the eye to determine if this is a new finding or this is new onset. All other options the nurse can do after this is determined. (less)
A nurse is testing a client's corneal reflex but notices that the reflex appears to be reduced. The client is otherwise alert and oriented, with no signs of neurologic degeneration. What is an appropriate action by the nurse?
Ask the client about the presence of contact lenses The corneal reflex test is done to assess the sensory portion of cranial nerve V (trigeminal). If the client has an intact nervous system, the nurse should ask about the presence of contact lenses because they can cause the reflex to be absent or reduced. Touching the cornea with a small piece of cotton is how the test is performed. Blinking or rinsing the eyes is not an appropriate action. (less)
A nurse experiences difficulty with palpation of the apical impulse on the precordium. What is an appropriate action by the nurse?
Ask the client to assume the left lateral position If unable to locate the apical impulse, ask the client to turn to the left lateral position. This displaces the heart towards the left chest wall and relocates the apical impulse father to the left. Using one finger is appropriate after locating the pulse for a more accurate palpation. Coughing will not assist in location of the apical impulse. The nurse should locate the apical impulse by palpation be fore auscultating heart sounds. (less)
A Chinese client is admitted to the health care facility with blockage in the coronary arteries. The cardiologist advises the client to undergo angioplasty. The client refuses the procedure. Later the nurse discovers that the client believes in naturopathy and is taking herbal extract to unclog his coronary arteries. Which of the following suggestions should the nurse give to the client? -Tell the client that herbal therapy has not proven to be effective -Ask the client to opt for herbal therapy and also undergo surgery -Warn the client that the majority of the herbalists are all quacks -Tell the client that herbal medicines could lead to other complications
Ask the client to opt for herbal therapy and also undergo surgery
During an assessment, around his neck. Which action by the the nurse notices that a patient is handling a small charm that is tied to a leather strip nurse is appropriate?
Ask the patient about the item and its significance.
During a health history interview, a female patient states that she has noticed a few drops of clear discharge from her right nipple. What should the nurse do next?
Ask the patient some additional questions about the medication she is taking
The nurse suspects an enlarged thyroid in a patient during the physical examination of the head and neck. What should the nurse first? Displace the trachea to the right. Listen over the thyroid with a stethoscope. Ask the patient to sip and swallow water. Ask the client to lie down for further assessment
Ask the patient to sip and swallow water.
Which technique by the nurse demonstrates proper use of the ophthalmoscope?
Asks the client to fix the gaze upon an object and look straight ahead After turning on the ophthalmoscope, the nurse should ask the client to gaze straight ahead and slightly upward. Ask the client to remove glasses but keep contact lens in place. The nurse should use the right eye to examine the right eye & left eye to examine the client's left eye. This allows the nurse to get as close as possible to the client's eye. Begin about 10-15 inches from the client at a 15 degree angle. The nurse should keep the ophthalmoscope still & ask the client to look into the light to view the fovea and macula. (less)
A client with a cervical spine injury has chronic pain. What would be the most appropriate initial nursing intervention for this client? Work with medical team to evaluate possible surgery Discuss pharmacologic interventions Chronic pain related to cervical spine injury Assess characteristics
Assess characteristics
A client with a cervical spine injury has chronic pain. What would be the most appropriate initial nursing intervention for this client? A. Work with medical team to evaluate possible surgery B. Discuss pharmacologic interventions C. Chronic pain related to cervical spine injury D. Assess characteristics
Assess characteristics
How should a nurse assess a client for pulse rate deficit?
Assess for a difference between the apical and radial pulse The nurse should assess the pulse deficit by assessing the difference in the apical and radial pulse. Pulse deficit is the difference between the apical and peripheral/radial pulses. Differences in the amplitude or rate of the carotid pulse may indicate stenosis. A split S1 occurs when the left and right ventricles contract at different times (asynchronous contraction). Decrease in jugular venous pressure can occur with dehydration secondary to a decrease in total blood volume but does not cause a pulse deficit. (less)
During the health history a client reports a decrease in his ability to smell. During the physical assessment, the nurse would make sure to assess which cranial nerve?
Assess for nonverbal signs. The GCS is a tool for assessing a patient's response to stimuli. Scores range from 3 (deep coma) to 15 (normal). Eye opening response: Spontaneous 4 To voice 3 To pain 2 None 1 Best verbal response: Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 None 1 Best motor response: Obeys command 6 Localizes pain 5 Withdraws 4 Flexion 3 Extension 2 None 1 Total 3-15. A score of three indicates deep coma; therefore, the client is unable to verbalize pain level on numerical scale or FACES scale. A client in a coma can still experience pain.
A nurse caring for an older adult client following a total abdominal hysterectomy documents administration of morphine 4 mg intravenously for pain of 8 on 1-10 scale, bed in the lowest position, bed alarm on, side rails up times two, and call light in reach. After the nurse leaves the room, the client gets out of bed and falls. In which order should the nurse proceed? A. Assess the client for injury. B. Assist the client back into bed. C. Notify the physician. D. Document the incident. E. Complete an incident report.
Assess the client for injury. Assist the client back into bed. Notify the physician. Document the incident. Complete an incident report.
A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action should the nurse perform next? Assess the client's blood pressure. Provide medication for pain relief. Inquire about family history of headaches. Review the client's medical record.
Assess the client's blood pressure.
The nurse palpates a client's pulse and notes that the rate is 61 beats per minute, with an amplitude that is weak and thready. How should the nurse respond to this assessment finding?
Assess the client's pulse at the carotid site. These data do not warrant a code blue. The nurse should follow up on abnormal amplitude and contour findings by palpating the carotid arteries, which provides the best assessment of amplitude and contour. Assessment of JVP is not indicated. (less)
An 86-year-old male patient with a diagnosis of vascular dementia and cardiomyopathy is exhibiting signs and symptoms of pneumonia. The nurse has attempted to assess his temperature using an oral thermometer but the patient is unable to follow directions to close his mouth and secure the thermometer sublingually. As well, he repeatedly withdraws his head when the nurse attempts to use a tympanic thermometer. How should the nurse proceed with assessment?
Assess the patient's temperature by axilla The axillary site is an accurate and acceptable alternative when other sites are impractical or contraindicated. Rectal temperatures are contraindicated in cardiac patients; mercury thermometers are not commonly used. It is unacceptable for the nurse to rely solely on subjective assessments to determine whether the patient is febrile. (less) The vagus nerve runs from the brain to the rectum, passing the heart in the process. Pressure on the vagus nerve can cause the heart to slow down, and blood pressure to drop. This is the main reason that a lot of elderly people come into the hospital. (They passed out while on the toilet.) Taking a rectal temperature can put pressure on the vagus nerve, causing a decline in the blood pressure and heart rate of your patient. You can actually cause a cardiac event, and even, death in some cases by taking the rectal temp, on a cardiac patient. (a patient with heart disease)
The nurse is making morning rounds after receiving reports on clients. The nurse takes the opportunity to greet the clients and do an initial observation. The nurse is actually accomplishing which step of the nursing process? -Assessment -Evaluation -Implementation -Planning
Assessment
What step of the nursing process includes data collection by health history, physical examination, and interview?
Assessment
Which of the following steps in the nursing process is the careful taking of a history and a nursing examination? -Evaluation -Assessment -Nursing diagnosis -Planning
Assessment
The nursing process is a sequential method of problem solving that nurses use and includes which steps?
Assessment, diagnosis, outcome identification, planning, implemenataion and evaluation
What are 5 parts of the Nursing Process? ADPIE
Assessment-collect data Diagnosis-identify problems using North American Nursing Diagnosis Association (NANDA-I) Page 3 Lab Packet Plan-set treatment goals & outcomes Intervention-provide care Evaluation-measure outcomes- did the care work?
A woman who has lived in the United States for a year after moving from Europe has leaned to speak English and is almost finished with her college studies. She now dresses like her peers and says that her family in Europe would hardly recognize her. This nurse recognizes that this situation illustrates which concept?
Assimilation
A nurse cares for a client who is postoperative cholecystectomy. Which action by the nurse is appropriate to help prevent the occurrence of venous stasis?
Assist the client to walk as soon and as often as possible. Immobility creates an environment in which clotting (embolism formation) can be caused by venous stasis. Active exercise such as having the client ambulate as soon as possible will stimulate circulation and venous return. This reduces the possibility of clot formation. Raising the foot of the bed, vigorous massage, and active range of motion of the upper body may not prevent venous stasis. (less)
During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding?
Asymmetry is not unusual, but the nurse should verify that this change is not new
A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding?
At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet The Snellen chart tests distant visual acuity by seeing how far the client can read the letters standing 20 feet from the chart. The top number is how far the client is from the chart and the bottom number refers to the last line the client can read. A reading of 20/50 means the client sees at 20 feet what a person with normal vision can see at 50 feet. The minus number is the number of letters missed on the last line the client can distinguish. (less)
A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding? A. Client did not wear his glasses for this test and therefore it is not accurate. B. When 50 feet from the chart, the client can see better than a person standing at 20 feet. C. Client can read the 20/50 line correctly and two other letters on the line above. D. At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet.
At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet.
When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles? Applying pressure and assessing for induration Attempting to roll the structure up and down and side to side Palpating for lateral movement when the client swallows a sip of water Observing for hypertrophy when the client turns the head against resistance
Attempting to roll the structure up and down and side to side
For which of the following research activities is a phenomenological research method most appropriate? -Describing the health maintenance activities that are practiced by homeless, intravenous drug users -Attempting to understand non-English speaking immigrants' experiences of being hospital clients -Explaining how the particular characteristics of the Vietnam War affected the roles of nurses -Understanding how clients cope with a new diagnosis of Alzheimer's disease
Attempting to understand non-English speaking immigrants' experiences of being hospital clients
Audiometry is testing that measures hearing acuity precisely. Who does the nurse know can perform audiometric testing?
Audiologist Audiometry is done by an audiologist. Audiometric testing measures hearing acuity precisely. Options A, B and D can screen hearing but they cannot do audiometric testing.
The nurse palpates a client's pulse and notes that the rate is 71 beats per minute, with an irregular rhythm. How should the nurse follow up this assessment finding?
Auscultate the client's apical pulse. The nurse should perform auscultation of the apical pulse if the client exhibits irregular intervals between beats. The ulnar pulse is not normally palpated, and the administration of nitroglycerin is not warranted. Repositioning the client is not a relevant or an appropriate response. (less)
A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first when beginning the examination?
Auscultate the lungs and heart while the infant is still sleeping.
A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first? Immediately notify the health care provider Document the findings in the nurse notes Auscultate with the bell over the lateral lobes Ask the client about past history of hypothyroidism
Auscultate with the bell over the lateral lobes
A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first? A. Immediately notify the health care provider B. Document the findings in the nurse notes C. Auscultate with the bell over the lateral lobes D. Ask the client about past history of hypothyroidism
Auscultate with the bell over the lateral lobes
A nurse is assessing a client with hyperthyroidism for the presence of a bruit. Which assessment technique should the nurse use? A. Inspection B. Palpation C. Auscultation D. Percussion
Auscultation
Which assessment technique should a nurse use to assess for the presence of a bruit in a client with hyperthyroidism? A. Inspection B. Palpation C. Auscultation D. Percussion
Auscultation
`A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client?
Avoid salty or excessively sweet fluids. To minimize thirst in a client on fluid restriction, the nurse should suggest the avoidance of salty or excessively sweet fluids. Gum and hard candy may temporarily relieve thirst by drawing fluid into the oral cavity because the sugar content increases oral tonicity. Fifteen to 30 minutes later, however, oral membranes may be even drier than before. Dry foods, such as crackers and bread, may increase the client's feeling of thirst. Allowing the client to rinse the mouth frequently may decrease thirst, but this should be done with water, not alcohol-based, mouthwashes, which would have a drying effect. (less) `
A nurse is assessing a 73-year-old client in terms of her psychosexual development. Which of the following would the nurse most likely identify as an abnormal finding in this client?
Avoidance of relationships Sexual intimacy; occasional forgetting or misplacement of things; and effective use of previous experiences, self, and others to grieve loss are all normal characteristics of older adults, according to Freud. Avoiding relationships, on the other hand, is an abnormal finding of psychosexual development. (less)
Which behavior by the nurse is stereotyping? A. Avoiding clients who are elderly because their care is time consuming. B. Openly ridiculing the practice of acupuncture. C. Explaining to others that Western medicine is always superior. D. Grouping care assignments to allow ample time to care for complex clients.
Avoiding clients who are elderly because their care is time consuming.
The brain is a network of interconnecting neurons that control and integrate the body's activities. What components make up these neurons? Select all that apply.
Axon • Dendrite • Cell body Each neuron contains a cell body , which serves as the control center; smaller receiving fibers called dendrites; and a connecting long fiber called an axon. Axons are white because they are covered with a myelin sheath that speeds up impulse conduction. Cell bodies are on the outside of the brain (gray matter or cerebral cortex), while axons that connect to other parts of the nervous system are directed toward the center of the brain. (less)
18. A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN I. Which of the following should the nurse do? A) Use a Snellen chart to test visual acuity. B) Ask a client to identify scents. C) Test extraocular eye movements. D) Perform the Weber test.
B
20. A nurse is testing a client's deep tendon reflex. The nurse taps the tendon above the olecranon process. The nurse is assessing which reflex? A) Brachioradialis B) Triceps C) Biceps D) Achilles
B
30. Examination of a client's gait reveals that the client is stooped over when walking and that he slowly shuffles. As well, the client maintains a stiff posture when walking. The nurse should document what type of gait? A) Scissors gait B) Parkinsonian gait C) Spastic hemiparesis D) Footdrop
B
6. The nurse assesses brisk reflexes in a client during a neurological assessment. The nurse should document this finding as which of the following? A) 1
B) 2+ C) 3+ D) 4+ +C
breast self-examinations (BSEs). She tells the nurse that she believes that mammograms do a much better job During an annual physical examination, a 43-year-old patient states that she does not perform monthly than I ever could to find a lump. The nurse should explain to her that:
BSEs may detect lumps that appear between mammograms.
A nurse is preparing to assess a client's cerebellar function. Which of the following would the nurse expect to test?
Balance Balance and coordination are functions of the pyramidal and extrapyramidal tracts of the motor and cerebellar systems. Remote memory and mental status exam provide information about the client's cognitive ability. Testing for sensation would address issues with specific cranial nerves or problems involving the parietal lobe. (less)
A nurse is preparing to assess a client's cerebellar function. Which of the following would the nurse expect to test?
Balance Balance and coordination are functions of the pyramidal and extrapyramidal tracts of the motor and cerebellar systems. Remote memory and mental status exam provide information about the client's cognitive ability. Testing for sensation would address issues with specific cranial nerves or problems involving the parietal lobe.
A nurse working with patients in a community is aware that which of the following is a true statement related to environmental factors in that community? -Environmental factors focus on the harmful effects on an individual's health -The quality of air and water are relatively consistent when comparing urban and rural environments -Barriers to accessing health care within a community may include lack of transportation -Lack of health insurance is a negative environmental factor affecting one's access to health care
Barriers to accessing health care within a community may include lack of transportation
A nurse working with patients in a community is aware that which of the following is a true statement related to environmental factors in that community? A. Barriers to accessing health care within a community may include lack of transportation. B. The quality of air and water are relatively consistent when comparing urban and rural environments. C. Environmental factors focus on the harmful effects on an individual's health. D. Lack of health insurance is a negative environmental factor affecting one's access to health care.
Barriers to accessing health care within a community may include lack of transportation.
A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify? Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor Homelessness Syndrome related to lack of housing as evidenced by visibly soiled clothing Inadequate Hygiene related to homelessness as evidenced by client's stink Impaired Impulse Control related to poor socioeconomic conditions as evidenced by visibly soiled clothing
Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor
A client admitted to a mental health unit has exhibited physical behaviors that put him and others at risk. The nurse applies four-point restraints on the client without obtaining a physician's order or the client's consent. The nurse is at risk of being accused of which of the following? A. Slander B. Negligence C. Battery D. Malpractice
Battery
When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly
Be silent, and allow him to continue when he is ready.
Which is a common anion?
Chloride Explanation: Chloride is a common anion, which is a negatively charged ion. Magnesium, potassium, and calcium are cations, or positively charged ions.
43-year-old woman is at the clinic for a routine examination. She reports that she has had a breast lump in her right breast for years. Recently, it has 5 cm from the nipple. It is firm, mobile, and nontender, with borders that are not well defined. The nurse The examination validates the presence of a mass in the right upper outer quadrant at 1 oclock, approximately the lump and determined that it was nothing to worry about begun to change in consistency and is becoming harder. She reports that 5 years ago her physician evaluated replies:
Because of the change in consistency of the lump, it should be further evaluated by a physician.
A woman is in the family planning clinic seeking birth control information. She states that her breasts change all month long and that she is worried that this is unusual. What is the nurses best response? The nurse should tell her that:
Because of the changing hormones during the monthly menstrual cycle, cyclic breast changes are common.
A nursing student's parents are both physicians. The nursing instructor may feel the student has A. Been educated in healthcare B. Been socialized in healthcare C. Difficulty in changing her attitudes D. Defined her future
Been socialized in healthcare
A client makes a decision to quit smoking and joins a smoking cessation class. This is an example of which of Dunn's processes that help a person know who and what he or she is? -Becoming -Being -Belonging -Befitting
Befitting
An oncology nurse is caring for a client suffering from metabolic encephalopathy and end stage kidney disease. The client has no known family and no advanced directives. Upon entering the room, the nurse observes the client is pale and has no spontaneous respiration. What is the priority action the nurse should take? A. Contact the physician. B. Call the coroner. C. Notify the charge nurse. D. Begin CPR.
Begin CPR.
The nurse is preparing to palpate the posterior tibial pulse. At which location would the nurse expect to palpate?
Behind the ankle The posterior tibial pulse is palpated behind the medial malleolus of the ankle. The popliteal pulse is palpated just behind the knee. The dorsalis pedis pulse is palpated on the top of the foot along the great toe side. The femoral pulse is palpated in the groin area, just under the inguinal ligament. (less)
The nurse who demonstrates accountability and responsibility for clients in their care is responsive to client needs. The client's hospital stay is often limited to a few days, and nurse-client assignments change. There is not much time to really get to know the client. What are ways to develop responsible caring? Select all that apply. -Developing my strengths and weaknesses in client care -Demonstrating concern for the client regardless of what happens on the unit -Being attentive and responsive to the client's needs -Reporting to the on-coming shift to ensure continuity of care -Ensuring that the nurse is comfortable before communicating with the health care team
Being attentive and responsive to the client's needs, Demonstrating concern for the client regardless of what happens on the unit, Reporting to the on-coming shift to ensure continuity of care
The committed nurse takes the opportunity to interact with the client while providing care. This is an opportunity to enrich both the client and the nurse. Select the nursing behavior that describes how to give care that "makes a difference." -Recognizing the significance of completing the plan of care and reaching outcomes -Being conscious of how one's responses may influence the well-being of another. -Providing care based on best practices: the correct procedures and policies -Accomplishing all tasks for the day required by the client and family
Being conscious of how one's responses may influence the well-being of another.
A student nurse is preparing a presentation regarding different cultures. Which definition of culture is most accurate? -Altruistic grouping -Cluster of individuals -Complete uniformity of members -Belief system that guides behavior
Belief system that guides behavior
While auscultating heart sounds, the nurse hears a murmur. Which of these instruments should be used to assess this murmur?
Bell of stethoscope
HCO3- REGULATION
Bicarbonate levels regulated primarily by the kidneys Bicarbonate readily available as a result of carbon dioxide formation during metabolism
A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient?
Bilaterally percuss the thorax, noting any differences in percussion tones.
The narse is reviewing statistics regarding breast cancer. Which woman, aged 40 years in the United States. has the highest risk for developing breast cancer?
Black
The nurse is preparing for a class in early detection of breast cancer. Which statement is true with regard to breast cancer in black women in the United States
Black women are more likely to die of breast cancer at any age.
COMPLETE ARTERIAL OCCLUSION/ OCCLUSIVE PERIPHREAL ARTERIAL DISEASE (LIFE THREATENING SITUATION)
Blockage or narrowing of an artery in the legs (or rarely the arms), usually due to atherosclerosis and resulting in decreased blood flow. SIGNS= PAIN, NUMBNESS, COOLNESS, COLOR CHANGE, (THERE IS NO CIRCULATION)
A client is experiencing decreased cardiac output. Which vital sign is priority for the nurse to monitor frequently?
Blood pressure With decreased cardiac output, the heart pumps inadequate blood to meet the body's metabolic demands. The blood pressure is most important to assess frequently.
A 55-year-old bookkeeper comes to the office for a routine visit. The nurse notes that on a previous visit for treatment of contact dermatitis, the client's blood pressure was elevated. She does not have prior elevated readings, and her family history is negative for hypertension. The nurse measures her blood pressure in the office today. Which of the following factors can result in a false high reading?
Blood pressure cuff is tightly fitted. A blood pressure cuff that is too tightly fitted can result in a false high reading. Resting prior to assessment, measuring on a bare arm, and supporting the client's arm at mid-chest level all foster accurate BP measurement. (less)
A 55-year-old bookkeeper comes to the office for a routine visit. The nurse notes that on a previous visit for treatment of contact dermatitis, the client's blood pressure was elevated. She does not have prior elevated readings, and her family history is negative for hypertension. The nurse measures her blood pressure in the office today. Which of the following factors can result in a false high reading?
Blood pressure cuff is tightly fitted. A blood pressure cuff that is too tightly fitted can result in a false high reading. Resting prior to assessment, measuring on a bare arm, and supporting the client's arm at mid-chest level all foster accurate BP measurement. (less)
A diabetes educator is teaching a group of adults about the risks to vision that result from poorly controlled blood glucose levels. Which of the following pathophysiologic processes underlies the vision loss associated with diabetes mellitus? A. Diabetes contributes to increased intraocular pressure. B. Increased blood glucose levels cause osmotic changes in the aqueous humour. C. Blood vessels supplying the retina become weak and bleeding occurs. D. Diabetes is associated with recurrent corneal infections and consequent scarring.
Blood vessels supplying the retina become weak and bleeding occurs.
The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?
Body areas appropriate to the problem should be examined and then the assessment completed after the problem has resolved.
A nurse auscultates a client's heart sounds and obtains a rate of 56 beats per minute. How should this rate be documented by the nurse?
Bradycardia The proper documentation of this rate is bradycardia, a rate less than 60 beats per minute. The normal adult heart rate is 60-100 beats per minute. Tachycardia is a heart rate above 100 beats per minute. This heart rate is decreased but this is not a proper documentation term. (less)
The evening nurse received a change-of-shift report from the day nurse. The day nurses' report states, "The client required intubation for respiratory distress this morning, but has been stable all day." The evening nurse collects the following information during the first assessment: Skin flushed. Client lethargic. Temperature 103.0°F. A review of the client's chart reveals that the client's last assessment was done 7 hours earlier. A review of the findings by the nurse attorney determines which facts might be in place regarding liability? Select all that apply. A. Duty has not occurred since the evening nurse just started the shift. B. The facility will have to fire the nurse for malpractice. Breach of duty has occurred. C. The facility will settle the case. D. The spouse was notified of the change in condition.
Breach of duty has occurred.
During an interview, a patient reveals that she is pregnant. She states that she is not sure whether she will breastfeed her baby and asks for some information about this. Which of these statements by the nurse is accurate?
Breastfeeding provides the perfect food and antibodies for your baby.
A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?
Breathing, pain, and sleep
A nurse cares for a client who suffered a cerebrovascular accident and demonstrates the inability to speak clearly. The nurse recognizes that injury has occurred to what portion of the brain? A. Temporal lobe B. Occipital lobe C. Broca's area D. Medulla oblongata
Broca's area
A nurse cares for a client who suffered a cerebrovascular accident and demonstrates the inability to speak clearly. The nurse recognizes that injury has occurred to what portion of the brain?
Broca's area The Broca's area is the center that is responsible for speech. The temporal lobe helps with receiving and interpreting impulses from the ear. The occipital lobe influences the ability to read with understanding and is the primary visual receptor center. The medulla oblongata contains the nuclei for the cranial nerves and has centers that control and regulate respiratory function, heart rate and force, and blood pressure. (less)
The nurse is instructing a young woman on her dietary needs for calcium in the prevention of osteoporosis. What food supplies the greatest amount of calcium?
CHEESE Dairy products are excellent sources of calcium.
Which is a common anion?
CHLORIDE Chloride is a common anion, which is a negatively charged ion. Magnesium, potassium, and calcium are cations, or positively charged ions.
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?
CHRONIC LOW SELF-ESTEEM The major task of the school-aged child is industry versus inferiority. Failure to achieve this task can cause a sense of failure and consequent low self-esteem. There is not likely an accompanying risk for injury, disturbance in thinking, or sense of fear. (less)
During the health history, a client reports a decrease in his ability to smell. During the physical assessment, the nurse would make sure to assess which cranial nerve?
CN I CN I (olfactory) would be evaluated to determine if the client was experiencing a problem here related to a report of a decrease in smell. Evaluation of CN II (optic) would be indicated if the client reported changes in vision. Evaluation of CN VII (facial) or IX (hypoglossal) would be indicated if the client reported a decrease in his or her ability to taste. (less)
During the health history a client reports a decrease in his ability to smell. During the physical assessment, the nurse would make sure to assess which cranial nerve?
CN I CN I (olfactory) would be evaluated to determine if the client was experiencing a problem here related to his report of a decrease in smell. Evaluation of CN II (optic) would be indicated if the client reported changes in vision. Evaluation of CN VII (facial) or IX (hypoglossal) would be indicated if the client reported a decrease in his ability to taste. (less)
During the health history, a client reports a decrease in his ability to smell. During the physical assessment, the nurse would make sure to assess which cranial nerve?
CN I CN I (olfactory) would be evaluated to determine if the client was experiencing a problem here related to a report of a decrease in smell. Evaluation of CN II (optic) would be indicated if the client reported changes in vision. Evaluation of CN VII (facial) or IX (hypoglossal) would be indicated if the client reported a decrease in his or her ability to taste.
CHF
CONGESTIVE HEART FAILURE= A chronic condition in which the heart doesn't pump blood as well as it should. FLUID BUILDS UP AROUND YOUR HEART, CAUSING IT TO PUMP INEFFICIENTLY. HEART ISN'T PUMPING EFFECTIVELY, COULD BE TRIGGERED BY A BAD KIDNEY
Which of the following would be most appropriate for the nurse to do to determine stroke volume?
Calculate the difference between the diastolic and systolic pressures. The stroke volume is reflected by the pulse pressure, which is the difference between the diastolic and systolic blood pressures. Taking the blood pressure while the client is standing, measuring the strength of the radial pulse, or adding the radial pulse to the systolic blood pressure would not be appropriate to determine stroke volume. (less)
Which of the following would be most appropriate for the nurse to do to determine stroke volume?
Calculate the difference between the diastolic and systolic pressures. The stroke volume is reflected by the pulse pressure, which is the difference between the diastolic and systolic blood pressures. Taking the blood pressure while the client is standing, measuring the strength of the radial pulse, or adding the radial pulse to the systolic blood pressure would not be appropriate to determine stroke volume. (less)
A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurses best response?
Can you point to where it hurts?
The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L. For what complications should the nurse be aware, related to the potassium level?
Cardiac dysrhythmias TYpical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Pulmonary emboli and fluid volume excess are not related to a low potassium level. Tetany can be a result of low calcium or high phosphorus but is not related to potassium levels
Cardiac Outpput
Cardiac output is the volume of blood pumped by the heart per minute (mL blood/min). Cardiac output is a function of heart rate and stroke volume CO= HEARTRATE * STROKE VOLUME
The nurse is caring for elderly patients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these patients?
Cardiac volume intolerance The elderly patient is more likely to experience cardiac volume intolerance related to the heart having less efficient pumping ability. The elderly typically experience a decreased sense of thirst, loss of nephrons, and decreased renal blood flow. (less)
The nurse is caring for elderly patients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these patients?
Cardiac volume intolerance The elderly patient is more likely to experience cardiac volume intolerance related to the heart having less efficient pumping ability. The elderly typically experience a decreased sense of thirst, loss of nephrons, and decreased renal blood flow
An adult client comes to the ED with a new onset of pain in his neck and jaw. What system requires emergency assessment? Cardiovascular Integumentary Respiratory Nervous
Cardiovascular
Inperfoming an assessment of a womans axillary lymph system, the nuse should assess which of these nodes?
Central, lateral, pectoral, and subscapular
During the Romberg test, a client is unable to stand with the feet together and demonstrates a wide-based, staggering, unsteady gait. The nurse would identify this as which of the following?
Cerebellar ataxia A wide-based, staggering, unsteady gait and positive Romberg's test (client unable to stand with feet together) suggests cerebellar ataxia. Spastic hemiparesis is characterized by a flexed arm held close to the body while the client drags the toes of the leg or circles it stiffly outward and forward. A Parkinsonian gait is a shuffling gait. A scissors gat is a short stiff gait with the thighs overlapping each other with each step. (less)
The nurse working in the emergency department is assessing an intoxicated driver involved in a motor vehicle crash when the client insists on ambulating to the bathroom. The nurse escorts the client and calls for help while anticipating which abnormal gait in this client that places him at risk for falls?
Cerebellar ataxia Cerebellar ataxia, a wide-based gait with staggering and lurching, is often due to alcohol intake or cerebral palsy. Spastic hemiparesis is usually caused by stroke, not alcohol intoxication. Scissors gait is spastic diplegia associated with bilateral spasticity of the legs. Sensory ataxia is due to cerebral palsy also resulting in a wide-based gait. (less)
During the Romberg test, a client is unable to stand with the feet together and demonstrates a wide-based, staggering, unsteady gait. The nurse would identify this as which of the following?
Cerebellar ataxia A wide-based, staggering, unsteady gait and positive Romberg's test (client unable to stand with feet together) suggests cerebellar ataxia. Spastic hemiparesis is characterized by a flexed arm held close to the body while the client drags the toes of the leg or circles it stiffly outward and forward. A Parkinsonian gait is a shuffling gait. A scissors gat is a short stiff gait with the thighs overlapping each other with each step.
When providing care for a client who has a peripheral intravenous catheter in situ, the nurse should do what?
Change the site every three to four days. Peripheral IV sites should be rotated every 72 to 96 hours, depending on the institutional protocol. IV insertion sites are not cleansed daily. Flushes are not necessary every six hours. Hypertonic solution is not used for IV flushes. The smallest gauge that is practical should be inserted in order to minimize trauma.
A middle aged female client presents to the emergency department complaining of indigestion and left arm pain. What is the nurse's best action?
Check the client's vital signs and connect her to a cardiac monitor. Pain nociception has various locations. Visceral pain originates from abdominal organs; patients often describe this pain as crampy or gnawing. Somatic pain originates from skin, muscles, bones, and joints; patients usually describe somatic pain as sharp (D'Arcy, 2014). Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues. It is often burning or sharp, such as with a partial-thickness burn. Referred pain originates from a specifi c site, but the person experiencing it feels the pain at another site along the innervating spinal nerve (Fig. 6.3). An example is cardiac pain that a person experiences as indigestion, neck pain, or arm pain. Phantom pain is pain in an extremity or body part that is no longer there (e.g., a patient who experiences pain in a leg with an amputation). The client is presenting with atypical chest pain and should be assessed for pain of a cardiac origin. (less)
Which of the following activities is the clearest example of the evaluation step in the nursing process? -Giving the patient a PRN dose of captopril (an antihypertensive) in light of this blood pressure reading -Recognizing that the client's blood pressure of 172/101 is an abnormal finding -Checking the client's blood pressure 30 minutes after administering the captopril -Taking a client's blood pressure on both arms at the beginning of a shift
Checking the client's blood pressure 30 minutes after administering the captopril
e short-term nature of peripheral IVs, and the fact that they are sited in small-diameter vessels, makes them inappropriate for the administration of
Chemotherapy, which is long-term
The nurse is asking a patient for his reason for seeking care and asks about the signs and symptoms he is experiencing. Which of these is an example of a symptom?
Chest pain
A respiratory pattern that gradually becomes faster and deeper than normal, then slower, alternating with periods of apnea is known as which respiratory pattern?
Cheyne-Stokes Cheyne-Stokes respirations are described as respirations that gradually become faster and deeper than normal, then slower, alternating with periods of apnea. This pattern can be drug-induced, normal in frail elderly people while sleeping, or a sign of impending death. Kussmaul's respiratory pattern is described as faster and deeper respirations without pauses. Eupnea is a normal respiratory rate and rhythm. Tachypnea is an increased respiratory rate. (less)
What type of respiratory pattern would the nurse consider normal in a client with severe heart failure?
Cheyne-Stokes Cheyne-Stokes respirations, a regular respiratory pattern alternating with periods of deep, rapid breathing followed by periods of apnea, may result from severe heart failure. Biot's respirations (irregular pattern of varied depth and rate followed by periods of apnea) may be seen with severe brain damage or meningitis. Bradypnea is a rate less than 10/minute and can be associated with medication-induced depression of the respiratory center, diabetic coma, or neurologic damage. Kussmaul's respirations are associated with diabetic ketoacidosis. (less)
The nurse is examining a 2-year-old child and asks, May I listen to your heart now? Which critique of the nurses technique is most accurately
Children at this age like to say, No. The examiner should not offer a choice when no choice is available
A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure?
Childs reactions to previous hospitalizations
A nurse develops the following foreground question using the PICO format in preparation for a research study: "In overweight clients, how do chromium supplements compared to no supplements help with weight loss?" Which part of the question reflects the intervention? -Overweight clients -Chromium supplements -No supplements -Weight loss
Chromium supplements
An exacerbation refers to the reactivation of a disease. Which of the following conditions is associated with exacerbation? -Chronic illness -Hereditary illness -Congenital illness -Acute illness
Chronic illness
Upon inspection of a client's chest, a nurse observes an increase in the anterior posterior diameter. The nurse recognizes this as a finding in which disease process?
Chronic obstructive pulmonary disease An increase in the anterior posterior diameter is seen in clients with chronic obstructive pulmonary disease. This occurs be because of air trapping in the airways that causes hyperinflation and over distention. Carcinoma of the lungs, pneumothorax, and tuberculosis do not change the chest diameter. (less)
Upon inspection of a client's chest, a nurse observes an increase in the ratio of anteroposterior to transverse diameter. The nurse recognizes this as a finding in which disease process?
Chronic obstructive pulmonary disease An increase in the ratio of anteroposterior to transverse diameter is seen in clients with chronic obstructive pulmonary disease. This occurs because of air trapped in the airways that causes hyperinflation and overdistention. Carcinoma of the lungs, pneumothorax, and tuberculosis do not change the chest diameter. (less)
Upon entering the examination room, the nurse observes that the client is leaning forward with his arms supporting his body weight. The nurse would recognize this as a tripod position and suspect the presence of which of the following medical problems?
Chronic obstructive pulmonary disease The client is assuming the tripod position, which is often seen in chronic obstructive pulmonary disease. A client with heart failure would most likely assume an orthopneic position to ease any breathing difficulties. The tripod position is usually not associated with pneumonia or pleural effusion. (less)
A 62-year-old construction worker presents to the clinic reporting almost a chronic cough and occasional shortness of breath that have lasted for almost 1 year. Although symptoms have occasionally worsened with a cold, they have stayed about the same. The cough has occasional mucus drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married with two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. Examination reveals a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his symptoms?
Chronic obstructive pulmonary disease (COPD) This disorder is insidious in onset and generally affects the older population with a smoking history. The diameter of the chest is often enlarged like a barrel. Percussing the chest elicits hyperresonance; during auscultation there is often distant breath sounds. Coarse breath sounds of rhonchi are also often heard. It is important to quantify this client's exercise capacity because it may affect his employment and also allows examiners to follow the progression of his disease. Clinicians must offer smoking cessation as an option. (less)
NEUROPATHIC PAIN
Chronic pain is often defined as any pain lasting more than 12 weeks. Whereas acute pain is a normal sensation that alerts us to possible injury, chronic pain is very different. Chronic pain persists—often for months or even longer.
When analyzing the nursing history recently taken on a client, which factor would alert the nurse to a significantly increased risk for chronic arterial insufficiency?
Cigarette smoking The use of any form of tobacco significantly increases a person's risk for chronic arterial insufficiency. The risk increases according to the length of time a person smokes and amount of tobacco smoked. Daily exercise would be a measure to reduce a person's risk for vascular disease. Family history of diabetes, hypertension, coronary heart disease, intermittent claudication, or elevated lipid levels would be important because these disorders tend to be heredity and cause damage to the blood vessels. Alcohol intake is unrelated to the development of chronic arterial insufficiency. (less)
Therapeutic Communication Techniques
Clarification the nurse encourages the patient to explain a vague or incomprehensible statement. i.e. Patient: "I didn't think it would be a problem when I went to thebeach. I thought I would feel better after awhile." Nurse: "What seemed to lead up to you not feeling well?" Summarizing the nurse abbreviates(condenses) key points of the patient's concern. Permits identification of progress and/or potential methods to manage patient concerns or issues. i.e. Patient: "I want to be able to manage my diet to maintain a healthy weight." Nurse: "There are various methods to assist people to lose weight. These include support groups, regular meetings with a dietitian, and exercise programs. I have some literature that you can review for our next meeting so you can decide if any of these might be an option for you."
The nurse positions the client for auscultation of heart sounds. What does the nurse do first?
Clean the stethoscope A stethoscope can transmit bacteria among clients. Thus, before beginning, the nurse should clean the diaphragm of the stethoscope with the alcohol swab before bringing the diaphragm into contact with the client. (less)
A patient is at the clinic to have her blood pressure checked. She has been coming to the clinic weekly since she changed medications 2 months ago. The nurse should:
Collect a follow-up data base and then check her blood pressure.
A nurse is unable to palpate the apical impulse on an older client. Which assessment data in the client's history should the nurse recognize as the reason for this finding?
Client has an increased chest diameter The apical impulse may not be palpable in clients with increased anteroposterior diameters. Irregular heart rate should not interfere with the ability to palpate an apical impulse. Respiratory rate does not impact the apical impulse. Heart enlargement would displace the apical impulse but not cause it to be nonpalpable. (less)
After having a client perform a Romberg test, which of the following would indicate to the nurse that the test is negative?
Client maintains the position during the exam A negative Romberg test is documented when the client maintains position for 20 seconds without swaying or with minimal swaying. The test is positive if the client moves the feet apart to prevent falls, or starts to fall from loss of balance. (less)
A nurse is documenting a client's headache. Which of the following would be the best entry to include for this finding?
Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m. As this is subjective data, the nurse should record it as the "client reports" instead of the "client has," to clarify that this is based on the client's perception. The nurse should use phrases instead of sentences for brevity. Finally, the nurse should record complete information and details for all client symptoms or experiences, not just, "Client reports headache." (less)
Which entry demonstrates correct documentation by a nurse regarding assessment of the client admitted for abdominal pain?
Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10 Documentation should be concise and precise. The nurse should record what the client tells her in detail. When documenting pain, the mnemonic COLDSPA is used to provide details on the pain. Nurses should not make judgments or diagnosis about the information gathered until all data has been collected and validated. The use of the statement "within normal limits" should not be used-the nurse should document the actual data that was collected. (less)
What components are located at the center of a concept map? -Nursing interventions and client responses -Client's current and past medical histories -Nursing diagnoses and assessment data -Short-term and long-term goals
Client's current and past medical histories
A registered nurse plans to return to the nursing profession after a long hiatus. Which statement about the trend in health care services would be most important for the nurse to keep in mind? -Health care delivery systems are less controversial now -Hospital stays are much longer these days -Clients enter the health care system acutely ill -Nurses rely on intuition to make decisions today
Clients enter the health care system acutely ill
The nurse working in research correctly identifies which of the following to be mandatory for the ethical conduction of research in a hospital setting? -All intervention must benefit all clients -Descriptive studies are more ethical than experimental studies -Clients must grant informed consent if they are to participate -The client must directly and personally benefit from the research
Clients must grant informed consent if they are to participate
The nurse is preparing a presentation about cancer pain for a group of caregivers of clients with cancer. Which of the following would the nurse expect to include in the description of this type of pain?
Clients often experience brief severe pain despite medication. Cancer pain is a special category of pain because it may reflect all of the pain types at the same time, or at different times during the course of the disease. Cancer pain may be caused by the cancer, its treatment, or metastasis. Many cancer patients experience breakthrough pain (brief, severe pain that occurs in spite of pain medication). Cancer pain depends on many factors, including the type and stage of the cancer. Cancer pain may be triggered by blocked blood vessels or pressure on a nerve from a tumor. Side effects of cancer treatments, such as surgery, radiation, and chemotherapy, may include pain Cancer pain can be acute (sudden and severe) or chronic (lasting more than 3 months).
Which of the following clients are candidates for TPN TOTAL PARENTEL NUTRITION
Clients with major trauma or burns • Clients with liver and renal failure • Clients with inflammatory bowel disease Explanation: The nurse knows that clients with major trauma or burns, clients with liver and renal failure, and clients with inflammatory bowel disease are likely candidates for TPN. Clients who have not eaten for a day or clients recovering from cataract surgery are not likely candidates for TPN. Clients who have not eaten for 5 days and are not likely to eat during the next week are considered for TPN
A client complains of weakness following his administration of insulin. The nurse decides to assess the client's blood sugar and prepare a snack in case the blood sugar is low What action has the nurse implemented? -Assessment -Caring -Clinical reasoning -Reflection
Clinical reasoning
A nurse recognizes that the second heart sound, S2, is produced by which cardiac action?
Closure of the semilunar valvesClosure of the semilunar valves Closure of the semilunar valves, which are the aortic and pulmonic valves, causes the second heart sound, S2. The closure of these valves signals the end of systole. Isometric cont ... (more)
During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched, bubbling, moist sounds that persist from early inspiration to early expiration. How should the nurse document these sounds?
Coarse crackles Low-pitched bubbling, moist sounds that persists from early inspiration to early expiration and sounds like softly separating Velcro should be documented as coarse crackles. These sounds are produced when inhaled air comes into contact with secretions in the large bronchi and trachea. Pleural friction rub is low-pitched, dry, grating sound that is superficial and occurs during both inspiration and expiration. Sonorous wheezes are low-pitched snoring or moaning sounds that may be heard primarily during expiration but may be heard throughout the respiratory cycle. Sibilant wheezes are high-pitched musical sounds heard primarily during expiration but may also be heard on inspiration
Nursing diagnoses that require physician-prescribed and nurse-prescribed actions would be what type of problems? Independent health problems Collaborative health problems Physician-developed problems Interdisciplinary health problems
Collaborative health problems
The parents of a blended family have a baby boy age six months who is due for immunizations. The clinic closest to their home has recently closed, and they feel intimidated by the prospect of going to the large, university hospital near their home. Which of the following factors is the primary influence on this aspect of the family's health? A. Community health care structure B. Economic factors C. Family risk factors D. Lifestyle influences
Community health care structure
The parents of a blended family have a baby boy age six months who is due for immunizations. The clinic closest to their home has recently closed, and they feel intimidated by the prospect of going to the large, university hospital near their home. Which of the following factors is the primary influence on this aspect of the family's health? -Lifestyle influences -Community health care structure -Economic factors -Family risk factors
Community health care structure
Which patient medical record does the nurse consult when determining activity orders for the patient?
Computerized Provider Order Entry To determine activity orders for the patient, the nurse consults the Computerized Provider Order Entry. Health care providers enter all orders for the patient, using the Computerized Provider Order Entry. The nurse uses the Electronic Medication Record to review medication orders for the patient. The Risk Assessment Report provides risk scores on criteria of interest, such as sepsis, pressure ulcers, and falls. HIPAA refers to the Health Insurance Portability and Accountability Act, which regulates all areas of information management including confidentiality of the patient's personal health information. (less)
The student nurse walks into her 8-year-old patient's room and finds him looking at a collection of baseball cards. He has spread the cards out all over the bed and arranged them into different piles of teams and positions. This young patient is showing signs of being in which of the following stages of Piaget?
Concrete operational Piaget divides the preoperational stage into two substages: symbolic and intuitive thought. These substages last from 2 to 7 years of age. The concrete operational stage begins at 7 years of age and lasts until 11 years of age. Concrete operational means executing operations that are reversible mental actions. Collecting baseball cards and carefully organizing them into teams and positions are two examples of concrete thinking. (less)
The home health nurse is conducting the health history interview with a client who does not speak the dominant language. What would be the best action made by the nurse? A. Use simple words with simple actions. B. Write out all questions using appropriate medical terms. C. Conduct the health history utilizing a telephonic interpreter (over-the-phone translation). D. If the client does not answer, repeat the question again.
Conduct the health history utilizing a telephonic interpreter (over-the-phone translation).
In using verbal responses to assist the patients narrative, some responses focus on the patients frame of reference and some focus on the health care providers perspective. An example of a verbal response that focuses on the health care providers perspective would be:
Confrontation
While the nurse examines a patient's pupillary response to light in the right eye, the pupil in the left eye is constricted. What does this finding suggest to the nurse?
Consensual reaction The consensual reaction is when the pupil constricts in the opposite eye. Myopia is impaired far vision. Presbyopia is impaired near vision often seen in middle-aged and older patients. The direct reaction is when the pupil constricts in the same eye. (less)
A nurse shines a light into one eye during ocular exam and the pupil of the other constricts. The nurse interprets this as which of the following?
Consensual response When a light is shone in one eye, that eye will constrict and the opposite (consensual) eye will also constrict. Shining a light on one eye with the resulting constriction of that eye demonstrates the direct reflex. The optic chiasm is the point where the optic nerves from each eyeball cross. Accommodation occurs when the client moves the focus of vision from a distant point to a near object, causing the pupils to constrict. (less)
While inspecting a patients breasts, the nurse finds that the left breast is slightly larger than the right with bilateral presence of Montgomery glands. The nurse should:
Consider these findings as normal, and proceed with the examination.
The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child. The nurse should:
Consider this finding as normal for a child this age, and proceed with the examination.
In preparing a care plan for a patient receiving opioid analgesics, the nurse selects which of the following as an applicable nursing diagnosis associated with side effects of opioid use?
Constipation The most common side effects associated with opioid use are sedation, nausea, and constipation. Respiratory depression is also a commonly feared side effect of opioid use.
Which nursing diagnosis is the priority according to Maslow's hierarchy of basic needs? -Constipation related to decreased motility -Impaired Social Interaction related to disturbed body image -Risk for Falls related to unsteady gait following stroke -Anxiety related to inability to cope with pending prognosis
Constipation related to decreased motility
A client reports not having a bowel movement for 7 days, followed by a day of small, loose stools. How does the nurse define the health problem? Constipation related to irregular evacuation patterns Readiness for Enhanced Nutrition related to constipation Bowel incontinence related to depressive state Diarrhea related to client report of small, loose stools
Constipation related to irregular evacuation patterns
A newly graduated nurse is unable to determine the significance of data obtained during an assessment. What would be the nurse's most appropriate action? Consult with a more experienced nurse. Continue to collect assessment data. Document the data for future reference. Contact the client's health care provider.
Consult with a more experienced nurse.
The nurse is caring for a newly admitted client. How can a nurse arrive at a more complete database for this client? -Review of the chart -Through clustering of data -Analysis of lab values -Consult with several sources
Consult with several sources
A nurse assesses a client with psychotic symptoms and determines that the client needs vest restraints. However, the client asks the nurse not to put on vest restraints. What would be the best nursing action? A. Contact the physician and obtain necessary orders. B. Restrain the client with vest restraints. C. Apply restraints after giving a sedative. D. Apply wrist restraints instead of vest restraints.
Contact the physician and obtain necessary orders.
FUNCTIONS OF POTASSIUM K+ ELECTROLYTE
Controls intracellular osmolality Regulator of cellular enzyme activity Role in the transmission of electrical impulses in nerve, heart, skeletal, intestinal, and lung tissue; protein and carbohydrate metabolism; and cellular building Regulation of acid-base balance by cellular exchange with H+
A nurse is talking to an 8-year-old boy who is proud of himself for washing his hands before every meal this past week. The nurse recognizes that this client is eager to please the nurse and his own parents. The nurse realizes that this boy is most likely in which level of moral development, according to Kohlberg?
Conventional This boy appears to be in the conventional level of moral development according to Kohlberg, in which one maintains external expectations of others. This stage typically begins at school age and extends into adulthood. The preconventional level, which typically occurs from preschool through late school age, is characterized by actions being guided by desire to avoid punishment or receive reward. The postconventional level, which typically begins in middlescence and extends through older adulthood (only 10%-20% of the dominant American culture attain this stage), is characterized by maintaining internal principles of self. The latent phase is a concept of Freud, not Kohlberg. (less)
A nurse palpates a client's hands and fingers. Which of the following findings would be consistent with arterial insufficiency?
Cool skin A cool extremity may be a sign of arterial insufficiency. The other findings listed are all normal.
A client has sustained an injury to the cerebellum. Which area would be the primary area for assessment?
Coordination The cerebellum's primary functions include coordination and smoothing of voluntary movements, maintenance of equilibrium, and maintenance of muscle tone. Therefore, a priority assessment area would be coordination. (less)
A client has sustained an injury to the cerebellum. Which area should be the nurse's primary focus for assessment?
Coordination The cerebellum's primary functions include coordination and smoothing of voluntary movements, maintenance of equilibrium, and maintenance of muscle tone. Therefore, a priority assessment area would be coordination. Vital signs, respiratory status, and cardiac function are not controlled by the cerebellum. (less)
A client has sustained an injury to the cerebellum. Which area would be the primary area for assessment?
Coordination The cerebellum's primary functions include coordination and smoothing of voluntary movements, maintenance of equilibrium, and maintenance of muscle tone. Therefore, a priority assessment area would be coordination.
A client has sustained an injury to the cerebellum. Which area should be the nurse's primary focus for assessment?
Coordination The cerebellum's primary functions include coordination and smoothing of voluntary movements, maintenance of equilibrium, and maintenance of muscle tone. Therefore, a priority assessment area would be coordination. Vital signs, respiratory status, and cardiac function are not controlled by the cerebellum.
CORANARY ARTERIES AND VEINS (THE HEART HAS ITS OWN BLOOD SUPPLY) The heart receives its own supply of blood from a network of arteries, called the coronary arteries!
Coronary circulation is the circulation of blood in the blood vessels of the heart muscle (myocardium). The vessels that deliver oxygen-rich blood to the myocardium are known as coronary arteries. The vessels that remove the deoxygenated blood from the heart muscle are known as cardiac veins.
A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition?
Corrective lenses Astigmatism is corrected with a cylindrical lens that has more focusing power in one access than the other. These corrective lenses can and should be worn while driving at night. Eye drops and surgery are not usual treatments for this condition. (less)
A nurse is demonstrating the technique for auscultating heart sounds. Which of the following would be most important for the nurse to emphasize?
Cover the entire precordium. When auscultating heart sounds, the nurse would need to emphasize the need to cover the entire precordium, using a systematic approach moving the stethoscope from left to right across the entire heart area from the base to the apes or from the apex to the base. Although both the diaphragm and bell are used, this is not as important as making sure the nurse covers the entire precordium. The nurse covers the entire precordium, not just the areas of each heart chamber. (less)
The nurse notes unilateral facial drooping and reports the finding immediately to the healthcare provider. The client is diagnosed with Bell palsy. The nurse should include assessment of which affected cranial nerve in the client's head and neck assessment? A. Cranial nerve V B. Cranial nerve VI C. Cranial nerve VII D. Cranial nerve VIII
Cranial nerve VII
A nurse will be assessing many clients and needs an assessment form that will promote easy and rapid documentation, while at the same time allowing the categorization of information. Which assessment form should the nurse use?
Cued or checklist forms Cued or checklist forms promote easy and rapid documentation while categorizing information. Open-ended forms are the traditional forms that individualize information and allow the narrative description of problems. An integrated cued checklist combines assessment data with identified nursing diagnoses. A nursing minimum data set is usually a computerized document and is often used in long-term care facilities. (less)
A client, origianlly from Asia, believes that her illness is caused by an imbalance of yin and yang. The nurse states, "You can call it whatever you believe, but you have a metabolic disorder." What is this nurse demonstrating? A. Ethnocentrism B. Cultural diversity C. Stereotyping D. Cultural blindness
Cultural blindness
A client from Pakistan informs the nurse of his cultural dietary requests. The nurse response to the special dietary needs by stating, "You are now living in the United States, and you should try to start eating those foods common to an American diet." This inappropriate response is an example of what? -Cultural diversity -Cultural imposition -Cultural blindness -Cultural assimilation
Cultural imposition
A parent informs the nurse that immunizations are against her cultural and religious beliefs and she does not want her child to receive immunizations. The nurse proceeds to inform the parent that the child will be consistently ill and will not be allowed to start school unless immunized. The nurse also informs the parent that she had all of her children vaccinated. What is the nurse's behavior an example of? A. Stereotyping B. Cultural blindness C. Cultural imposition D. Cultural conflict
Cultural imposition
A parent informs the nurse that immunizations are against her cultural and religious beliefs and she does not want her child to receive immunizations. The nurse proceeds to inform the parent that the child will be consistently ill and will not be allowed to start school unless immunized. The nurse also informs the parent that she had all of her children vaccinated. What is the nurse's behavior an example of? -Stereotyping -Cultural blindness -Cultural conflict -Cultural imposition
Cultural imposition
Which of the following is the tendency to impose one's cultural beliefs, values, and patterns of behavior on a person or people from a different culture? -Cultural imposition -Cultural taboos -Cultural blindness -Acculturation
Cultural imposition
Health care facilities that sponsor health-promotion activities only in affluent areas are considered what? -Culturally affluent -Culturally blind -Culturally different -Culturally sensitive
Culturally blind
Durin g a seminar on cultural aspects of nursing, the nurse recognizes and distinct knowledge, beliefs, skills, and customs acquired by members of a society reflects which term? that the definition stating the specific
Culture
During a class on the aspects of culture, the nurse shares that culture has four basic characteristics. Which statement correctly reflects one of these characteristics?
Culture adapts to specific environmental factors and available natural resources.
A nurse is reading a journal article about culturally competent nursing care. The article begins discussing culture and its unique characteristics. Which characteristics would the nurse expect to be identified? Select all that apply. A. Culture is innate. B. Culture is ever-changing. C. Culture makes sense to its members. D. Culture is shared through communication. E. Culture puts a limit on ideas.
Culture is ever-changing. Culture makes sense to its members. Culture is shared through communication.
Upon moving to China, an American college student is experience many new feelings that she associated with her placement in a different culture. What are the feelings experiences by this student? -Stereotyping -Cultural assimilation -Culture shock -Ethnocentrism
Culture shock
The nurse is obtaining a health history on an 87-year-old woman. Which of the following areas of questioning would be most useful at this time?
Current health promotion activities
An adult client is admitted to the hospital with severe diarrhea. When assessing the client, the nurse notes a round "moon" face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What are these signs indicative of? A. Myxedema B. Cushing's syndrome C. Scleroderma D. Bell's palsy
Cushing's syndrome
10. When assessing cranial nerves IX and X, which of the following would the nurse consider as a normal finding? A) Stationary soft palate on phonation B) Deviation of uvula when client says ìahî C) Asymmetrical soft palate D) Uvula and soft palate rising bilaterally
D
12. During the Romberg test, a client is unable to stand with the feet together and demonstrates a wide-based, staggering, unsteady gait. The nurse would interpret this finding as suggestive of which of the following? A) Spastic hemiparesis B) Parkinsonian gait C) Scissors gait D) Cerebellar ataxia
D
5. A nurse is preparing to assess a client's cerebellar function. Which of the following aspects of neurological function should the nurse address? A) Remote memory B) Sensation C) Judgment D) Balance
D
D-DIMER
D-dimer (or D dimer) is a fibrin degradation product (or FDP), a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis. Blood test to check coagulation check for blood-clotting problems.D-dimer concentration may be determined by a blood test to help diagnose thrombosis
DVT
DEEP VEIN THROMBOSIS= A blood clot in a deep vein, usually in the legs. SIGNS= EDEMA, SWELLING, (UNI-LATERAL OR ONE EXTREMETY) WARMTH
SOLUTES ARE SUBSTANCES THAT ARE
DISSOLVED IN A SOLUTION
Which of the following is not released during the stress response?
DOPAMINE IS NOT RELEASED DURING THE STRTESS RESPONSE The stress response causes the release of epinephrine, norepinephrine, and cortisol.
Information is collected for analysis in both quantitative and qualitative research. What is the information called? -Surveys -Data -Interviews -Answers
Data
The patients record, laboratory studies, objective data, and subjective data combine to form the:
Data base.
A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?
Decreased potassium levels Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia.
A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?
Decreased potassium levels Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia.
During an admission assessment, the nurse notes that the client has diabetes with peripheral neuropathy. What finding would the nurse expect to find? A. Decreased sensation in the feet B. Severe pain in legs C. Open sores on legs D. Bluish discoloration
Decreased sensation in the feet
the elderly typicall experience WHAT DECREASES?
Decreased sense of thirst loss of nephrons decreased renal blood flow.
A nurse palpates for tactile fremitus and notes that the vibrations diminish towards the base of the lungs. What should the nurse recognize about this finding?
Decreasing intensity is normal at the base Fremitus should be symmetrical and easily identifiable in the upper lobes. A decrease in intensity is normal when moving towards the base of the lungs. Unequal fremitus is a result of consolidation, bronchial obstruction, air trapping, pleural effusion, or pneumothorax. Speaking louder would be necessary if no vibrations were felt at any location on the thorax. (less)
When obtaining an oral temperature on a client, the nurse inserts the thermometer:
Deep in the posterior sublingual pocket When taking an oral temperature, the nurse places the thermometer under the client's tongue to the right or left of the frenulum deep in the posterior sublingual pocket. The thermometer is not placed between the cheek and tongue, at the gingival level, or just below the tongue after the teeth. (less)
A patient asks a nurse if any foods promote eye health. What food would the nurse A. Deep-water fish B. Low-fat meat C. Foods that contain lots of water D. Multigrain foods
Deep-water fish
HEALTH HISTORY COMPONENTS
Demographic & Information Source Chief Complaint (reason for seeking care in patient's words) History of Present Illness (elaborates chief complaint to obtain a concise & complete history of problem OLDCART - Onset, Location, Duration, Characteristic Symptoms, Associated Manifestations, Relieving/Exacerbating Factors, & Treatment Past Medical History (allergies, medications, childhood & adult illnesses, health maintenance) Family History Functional Health Assessment - Health Patterns (personal/psychosocial history/ADLs & impact on quality of life
A female patient has denied any abuse when answering the Abuse Assessment Screen, but the nurse has noticed some other conditions that are associated with IPV. Examples of such conditions include:
Depression
A patient tells the nurse that he is allergic to penicillin. What would be the nurses best response to this information?
Describe what happens to you when you take penicillin
The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response?
Describe what she is doing to indicate she is having pain.
A client cannot differentiate between sharp and dull pain sensations when a nurse tests with a safety pin. What is an appropriate action by the nurse?
Determine the ability to differentiate hot and cold temperatures If a client cannot correctly differentiate between sharp and dull pain sensations, the nurse should test for temperature sensation. Temperature and pain sensations travel in the lateral spinothalamic tract, thus temperature is only tested if pain sensation is altered. If a client cannot feel pain, feeling a lighter touch is unlikely. Striking a tuning fork and placing it on the top of one foot tests vibratory sensation, not pain or touch. The nurse should not try another object and test on the upper dermatomes, as this would not likely change the results. (less)
The client is an Inuit woman recently admitted to the hospital with a ruptured ovarian cyst. She has expressed that it is very important that her husband be present to receive all medical information. Using the concepts of culturally competent care, which is the best response? A. Explain to the client that she is required to make all of her own decisions related to her health care. B. Document the client's request in the nursing care plan. C. Bring the client's husband into the hallway to discuss surgical options for her. D. Explain to the client that it is not a good idea to have her husband in the room when discussing such a private matter.
Document the client's request in the nursing care plan.
A client cannot differentiate between sharp and dull pain sensations when a nurse tests with a safety pin. What is an appropriate action by the nurse?
Determine the ability to differentiate hot and cold temperatures If a client cannot correctly differentiate between sharp and dull pain sensations, the nurse should test for temperature sensation. Temperature and pain sensations travel in the lateral spinothalamic tract, thus temperature is only tested if pain sensation is altered. If a client cannot feel pain, feeling a lighter touch is unlikely. Striking a tuning fork and placing it on the top of one foot tests vibratory sensation, not pain or touch. The nurse should not try another object and test on the upper dermatomes, as this would not likely change the results.
The nurse is interviewing a male patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient?
Determine the communication method he prefers.
A nurse examines a client's retina during the ophthalmic examination and notices light-colored spots on the retinal background. The nurse should ask the client about a history of what disease process? Anemia Renal insufficiency Diabetes Retinal detachment
Diabetes
Which step of the nursing process is the nurse performing when analyzing client data to identify client strengths and health problems that independent nursing interventions can prevent or resolve? -Diagnosing -Assessing -Evaluating -Implementing
Diagnosing
A patient is experiencing acute pain and has asked the nurse for medication. The patient rates the pain as an 8 on a scale of 0 to 10. During assessment, a physiological response from the patient that the nurse can expect is:
Diaphoresis (sweating) Diaphoresis is an expected physiological response to pain resulting from sympathetic nerve stimulation. Decreases in pulse, blood pressure, and muscle tension are not expected findings when a patient is experiencing pain. (less)
Which of the following muscles is primarily responsible for thoracic cavity enlargement?
Diaphragm The diaphragm is the primary muscle of inspiration; when it contracts, its descent enlarges the thoracic cavity.
The nurse is providing care to a client who has a serum potassium level of 5.2 mEq/L. Which finding would the nurse expect to assess? Select all that apply.
Diarrhea • Cardiac dysrhythmia Explanation: The client's potassium level suggests hyperkalemia, which is manifested by anxiety; irritability; gastrointestinal hyperactivity (diarrhea and intestinal cramping); tall, peaked T waves on electrocardiogram; and cardiac dysrhythmias. Muscle weakness, polyuria and polydipsia would be noted with hypokalemia. (less)
Diastolic Blood Pressure
Diastolic: Referring to the time when the heart is in a period of relaxation and dilatation (expansion). The noun for diastolic is diastole. (The final letter in "diastole" is pronounced as a long "e" as in "lee.") The diastolic pressure is specifically the minimum arterial pressure during relaxation and dilatation of the ventricles of the heart when the ventricles fill with blood. In a blood pressure reading, the diastolic pressure is typically the second number recorded. For example, with a blood pressure of 120/80 ("120 over 80"), the diastolic pressure is 80. By "80" is meant 80 mm Hg (millimeters of mercury). A diastolic murmur is a heart murmur heard during diastole, the time the heart relaxes. "Diastolic" came from the Greek diastole meaning "a drawing apart." The term has been in use since the 16th century to denote the period of relaxation of the heart muscle. (when the heart muscle is resting between beats and refilling with blood).
A woman has come to the clinic to seek help with a substance abuse problem. She admits to using cocaine just before arriving. Which of these assessment findings would the nurse expect to find when examining this woman?
Dilated pupils, pacing, and psychomotor agitation
The definition of chronic conditions can be complex. Which factors would you expect to be included in the definition of chronic conditions? Select all that apply. -Diseases that have a prolonged course -Diseases that resolve spontaneously -Diseases that have a short course -Diseases that do not resolve spontaneously -Diseases where complete cures are rare
Diseases where complete cures are rare, Diseases that do not resolve spontaneously, Diseases that have a prolonged course
A 55-year-old postmenopausal woman is being seen in the clinic for her annual examination. She is concerned about changes in her breasts that she has noticed over the past 5 years. She states that her breasts have decreased in size and that the elasticity has changed so that her breasts seem flat and flabby. The nurses best reply would be:
Do you creases the hormones after menopause cause a trophy of the granular tissue in the breast and is a normal process of aging
The nurse is conducting a heritage assessment. Which question is most appropriate for this assessment?
Do you mostly participate in the religious traditions of your family?
The nurse is performing a health interview on a patient who has a language barrier, and no interpreter is available. Which is the best example of an appropriate question for the nurse to ask in this situation?
Do you take medicine?
A client states that his recent fall was caused by the fact that his scheduled antihypertensive medications were mistakenly administered by two different nurses, an event that is disputed by both of the nurses identified by the client. Which measure should the nurses prioritize when anticipating that legal action may follow? A. Document the client's claims and the events surrounding the alleged incident. B. Consult with the hospital's legal department as soon as possible. C. Consult with practice advisors from the state board of nursing. D. Enlist support from nursing and non-nursing colleagues from the unit.
Document the client's claims and the events surrounding the alleged incident.
MG2+ SOURCES AND LOSSES
Enters the body via gastrointestinal tract Magnesium found in green, leafy vegetables; nuts; seafood; whole grains; dried peas and beans; cocoa Lost via urine with use of loop diuretics
The nurse is assessing a toddler and observes the toddler removing clothing and partially dressing himself. What is the nurse's best action based on this finding?
Document the finding. A toddler may be able to remove clothing and partially dress himself. However, the nurse should not expect the toddler to completely dress himself without help. The nurse should document the expected finding. The child is not exhibiting a developmental delay. Tying shoes should not be expected of a toddler; this activity is more appropriate for an older child. (less)
The nurse is going to assess a patient's ankle-brachial index. Which equipment will the nurse use for this assessment? (Select all that apply.)
Doppler device • Blood pressure cuff Explanation: To assess the ankle-brachial index, the nurse will apply a blood pressure cuff above the patient's malleolus. The Doppler device is used to hear the blood flow as the blood pressure cuff is released. A tape measure, stethoscope, or reflex hammer is not used to assess the ankle-brachial index. (less)
The nurse is having trouble obtaining the pulse and BP in a patient who is in shock. What device would assist the nurse in obtaining the needed vital signs?
Doppler ultrasound Pulse and BP are difficult to auscultate or palpate in some patients, such as those in shock or with poor peripheral circulation. In such cases, health care providers use a handheld device called a Doppler transducer. This device senses and amplifies changes in sound frequency
The nurse is having trouble obtaining the pulse and BP in a patient who is in shock. What device would assist the nurse in obtaining the needed vital signs?
Doppler ultrasound Pulse and BP are difficult to auscultate or palpate in some patients, such as those in shock or with poor peripheral circulation. In such cases, health care providers use a handheld device called a Doppler transducer. This device senses and amplifies changes in sound frequency. (less)
The nurse is assessing a patients skin during an office visit. What part of the hand and technique should be used to best assess the patients skin temperature?
Dorsal surface of the hand; the skin is thinner on this surface than on the palms.
A client in the ED tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding?
Dyspnea Dyspnea is a subjective term used when the client reports labored breathing and breathlessness. This response to exercise or heavy activity is normal if it rapidly disappears upon return to rest. Difficulty breathing, in appropriate medical terminology, is not tachypnea, shortness of breath, or anxiety. (less)
The nurse is reviewing information about evidence - based practice ( EBP ) which statement best reflects ЕВР ?
EBP emphasizes the use of best evidence with the clinicians experience .
body weight water percentage in infants
ECF (INTRAVASCULAR AND INTERSTITIAL) INTRAVASCULAR- 4% INTERSTITIAL- 25% INTRACELLULAR- 48% TOTAL = 77% WATER
Assessment of a client reveals the following findings: elevated body temperature, dry skin, low urinary output, and increased pulse rate. The client's health record indicates that he is taking diuretics. Which nursing diagnosis would be most appropriate for the client?
ECF Deficient Fluid Volume The most appropriate nursing diagnosis is ECF deficient fluid volume deficit because the client has the defining characteristics of the diagnosis. Impaired skin integrity is associated with edema and diarrhea. Risk for injury can occur if electrolyte or fluid imbalances cause postural hypotension, loss of consciousness, or impaired cognition. Water excess is characterized by symptoms like weight gain, headache, and delirium. (less)
The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome?
ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. If the client is taking a potassium-conserving diuretic, he must be mindful of the amount of potassium he is ingesting because the potassium level is more likely to elevate above normal. Cardiac dysrhythmias may result if hyperkalemia occurs. Supplemental potassium should not be added to the client's intake. Potassium does not have a direct impact on bowel motilit
The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome?
ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. If the client is taking a potassium-conserving diuretic, he must be mindful of the amount of potassium he is ingesting because the potassium level is more likely to elevate above normal. Cardiac dysrhythmias may result if hyperkalemia occurs. Supplemental potassium should not be added to the client's intake. Potassium does not have a direct impact on bowel motility.
STANDING POSITION
EXAMINATION OF MALE GENITALS, INGUINAL HERNIAL, SCREENING TEST FOR SCOLIOSIS.
body weight percentage in elderly person
EXTRACELLULAR- 5% INTERSTITIAL- 15% INTRACELLULAR- 25% TOTAL= 45% WATER
The nurse is performing an extensive dressing change on a client with burns. The nurse explains each step as it is being performed. The nurse is acting in which role by providing explanation of each step? -Caregiver -Client advocate -Decision-maker -Educator
Educator
In what stage of Erik Erikson's model of development does the older adult come to terms with his or her life choices?
Ego integrity vs. despair Erik Erikson's eighth and last stage applies to late adulthood. The task for the older adult is ego integrity vs. despair. The older adult with ego integrity has come to terms with his or her life choices. He or she comes to recognize that the life that has been lived was the only possible one and that it had dignity, which the person is ready to defend against physical or economic threats. Generativity vs. stagnation is used to describe the middle adult stage. Intimacy vs. isolation is used to describe the early adult stage. Identity vs. role confusion is used to describe the adolescence stage. (less)
The nursing student who has diarrhea before every test and every clinical understand that this is not a healthy behavior. The student is aware that this negative effect can impact overall health. The nurse recognizes that this student needs to focus on which of the following dimensions of health? -Physical dimension -Emotional dimension -Sociocultural dimension -Intellectual dimension
Emotional dimension
According to Archer, what are the three general types of communities? A. Financial, protective, and valued B. Healthy, cultural , and independent C. Emotional, structural, and functional D. Connected, casual, and formal
Emotional, structural, and functional
A hospice nurse is meeting with the parents of a terminally ill child. The nurse listens to the concerns and fears that the parents are verbalizing as they prepare to allow the child to die peacefully at home. What Critical Thinking Indicator characterizes the behavior of the hospice nurse? -Flexible -Empathic -Creative -Self-disciplined
Empathic
While examining a client, the nurse observes the client's chest to be barrel shaped. The nurse would interpret this as indicating which of the following?
Emphysema A barrel chest is often seen in emphysema because of hyperinflation of the lungs. A change in chest shape would be rare with pneumonia. Pectus excavatum or funnel chest is a congenital malformation. (less)
Which action by the nurse indicates the appropriate use of ophthalmoscope?
Employ the right eye to examine the client's right eye The nurse should employ the right eye to examine the client's right eye; this action of the nurse indicates the correct use of the ophthalmoscope. The nurse should hold the ophthalmoscope with the left hand and the index finger on the lens wheel. The nurse should ask the client to gaze at an object straight ahead and slightly upward, not downward. (less)
The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. What can the nurse focus on while doing discharge teaching? A. Encourage the use of safety equipment B. Encourage proper nutrition to promote healing C. Encourage the client to take a safety course D. Teach proper posture, bending, and lifting
Encourage the use of safety equipment
Which of the following nursing actions best exemplifies the nurse's role in promoting health? -Encouraging a group of junior high school students to engage in regular physical activity -Administering a beta-adrenergic blocker and diuretic to a client who has a history of hypertension -Performing deep suctioning on a client who has a tracheotomy and copious secretions -Facilitating a support group for the friends and families of clients affected by stroke
Encouraging a group of junior high school students to engage in regular physical activity
The children of an elderly male client who has suffered an ischemic stroke have informed the nurse that an herbalist will be coming to their father's bedside tomorrow to make recommendations for his care. Which of the following considerations should the nurse prioritize in light of the practitioner's planned visit? -Take measure to prevent cultural conflict when the practitioner comes to the hospital -Ensure that the care team does not impose their beliefs on the family or the complementary practitioner -Ensure any complementary therapies are safe when combined with his prescribed treatments -Identify whether the family would prefer to pursue alternative or conventional treatment for their father
Ensure any complementary therapies are safe when combined with his prescribed treatments
A nurse is required to initiate IV therapy for a client. Which of the following should the nurse consider before starting the IV? Ensure that the prescribed solution is clear and transparent. Correct Explanation: Before preparing the solution, the nurse should inspect the container and determine that the solution is clear and transparent, the expiration date has not elapsed, no leaks are apparent, and a separate label is attached. The primary tubing should be approximately 110 inches (2.8 m) long and the secondary tubing should be about 37 inches (94 cm) long. To reduce the potential for infection, IV solutions are replaced every 24 hours even if the total volume has not been completely instilled. (less)
Ensure that the prescribed solution is clear and transparent. Before preparing the solution, the nurse should inspect the container and determine that the solution is clear and transparent, the expiration date has not elapsed, no leaks are apparent, and a separate label is attached. The primary tubing should be approximately 110 inches (2.8 m) long and the secondary tubing should be about 37 inches (94 cm) long. To reduce the potential for infection, IV solutions are replaced every 24 hours even if the total volume has not been completely instilled. (less)
A new storefront health outreach centre has been proposed for a community. The community health nurse can demonstrate the standards of community health by performing what action? A. Considering demographic trends in the community and in Canada as a whole B. Collaborating with hospital nurses who provide care in the community C. Involving occupational therapists, physiotherapists, and other health disciplines in the planning stage D. Ensuring that community residents have fair and equitable access to the facility
Ensuring that community residents have fair and equitable access to the facility
A new storefront health outreach centre has been proposed for a community. The community health nurse can demonstrate the standards of community health by performing what action? -Considering demographic trends in the community and in Canada as a whole -Collaborating with hospital nurses who provide care in the community -Involving occupational therapists, physiotherapists, and other health disciplines in the planning stage -Ensuring that community residents have fair and equitable access to the facility
Ensuring that community residents have fair and equitable access to the facility
PO4- SOURCES AND LOSSES
Enters body via gastrointestinal tract Sources include all animal products (meat, poultry, eggs, milk, bread, ready-to-eat cereal) Absorption is diminished by concurrent ingestion of calcium, magnesium, and aluminum
Risk factors for illness are divided into six categories. Working with carcinogenic chemicals is an example of which type of risk factor? -Lifestyle risk factor -Health habits risk factor -Environmental risk factor -Physiologic risk factor
Environmental risk factor
The nurse is assessing the cognitive function of an older adult. During the interaction, the patient accurately describes the first date with his spouse of 50 years. Which type of memory has the patient demonstrated?
Episodic long-term memory Episodic long-term memory involves the recall of past events and personally relevant information, validated by the older adult's accurate description of the first date with his spouse. Short-term memory represents things the person is presently and actively thinking about, whereas sensory memory is retention of a sensory image for a very brief period of time. Semantic long-term memory involves the retrieval of facts, vocabulary, and general knowledge. (less)
A nurse is educating a client about the function of the parts of the auditory system. Which is the function of the eustachian tube?
Equalizes the pressure in the middle ear with atmospheric pressure. The eustachian tube opens during swallowing or yawning. Its function is to equalize the pressure in the middle ear with atmospheric pressure so that there is equal pressure on both sides of the tympanic membrane to allow the drum to vibrate freely. The stapes transmits the vibration to the fluid-filled inner ear at the oval window. The vestibule sends information to the cerebellum and the midbrain. The tympanic membrane separates the external from the middle ear. (less)
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?
Erikson Erikson emphasized the conflict between ego integrity and despair in late adulthood. Central tasks involved accepting death and appraising the value and worth of the life one lived. (less)
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?
Erikson Erikson emphasized the conflict between ego integrity and despair in late adulthood. Central tasks involved accepting death and appraising the value and worth of the life one lived. (less)
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?
Establishing a personal identity During adolescence, Erikson prioritized the crisis of identity versus role confusion. Erikson emphasized this over the importance of exerting influence, appraising religious beliefs, or evaluating their parents' beliefs. (less)
When a home-bound client expresses her past-oriented ancestral heritage and family rituals, the nurse recognizes that the patient is expressing what? -Ethnic identity -Assimilation -Race -Subculture
Ethnic identity
When describing the concept of ethnicity, which statement would be most appropriate to use? A. Ethnicity is an alternative term that implies the same ideas as culture. B. Ethnicity allows people to define themselves and others to define them. C. Culture involves self-consciousness while ethnicity does not. D. Ethnicity is a present-oriented form of identity.
Ethnicity allows people to define themselves and others to define them.
After a class on culture and ethnicity, the new graduate nurse reflects a correct understanding of the concept of ethnicity with which statement?
Ethnicity pertains to a social group within the social system that claims shared values and traditions.
A client tells the nurse that the only thing that helps him sleep is a glass of warm milk. The nurse caring for the client insists that this practice is a myth and tries to convince the client that reading a book will help make him sleepy. What is the nurse demonstrating? A. Cultural pervasiveness B. Cultural superiority C. Stereotyping D. Ethnocentrism
Ethnocentrism
The nursing student hopefuls are taking a pre-nursing anatomy and physiology class. What will they learn is the anatomical feature that equalizes air pressure in the middle ear?
Eustachian tube The eustachian tube extends from the floor of the middle ear to the pharynx and is lined with mucous membrane. It equalizes air pressure in the middle ear. Options B, C and D do not equalize pressure in the middle ear. (less)
The client has been admitted through the emergency department with chronic bronchitis, has elevated CO2 levels, and has been placed on O2. What priority assessment would the nurse include?
Evaluate changes in respiratory pattern and rate. Observe quality and pattern of respiration. Note breathing characteristics as well as rate, rhythm, and depth. Labored and noisy breathing is often seen with severe asthma or chronic bronchitis. (less)
The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain . Which would be the next appropriate action?
Evaluate the individuals condition, and compare actual outcomes with expected outcomes.
The nurse is completing the assessment of a client who takes a beta-adrenergic blocker and a diuretic. Which assessment would be most important for the nurse to complete to ensure safety with a client receiving antihypertensive agents?
Evaluating for orthostatic hypotension For a client taking antihypertensive agents, the nurse should assess for possible orthostatic hypotension, which could increase the client's risk for falls. The blood pressure would fall with a change in position from lying to sitting or standing. A widening pulse pressure may be seen with aging. (less)
A nurse is caring for a post-operative Asian American client after knee arthroplasty. The nurse plans to help the client ambulate, but is aware that the client may feel threatened due to physical closeness. What would be the most appropriate nursing action? -Instruct family members to ambulate the client -Explain the purpose and need for assistance during ambulation -Let the client ambulate slowly on his own when he is stable -Ambulate the client without answering his questions
Explain the purpose and need for assistance during ambulation
The nurse is completing the assessment of a client who takes a beta-adrenergic blocker and a diuretic. Which assessment would be most important for the nurse to complete to ensure safety with a client receiving antihypertensive agents?
Evaluating for orthostatic hypotension A nurse assesses a female client's core body temperature and finds that she has a slightly elevated temperature. Which of the following factors could explain this finding? Select all that apply.Explanation: For a client taking antihypertensive agents, the nurse should assess for possible orthostatic hypotension, which could increase the client's risk for falls. The blood pressure would fall with a change in position from lying to sitting or standing. A widening pulse pressure may be seen with aging.
When looking at a model for evidence-based practice, what is the final step of the process? -Formulating a clinical question -Searching the literature -Evaluating practice change -Appraising evidence
Evaluating practice change
Once the nurse has administered pain medication, it is the nurse's responsibility to determine its effect and any other results. When accomplishing this followup with the client, the nurse is utilizing which step of the nursing process? -Evaluation -Assessment -Implementation -Planning
Evaluation
The nurse assesses a client's blood pressure, which was 160/90. Two hours following the administration of hydrochlorothiazide, the nurse reassesses the blood pressure at 140/78. What action has the nurse implemented? -Appraising -Planning -Implementation -Evaluation
Evaluation
Which phase of the nursing process enable the nurse to compare the actual outcomes with the expected outcomes? -Implementation -Planning -Evaluation -Assessment
Evaluation
After surgery, a client is on IV therapy for the next 4 days. How often should the nurse change the IV tubing for this client?
Every 72 hours IV tubings are generally changed every 72 hours or as per the facility's policy. Solutions are replaced when they finish infusing or every 24 hours, whichever occurs first. IV tubings are not replaced after every solution is over or after every 12, 24,or 36 hours.
The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes?
Evidence in a situation of wrongdoing The medical record can be used as a legal document to provide evidence of wrongdoing. Quality assurance is conducted to determine whether standards of care are provided to patients and documented in the medical record. Various members of the healthcare team document in the medical record to communicate information and make care decisions and plan for patient discharge. Information in the patient's medical record is used to determine reimbursement by Medicare, Medicaid, workers' compensation insurance, and third-party insurance companies for care. (less)
The nurse keeps in mind that the most important reason to share information and to offer brief teaching while performing the physical examination is to help the:
Examiner to build rapport and to increase the patients confidence in him or her.
WHAT MAY LEAD TO A FLUID VOLUME DEFICIT
Excessive use of laxatives, diaphoresis, and increased cardiac output may lead to a fluid volume deficit
The nurse is conducting an interview with a woman who has recently learned that she is pregnant and who has come to the clinic today to begin prenatal care. The woman states that she and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands during the interview and sighs loudly. Considering the concept of communication, which statement does the nurse know to be most accurate? The woman is:
Exhibiting verbal and nonverbal behaviors that do not match.
What is a characteristic symptom of Graves hyperthyroidism? A. Pterygium B. Exophthalmos C. Pinguecula D. Episcleritis
Exophthalmos
A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis?
Exophthalmos In exophthalmos, the eyeball protrudes forward. If it is bilateral, it suggests the presence of Graves' disease, although unilateral exophthalmos could still be caused by Graves' disease. Alternative causes include a tumour and inflammation in the orbit. (less)
When performing the cover test, a nurse notices that the client's left eye turns outward. How should the nurse document this finding in the client's record?
Exotropia With the cover test, the eyes of the client should remain fixed straight ahead. If the covered eye moves when uncovered to reestablish focus, it is abnormal. If the eye turns outward it is called exotropia. If the uncovered eye turns inward, it is called esotropia. Strabismus is constant malalignment of the eyes. Presbyopia is impaired near vision. (less)
A nurse researcher is examining the cause-and-effect relationship between the consumption of tap water containing minimal amounts of bleach, and the indigence of cancer in rats. The research is taking place in a laboratory setting. What type of quantitative research is being based upon this description? -Descriptive research -Correlational research -Quasi-experimental research -Experimental research
Experimental research
A nurse is caring for an Asian American client immediately postpartum. As the client seems exhausted after delivery, the nurse offers her warm milk to drink. The client refuses, saying that her cultural belief does not permit her to have any food before 24 hours have passed. What is the most appropriate response by the nurse? -Tell the client that her beliefs are wrong and she needs to have food -Call the nurse supervisor and inform her about the client -Put in an IV and start intravenous fluid to avoid dehydration -Explain the importance of the mother's nutritional status for lactation
Explain the importance of the mother's nutritional status for lactation
Which of the following is an essential topic when discussing risk factors for peripheral arterial disease with a client?
Extent of tobacco use and exposure Tobacco use is one of the most significant risk factors for PAD and would supersede exercise tolerance, prevention of varicose veins, or dysrhythmias.
Which of the following would a nurse expect to assess in a client with esotropia?
Eye turning inward Esotropia is a term used to describe eyes that turn inward. Exotropia refers to an outward turning of the eyes. Strabismus refers to a constant malalignment of the eyes. Nystagmus refers to oscillating or shaking movement of the eye. (less)
FOR NON-VERBAL/CHILDREN/INFANTS WITH PAIN WE USE
FACES (THE FACE)
The nurse is caring for a 4-year old patient with abdominal pain. The most appropriate pain assessment tool would be the:
FACES Pain Scale The FACES Pain Scale is appropriate for children age 3 and older, using six faces ranging from happy with a wide smile to sad with tears on the face. The other three scales are appropriate for use with older children and adults. The Numeric Pain Intensity Scale is a one-dimensional pain scale using an 11-poing Likert-type scale ranging from 0 to 10, where 0 means "no pain" and 10 means "worst possible pain." The Combined Thermometer Scale looks like a thermometer and has both numbers that increase from the bottom up and descriptor words to measure pain intensity. The Visual Analog Scale is a 100-mm line with "no pain" at one end and "worst possible pain" at the other. (less)
The nurse is working on a pediatric unit caring for a 4-year-old who is recovering from the surgical repair of the pelvis. When assessing the patient's pain, what is the most appropriate pain assessment tool for the nurse to use?
FACES Pain Scale Children 2 years and older can identify pain and point to its location. You can use a facial expression scale for children starting at approximately 3 years. The FACES scale uses six faces ranging from happy with a wide smile to sad with tears on the face. (less)
A nurse is caring for a 4-year-old patient who is crying and appears to be in pain. The nurse begins to assess the pain by showing pictures on a chart and asking the patient to point to the one that best represents the pain he is experiencing. This is an example of which of the following:
FACES scale The FACES scale is used for children who are 3 years or older. This tool allows the patient to point to the picture of the face that best represents the pain he or she is feeling. The FLACC scale uses face, legs, activity, cry, and consolability to assess the pain. The visual analog scale uses a 100-mm line with "no pain" at one end and "worst pain" at the other. The numeric scale is the most commonly used scale--an example is an 11-point Likert scale with 0 meaning no pain and 10 meaning the worst pain ever. (less)
A nurse is assessing a mentally challenged adult client who is in pain after a fall from a staircase. Which of the following scales should the nurse use to assess the client's pain?
FACES scale The nurse should use the Wong-Baker FACES scale, which is best for children and clients who are culturally diverse or mentally challenged. Nurses generally use a numeric scale, a word scale, or a linear scale to quantify the pain intensity of adult clients who can express their pain intensity in words, numbers, or linear fashion with the help of the respective scales. (less)
Approximately 60% of the body's calcium is found within the bones and teeth. TRUE OR FALSE
FALSE, Approximately 99% of the body's calcium is found within the bones and teeth. The remainder is in the serum.
d) If sodium is low, it means that there is not enough water.
FALSE, IF SODIUM IS LOW, THERE IS TOO MUCH WATER BECAUSE WATER USUYUALLY FOLLOWS SODIUIM
WHAT IS CONSIDERED SECONDARY DATA SOURCE?
FAMILY AND HEALTH RECORDS are - both are considered Secondary Data Sources - family provides their perspective of the patient's past & current problems. This is Subjective Data. The family is also evaluated by the nurse as either a Reliable or Unreliable Historian - Health Records provide both Subjective & Objective Data
fever, chills, headache, and malaise occur in
FEBRILE (FEVER) REACTIONS
The nurse is working in the post anesthesia care unit and assessing pain in a 6 month old infant. Which method should the nurse use to assess the infant's pain?
FLACC scale. The FLACC (Face, Legs, Activity, Cry, Consolability) scale was originally designed to measure acute postoperative pain in children 2 months to 7 years old. Heart rate and respirations are part of an infant pain assessment; however the FLACC scale is the most comprehensive tool. The BPIQ (brief pain impact questionnaire) is used mainly to assess chronic pain in adults. (less)
The nurse is caring for a 4-week-old postoperative patient. The most appropriate pain assessment tool would be the:
Face, Legs, Activity, Cry, Consolability Scale The Face, Legs, Activity, Cry, Consolability Scale is the appropriate pain assessment tool for a 4-week-old postoperative patient. This tool measures pain using observable behaviors as pain indicators. The FACES Pain Scale is appropriate for children age 3 and older, using six faces ranging from happy with a wide smile to sad with tears on the face. The other two scales are appropriate for use with older children and adults. The Numeric Pain Intensity Scale is a one-dimensional pain scale using an 11-poing Likert-type scale ranging from 0 to 10, where 0 means "no pain" and 10 means "worst possible pain." The Combined Thermometer Scale looks like a thermometer and has both numbers that increase from the bottom up and descriptor words to measure pain intensity. (less)
A 4-year-old boy is brought to the emergency department by his mother. She says he points to his stomach and says, It hurts so bad. Which pain assessment tool would be the best choice when assessing this childs pain?
Faces Pain Scale - Revised (FPS-R)
A man age 61 years is distraught because he has just learned that his most recent computed tomography (CT) scan shows that his colon cancer has metastasized to his lungs. Which of the following nursing aims should the nurse prioritize in the immediate care of this patient? -Preventing illness -Promoting health -Restoring health -Facilitating coping
Facilitating coping
Nontherapeutic Communication Techniques
False reassurance Sympathy Unwanted advice Biased questions Changes of subject Distractions Technical or overwhelming language Interrupting Role Boundaries (nonprofessional involvement, sexual boundary violation, HIPPA violation)
The nurse practitioner is discussing health promotion with a group of senior nursing students. What would be the best example of secondary health promotion? -Weight loss program -Family counseling -Immunizations -Workplace health and safety seminar
Family counseling
A nurse is working on an acute neurological unit. Which assessment form would the nurse most likely use to document assessment data?
Focused assessment form The nurse most likely would be using a focused assessment form, one that focuses on the neurologic system because the clients have a specific problem related to neurologic function. An open-ended form would be used for an initial assessment. A frequent or ongoing assessment form could be used to document vital signs or other assessment data to allow rapid comparison of recorded assessment data from one time period to the next. (less)
CARDIAC ASSESSMENT Subjective Data Collection
Focused health history related to common symptoms Common cardiovascular symptoms Questions to assess symptoms Lifespan considerations
A nurse assesses the parallel alignment of a client's eyes by testing the corneal light reflex. Where should the nurse shine the penlight to obtain an accurate result? Focused on the bridge of the nose Directly on the eye being examined Pointed at a fixed object on the wall Shined on the forehead
Focused on the bridge of the nose
A nurse assesses the parallel alignment of a client's eyes by testing the corneal light reflex. Where should the nurse shine the penlight to obtain an accurate result? A. Focused on the bridge of the nose B. Directly on the eye being examined C. Pointed at a fixed object on the wall D. Shined on the forehead
Focused on the bridge of the nose
Which of the following areas are typically included in a cultural assessment? -Employment status -Marital status -Ethics -Food preferences
Food preferences
Asian-American woman is experiencing diarrhea, which is believed to be cold or yin. The nurse expects that the woman is likely to try to treat it with:
Foods that are hot or yang
How is culture learned by each new generation? -Belonging to a subculture -Formal and informal experiences -Involvement in religious activities -Ethnic heritage
Formal and informal experiences
When the nurse asks for a description of who lives with a child, the method of discipline, and the support system of the child, what part of the assessment is being performed?
Functional assessment
The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what?
Funnel chest Pectus excavatum or funnel chest occurs when the sternum and adjacent cartilages are significantly sunken inward or dented. Pigeon chest or pectus carinatum occurs when the sternum protrudes backward. Intercostal bulging is noted with trapped air. Whispering pectoriloquy is identfied when sounds are louder and clearer than the wispered sounds. (less)
The nurse is preparing to conduct a mental status examination. Which statement is true regarding the mental status examination?
Gathering mental status information during the health history interview is usually sufficient.
Nonmodifiable RISK FACTORS FOR BREAST CANCER
Gender Age Family history Race Genetics Personal history Age at first full-term pregnancy Early menarche Late menopause Breast density
Review of Systems
General Health Nutrition/Hydration Skin/hair/nails HEENT (Head, Eyes, Ears, Nose, Throat) Neck Breasts Respiratory Cardiovascular/Peripheral vascular Gastrointestinal Urinary Musculoskeletal Neurological/Psychiatric Reproductive Endocrine Hematological
Which of the following theories emphasizes the relationships between the whole and the parts, and describes how parts function and behave? -Development theory -General systems theory -Nursing theory -Adaptation theory
General systems theory
One of the primary focuses of nursing research is to do what? -Generate knowledge to guide practice -Quantify outcomes related to patients -Prevent further disease and death -Determine outcomes for patients
Generate knowledge to guide practice
The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to:
Give him the Four Unrelated Words Test.
The nurse is preparing to examine a 4-year-old child. Which action is appropriate for this age group?
Give the child feedback and reassurance during the examination.
PART 3= PLAN (BOTH GOALS AND OUTCOMES)
Goals are a general end point of what the nurse and patient agree upon. Short Term Goals are statements that need to be addressed quickly (usually 24-48 hours). i.e. Patient will maintain correct body alignment while sitting in chair Long Term Goals are statements that progress over time (48hours to discharge &/or rehabilitation) i.e. Patient will progress to correct body alignment for ambulation. `
A male client 79 years of age who is postoperative Day 3 following hip replacement surgery has been approached by a nurse researcher and asked to participate in a research study. This study will test a new rehabilitation strategy. What aspect of the nursing research process addresses the client's understanding of the potential risks and benefits of this study? -Meeting with the hospital's institutional review board (IRB) -Going through the informed consent process with the client -Giving the client the opportunity to ask questions about the study -Obtaining the client's signature on a permission document
Going through the informed consent process with the client
Cheyne-Stokes respirations (CSR) VIC'S FEELINGS OF AFFECTION
Gradual increase in volume and frequency, followed by a gradual decrease in volume and frequency, with apnea periods of 10 - 30 seconds between cycle. Described as a crescendo - decrescendo pattern. Characterized by cyclic waxing and waning ventilation with apnea gradually giving way to hyperpneic breathing. Seen with low cardiac output states (CHF) with compromised cerebral perfusion Creates lag of CSF CO2 behind arterial PaCO2 and results in characteristic cycle. Delayed sensitivity to CO2 changes- during apnea the CO2 increase above the threshold for stimulus but the brain is slow to respond, then it over shoots by hyperventilating and the signal to reduce ventilation is slow to be recognized.
WHAT ARE THE TWO COMPONENTS OF THE HEALTH ASSESSMENT? (HP PRINTER)
Health History - Part 1 Interviews, past medical/surgical history (PMH), nutrition, development, mental health, social, cultural, spiritual, safety, risk factors, current symptoms) Physical Assessment - Part 2 Acute: current problems Non-acute: wellness/health promotion
Components of Health Assessment
Health History and physical assessment HEALTH HISTORY Interviews, past medical/surgical history (PMH), nutrition, development, mental health, social, cultural, spiritual, safety, risk factors, current symptoms) PHYSICAL ASSESSMENT Acute: current problems Non-acute: wellness/health promotion
A community health nurse arranges for a dental checkup camp for the local children in the school district. Which of the following would most likely be the nurse's goal for this health camp? -Reversal of self-care deficits -High-level wellness -Illness prevention -Health promotion
Health promotion
HOW TO DOCUMENT A HEART SOUND? (OBJECTIVELY)
Heart Sounds regular, normal beats per minute no S3 OR S4 sound heard regular rate/rhythm
During the health history interview with a 40-year-old man, the nurse uses the genogram to specifically assess for major family risk for cardiovascular disease by asking about which of the following?
Heart attacks in his father and siblings Risk of developing heart disease is increased if one or more immediate family members (parents or siblings) have had an MI, hypertension, or high cholesterol.
The nurse's assessment of a client reveals jugular venous distention. The nurse should conduct further assessments related to what health problem?
Heart failure Jugular venous distention (JVD) is associated with heart failure, tricuspid regurgitation, and fluid volume overload. The neck veins appear full, and the level of pulsation may be have elevated jugular venous pressure greater than 3 cm (about 1 1/4 in.) above the sternal angle. About 75% of patients with elevated JVD have heart failure. (less)
The nurse is completing the general survey of a client and determines that the client's temperature is 102°F. Which of the following would the nurse also expect to find?
Heart rate greater than 100 bpm The client would most likely exhibit tachycardia due to the increase in heart rate that occurs in response to increased body temperature. The pulse rate increases in an attempt to increase body metabolism and decrease temperature. Weak, thready pulse would be considered abnormal but not necessarily associated with a temperature of 102ºF. A respiratory rate between 12 and 20 breaths per minute would be normal. Blood pressure of 10 mm Hg greater than normal is not associated with fever. (less)
The nurse collects vital signs on a client with pain. Which of the following would indicate to the nurse that the client is experiencing pain?
Heart rate of 110 bpm Pain can increase the heart rate; a rate of 110 bpm is above the normal range. A respiratory rate of 18, temperature of 99.1o F, and blood pressure of 120/70 are within normal parameters. (less)
The nurse collects vital signs on a client with pain. Which of the following would indicate to the nurse that the client is experiencing pain?The nurse collects vital signs on a client with pain. Which of the following would indicate to the nurse that the client is experiencing pain?
Heart rate of 110 bpm Pain can increase the heart rate; a rate of 110 bpm is above the normal range. A respiratory rate of 18, temperature of 99.1o F, and blood pressure of 120/70 are within normal parameters. (less)
THE HEART SEPTUM
Heart septum: The dividing wall between the right and left sides of the heart. That portion of the septum that separates the right and left atria of the heart is termed the atrial, or interatrial, septum, whereas the portion of the septum that lies between the right and left ventricles of the heart is called the ventricular, or interventricular, septum.
Anthropometric Measurements INCLUDE (STUDY OF HUMAN BODY MEASUREMENTS)
Height Weight Calculation of BMI BMI=Weight (kg. or lbs.) ÷ Height (m squared or in squared) X 703
In the health promotion model, the focus of the health professional includes:
Helping the consumer choose a healthier lifestyle.
Understand the interactions between the members of the family. Teach the family to build on their current health status. Elicit the family's input into planning their care. Demonstrate healthy patterns of interactions. A. Helping the patient to provide regular status updates to his parents and siblings B. Encouraging the patient to reflect on the support and hope that he receives from his family C. Helping to facilitate the patient's parents coming to stay with the patient D. Encouraging the patient to be honest with his parents about his fear and anxiety
Helping to facilitate the patient's parents coming to stay with the patient
During a blood transfusion, a patient displays signs of immediate onset facial flushing, fever, chills, headache, low back pain, and shock. Which transfusion reaction should the nurse suspect?
Hemolytic transfusion reaction: incompatibility of blood product
The nurse is performing a mental status assessment on a 5-year-old girl. Her parents are undergoing a bitter divorce and are worried about the effect it is having on their daughter. Which action or statement might lead the nurse to be concerned about the girls mental status?
Her mother states that her daughter prefers to play with toddlers instead of kids her own age while in daycare.
A client presents with lymphedema in one arm, with nonpitting edema. Which of the following should the nurse assess for, based on this finding?
History of breast surgery Lymphedema results from blocked lymphatic circulation, which may be caused by breast surgery. It usually affects one extremity, causing induration and nonpitting edema. Raynaud's disorder is a vascular disorder caused by vasoconstriction or vasospasm of the fingers or toes and is typically bilateral. Peripheral artery disease involves reduced blood flow to the limbs and is characterized primarily by intermittent claudication, not by edema. Deep vein thrombosis is caused by obstruction of the veins and is not associated with lymphedema. (less)
When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these?
Holistic health views the mind, body, and spirit as interdependent.
A client recently diagnosed with pancreatic cancer tells the nurse, "I don't see any hope for my future." What would be the most appropriate nursing diagnosis for the nurse to formulate to address this health problem? Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis Disturbed Self-Concept related to pancreatic cancer diagnosis Ineffective Health Maintenance related to being overwhelmed by cancer diagnosis Knowledge Deficit: Cancer treatment options related to new diagnosis
Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis
A man arrives at the clinic for his annual wellness physical. He is experiencing no acute health problems. Which question or statement by the nurse is most appropriate when beginning the interview?
How has your health been since your last visit?
A patient states, I feel so sad all of the time. I cant feel happy even doing things I used to like to do. He also states that he is tired, sleeps poorly, and has no energy. To differentiate between a dysthymic disorder and a major depressive disorder, the nurse should ask which question?
How long have you been feeling this way?
A 29-year-old woman tells the nurse that she has excruciating pain in her back. Which would be the nurses appropriate response to the womans statement?
How would you say the pain affects your ability to do your daily activities?
What is the central theme of Betty Neuman's nursing theory? -Humans are in a constant relationship with stressors in the environment -Nursing is an art -Meeting the personal needs of the client within the environment -Nursing is a therapeutic, interpersonal, and goal-oriented process
Humans are in a constant relationship with stressors in the environment
When identifying the midline structures of the neck from the mandible to the sternal notch, the nurse notes the structures in what order? A. Cricoid cartilage, hyoid bone, tracheal rings, thyroid isthmus B. Thyroid cartilage, thyroid isthmus, cricoid cartilage, hyoid bone C. Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid D. Hyoid bone, tracheal rings, cricoid cartilage, lobes of the thyroid gland
Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid
HYPERKALEMIA (IF THE JUGULAR VEIN IS ENLARGED...THIS IS A SIGN OF HYPERKALEMIA
Hyperkalemia is the medical term that describes a potassium level in your blood that's higher than normal. Potassium is a nutrient that is critical to the function of nerve and muscle cells, including those in your heart. Your blood potassium level is normally 3.6 to 5.2 millimoles per liter (mmol/L). Having a blood potassium level higher than 7.0 mmol/L can be dangerous and requires immediate treatment.
A nurse is providing care to a client with hypocalcemia. The nurse would monitor the client's laboratory test results for which imbalance?
Hyperphosphatemia
A nurse is preparing a health education session for a local community group. When addressing the relationship between coronary artery disease (CAD) and culture, which information would the nurse include?
Hypertension is more prevalent in African Americans than among Caucasians. Ethnicity plays a role in developing coronary heart disease. African Americans, Mexican Americans, American Indians, native Hawaiians, and some Asian Americans have a higher risk of heart disease thought to be due to more severe hypertension and higher rates of obesity and diabetes in these populations. (less)
The nurse is examining a 62-year-old man and notes that he has bilateral gynecomastia. The nurse should explore his health history for which related conditions? Select all that apply.
Hyperthyroidism Liver disease History of alcohol abuse
A 9-year-old girl is in the clinic for a sport physical examination. After some initial shyness she finally asks, Am I normal? I dont seem to need a bra yet, but I have some friends who do. What if I never get breasts? The nurses best response would be:
I understand that it is hard to feel different from your friends. Breasts usually develop between8 and 10 years of age.
A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. For the mental status examination, the nurse should first assess the patients:
Level of consciousness and cognitive abilities
The nurse is caring for John, who was admitted after falling from a ladder. John has a brain injury which is causing the pressure inside his skull to increase, which may result in a lack of circulation and possible death to his brain cells. Considering this information, which intravenous solution would be most appropriate for John?
Hypertonic Explanation: Because a hypertonic solution has a greater osmolarity, water moves out of the cells and is drawn into the intravascular compartment, causing the cells to shrink. Because of a lower osmolarity, a hypotonic solution in the intravascular space moves out of the intravascular space and into intracellular fluid, causing cells to swell and possibly burst. An isotonic fluid remains in the intravascular compartment. Plasma is an isotonic solution.
A client who is admitted to the health care facility has been diagnosed with cerebral edema. Which of the following intravenous solutions needs to be administered to this client?
Hypertonic solution Hypertonic solutions are used in extreme cases when it is necessary to reduce cerebral edema or to expand the circulatory volume rapidly because it is more concentrated than body fluid and draws cellular and interstitial water into the intravascular compartment. Hypotonic solutions are administered to clients with fluid losses in excess of fluid intake, such as those who have diarrhea or vomiting. Isotonic solution is generally administered to maintain fluid balance in clients who may not be able to eat or drink for a short period. Colloid solutions are used to replace circulating blood volume because the suspended molecules pull fluid from other compartments. However, these solutions are not related to clients with cerebral edema. (less)
A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse most likely find?
Hypokalemia Intestinal secretions contain bicarbonate. For this reason, diarrhea may result in metabolic acidosis due to depletion of base. Intestinal contents also are rich in sodium, chloride, water, and potassium, possibly contributing to an ECF volume deficit and hypokalemia. Sodium and chloride levels would be low, not elevated. Changes in magnesium levels typically would not be associated with diarrhea. (less)
A nurse is reviewing the client's serum electrolyte levels which are as follows: Sodium: 138 mEq/L Potassium: 3.2 mEq/L Calcium: 4.4 mEq/L Magnesium: 1.6 mEq/L Chloride: 100 mEq/L Phosphate: 1.8 mEq/L Based on these levels, the nurse would identify which imbalance?
Hypokalemia Explanation: All of the levels listed are within normal ranges except for potassium, which is decreased (normal range is 3.5 to 5.3 mEq/L). Therefore the client has hypokalemia.
A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse most likely find?
Hypokalemia Explanation: Intestinal secretions contain bicarbonate. For this reason, diarrhea may result in metabolic acidosis due to depletion of base. Intestinal contents also are rich in sodium, chloride, water, and potassium, possibly contributing to an ECF volume deficit and hypokalemia. Sodium and chloride levels would be low, not elevated. Changes in magnesium levels typically would not be associated with diarrhea
Which part of the brain controls the vital functions of temperature, heart rate, blood pressure, sleep, the anterior and posterior pituitary, the autonomic nervous system, and emotions and maintains overall autonomic control?
Hypothalamus The hypothalamus controls the vital functions of temperature, heart rate, blood pressure, sleep, the anterior and posterior pituitary, the autonomic nervous system, and emotions. It maintains overall autonomic control. The medulla, part of the brain stem, controls the cardiac, respiratory, vomiting, and vasomotor centers, dealing with autonomic (involuntary) functions of breathing, blood pressure, and heart rate. The brain stem also contains the pons and midbrain. The cerebral cortex is the covering of the cerebrum. Its role is in memory, attention, and consciousness. (less)
Which part of the brain controls the vital functions of temperature, heart rate, blood pressure, sleep, the anterior and posterior pituitary, the autonomic nervous system, and emotions and maintains overall autonomic control?
Hypothalamus The hypothalamus controls the vital functions of temperature, heart rate, blood pressure, sleep, the anterior and posterior pituitary, the autonomic nervous system, and emotions. It maintains overall autonomic control. The medulla, part of the brain stem, controls the cardiac, respiratory, vomiting, and vasomotor centers, dealing with autonomic (involuntary) functions of breathing, blood pressure, and heart rate. The brain stem also contains the pons and midbrain. The cerebral cortex is the covering of the cerebrum. Its role is in memory, attention, and consciousness.
A client presents at the clinic for a routine check-up. The nurse notes that she is dressed in warm clothing even though the temperature outside is 73°F. The nurse also notes that the patient has gained 10 pounds since her last visit 9 months ago. What might the nurse suspect? A. Effects of age-related changes B. Brain tumor C. Hyperthyroidism D. Hypothyroidism
Hypothyroidism
During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible?
Hypovolemia The nurse should recognize that hypovolemia, also known as dehydration, may be responsible. Additional indicators of dehydration in older adults include mental status changes; increases in pulse and respiration rates; decrease in blood pressure; dark, concentrated urine with a high specific gravity; dry mucous membranes; warm skin; furrowed tongue; low urine output; hardened stools; and elevated hematocrit, hemoglobin, serum sodium, and blood urea nitrogen (BUN).
A client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of post-operative care teaching? A. I must take thyroid hormone replacement medication for the rest of my life. B. I will complete the entire course of thyroid hormone replacement over six weeks. C. I must keep my follow up appointments to receive my thyroid hormone injections. D. I will take my thyroid hormone replacement medication once every week.
I must take thyroid hormone replacement medication for the rest of my life.
The nurse is conducting a patient interview. Which statement made by the patient should the nurse more fully explore during the interview?
I never did too good in school.
The nurse is caring for Mrs. Roberts, an 86-year-old client, who fell at home and was not found for 2 days. Mrs. Roberts is severely dehydrated. The nurse is aware that older adults are at increased risk for fluid imbalance due to:
INCREASE IN FAT CELLS The decreasing percentage of body fluid in older adults is related to an increase in fat cells. In addition, older adults lose muscle mass as a part of aging. The combined increase of fat and loss of muscle results in reduced total body water; after the age of 60, total body water is about 45% of a person's body weight. This decrease in water increases the risk for fluid imbalance in older adults.
RESPIRATION (THE ACT OF BREATHING) INCLUDES TWO PHASES
INSPIRATION (INHALATION) DIAPHRAGM CONTRACTS AND MOVES DOWN EXPIRATION (EXHALATION) DIAPHRAGM RELAXES AND MOVES UPWARD
Grace, a 28-year-old woman, arrives at the emergency department with complaints of severe episodes of nausea and vomiting over the last 48 hours. She has a past medical history of Crohn's disease, a gastrointestinal (GI) problem for which she underwent bowel resection surgery 1 month ago. "I thought the surgery would help my problems," she says.
IV therapy was ordered to restore her fluid balance.
A patient is being discharged from the hospital after a below-the-knee amputation. The nurse has completed the discharge and gives a copy of the discharge summary with patient teaching and medications to the patient. The nurse understands the importance of doing a good assessment prior to discharge for which of the following purposes:
Identify necessary resources and strategies for successful home management. Assessment of the patient prior to discharge should indicate that he or she is stable and has recevied teaching regarding medications and follow-up care. It is used to identify necessary resources and strategies for successful home management. Such assessment is not done to increase the level of competence of the nurse, nor to complete the chart or make the patient feel more comfortable. The assessment information is also useful for social work, physical therapy, and occupational therapies, and follow-up care by the nurse and provider when returning to the outpatient setting. (less)
A hospital's protocols for assessment have been modified in light of standards established by the Joint Commission. What change would bring practice into alignment with these standards?
Identifying pain as the fifth vital sign and assessing clients accordingly Recent literature has emphasized the importance and undertreatment of pain and has recommended that pain be the fifth vital sign. Type of pain is not the primary basis for the triage process. Pain assessment should combine objective data with subjective data, and there is not normally a need to teach clients about the pathophysiology of pain. (less)
An adolescent patient is very quiet and withdrawn. The nurse notices that the mother and patient appear to converse and have a good relationship, but the patient begins to be more energetic and talkative when school friends come to visit. The nurse realizes that this patient is in which of Erikson's stages?
Identity vs. role confusion The nurse understands that the teenage patient is experiencing the stage of identity vs. role confusion. She is trying to gain independence and establish her own identity and self-concept. Trust vs. mistrust is during the infancy stage; initiative vs. guilt is during the preschool ages of 3 to 5 years; industry vs. inferiority is during the school years (6 to 12 years old). (less)
A nurse is interviewing an older adult client who has experienced a drastic weight loss following a CVA (cerebrovascular accident). The client states, "I have trouble getting groceries since I can no longer drive, so I don't have much food in the house." Based on this evidence, what would be the most appropriate nursing diagnosis? Imbalanced nutrition: Less than Body Requirements related to difficulty in procuring food Imbalanced Nutrition: Less than Body Requirements related to drastic weight loss Imbalanced Nutrition: Less than Body Requirements related to cerebrovascular accident Imbalanced nutrition: Less than Body Requirements related to decreased appetite
Imbalanced nutrition: Less than Body Requirements related to difficulty in procuring food
The nurse has just finished assessing a 48-year-old female client who is morbidly obese. The client claims that she overeats as a way to cope with stress. The client underwent a divorce 3 years ago and is currently single. She works 50 hours a week and cares for both her teenaged daughter and her elderly mother. When the nurse suggests changes to her nutrition, the client is resistant. Which of the following nursing diagnoses would be most appropriate for this client?
Imbalanced nutrition: more than body requirements This client clearly demonstrates an imbalanced nutrition, more than body requirements, related to overeating as a coping mechanism for stress. She is not ready for enhanced self-health management. There is no indication that she is at risk for suicide, despite her many stressors. Also, despite her divorce, she is not socially isolated, as she frequently interacts with her daughter and mother. (less)
The nurse is planning care for a patient recovering from orthopedic surgery. Interventions should be included to address which contributing factor to deep vein thrombosis development?
Immobility Immobility can lead to blood stasis, which is a contributing factor to the development of a deep vein thrombosis. Obesity is a risk factor for the development of arterial and venous disease. Smoking is a risk factor for arterial and venous disease and for the development of an abdominal aortic aneurysm. Hypertension is a risk factor for arterial disease and abdominal aortic aneurysm. (less)
A client presents to the health care facility with a two (2) week history of persistent dry, hacky cough, chest tightness, and shortness of breath with activity. The client admits to a one (1) pack per day history of cigarette smoking for 20 years. The nurse observes a respiratory rate of 16 breaths per minute, easy and regular. Which nursing diagnosis should the nurse confirm based on this assessment data?
Impaired Gas Exchange Impaired Gas Exchange related to chronic lung tissue damage secondary to chronic smoking can be confirmed because the major criteria of long standing smoking, shortness of breath, and activity intolerance. The client's cough is dry and hacky which does not meet the criteria for Ineffective Airway Clearance. There is no data to support the client is experiencing a disturbance in sleep or problems with nutrition. (less)
What should the nurse assess to test the function of the temporal lobe?
Impulses from the ear The function of the temporal lobe is assessed by testing for impulses from the ear. To assess the function of the parietal lobe, the nurse should test for tactile sensation. Assessment of the frontal lobe is done by testing the client's communication. To assess the function of the occipital lobe, the nurse should test the ability to read. (less)
OXYGEN SATURATION
In medicine, oxygen saturation (SO2), commonly referred to as "sats," measures the percentage of hemoglobin binding sites in the bloodstream occupied by oxygen. At low partial pressures of oxygen, most hemoglobin is deoxygenated. Oxygen saturation measures how much oxygen the blood is carrying compared with its full capacity. An SpO2 of greater than 95% is generally considered to be normal. An SpO2 of 92% or less (at sea level) suggests hypoxemia.
A nurse is planning meals for clients in a long-term care facility. Which cultural practice should the nurse take into consideration when choosing foods for these clients? A. For some Asians, Hispanics, and Seventh- Day Adventists, religious beliefs prohibit the consumption of pork. B. During holy days, Christians fast from all substances, including IV drips, from sunrise to sunset; however, illness is an exception to this practice. C. Many members of the black culture need diet counseling because they consume a diet high in starch. D. In the Asian and Hispanic culture, diseases and foods are classified as hot or cold, and a proper balance between them promotes wellness.
In the Asian and Hispanic culture, diseases and foods are classified as hot or cold, and a proper balance between them promotes wellness.
2. CONDUCTION
In the next phase, transmission, the action potential continues from the site of damage to the spinal cord, where it ascends up the spinal cord to higher centers in the brain.
A client has presented with signs and symptoms that are suggestive of Bell's palsy. What assessment finding is most consistent with this diagnosis?
Inability to wrinkle the forehead Inability to close the eyes, wrinkle the forehead, or raise the forehead, along with paralysis of the lower part of the face on the affected side, is seen with Bell's palsy. Inability to detect sharp and dull stimuli is associated with lesions of the trigeminal nerve (CN V). Closure of the affected eye from swelling would suggest trauma. Paralysis, not muscle spasm, occurs with Bell's palsy. (less)
A client has presented with signs and symptoms that are suggestive of Bell's palsy. What assessment finding is most consistent with this diagnosis?
Inability to wrinkle the forehead Bell's palsy is a peripheral injury to cranial nerve VII (facial) that causes the inability to close the eyes, wrinkle the forehead, or raise the forehead, along with paralysis of the lower part of the face. Drooping of the eyelids (ptosis) is seen with weak eye muscles such as in myasthenia gravis. Limited lateral gaze of the eyes may indicate increased intracranial pressure. Paralysis of the lower lip is not seen in any common disorder of cranial nerve function.
A small, rural hospital is revising the policies and procedures surrounding documentation in an effort to align practices with the Health Information Technology for Economic and Clinical Health (HITECH) Act. How can the requirements of this legislation best be met?
Increase the use of electronic health records (EHRs) in the hospital. HITECH was signed into law as part of the American Recovery and Reinvestment Act of 2009 to promote the adoption and meaningful use of health information technology (HIT). Since this Act was adopted, there has been a slow but steady increase in the use of electronic health records (EHRs) by health care agencies and primary health care providers. The Minimum Data Set is limited to long-term care settings, and interdisciplinary collaboration does not meet the specific criteria of HITECH. Verbal handoffs are not precluded by HITECH. (less)
A patient states that the pain medication is not working and rates his postoperative pain at a 10 on a 1-to-10 scale. Which of these assessment findings indicates an acute pain response to poorly controlled pain?
Increased blood pressure and pulse
The nurse is assessing a family parented by a 60-year-old grandmother and her three school-age grandchildren. The nurse is aware that which problem may occur in a single-parent family at a greater level than in other types of families? A. Lack of knowledge about child safety B. Increased financial concerns C. Child abuse and neglect D. Conflict between family members
Increased financial concerns
A nurse is reviewing a client's health record while interviewing her. The nurse sees in the patient's record a score of 3+ on the biceps reflex test from her previous visit. The nurse understands that this finding indicates which of the following?
Increased or brisk, but not pathologic Normal reflex scores range from 1+ (present but decreased) to 2+ (normal) to 3+ (increased or brisk, but not pathologic). Absent or markedly decreased (hyporeflexia) deep tendon reflexes (rated 0) occur when a component of the lower motor neurons or reflex arc is impaired and may be seen with spinal cord injuries. Markedly hyperactive (hyperreflexia) deep tendon reflexes (rated 4+) may be seen with lesions of the upper motor neurons and when the higher cortical levels are impaired. (less)
A nurse is reviewing a client's health record while interviewing her. The nurse sees in the patient's record a score of 3+ on the biceps reflex test from her previous visit. The nurse understands that this finding indicates which of the following?
Increased or brisk, but not pathologic Normal reflex scores range from 1+ (present but decreased) to 2+ (normal) to 3+ (increased or brisk, but not pathologic). Absent or markedly decreased (hyporeflexia) deep tendon reflexes (rated 0) occur when a component of the lower motor neurons or reflex arc is impaired and may be seen with spinal cord injuries. Markedly hyperactive (hyperreflexia) deep tendon reflexes (rated 4+) may be seen with lesions of the upper motor neurons and when the higher cortical levels are impaired.
Many chronic medical problems adversely affect a person's ability to maintain normal fluid, electrolyte, and acid-base homeostasis. What describes complications related to liver disease?
Increased plasma levels of antidiuretic hormone lead to water excess.
Which of the following would the nurse suspect when a client with a cardiac condition complains of not sleeping well and having to get up frequently at night to urinate?
Increased urination at rest may indicate heart failure. With heart failure, increased renal perfusion during periods of rest or recumbency may cause nocturia. Nocturia does not indicate that the heart is working efficiently. Depending on the client's fatigue level from not sleeping well, as well as other complaints, the client's ability to perform activities of daily living may be affected. If the client is experiencing dyspnea at night, he or she will likely be sleeping on more than one pillow at night. (less)
THYROID GLAND
Increases blood flow in the body by releasing thyroxine, leading to increased renal circulation and resulting in increased glomerular filtration and urinary output.
BREAST CANCER SCREENING
Individualized and BRCA1 and BRCA2 screening Mammography Clinical Breast Examination Breast Self-Examination Magnetic Resonance Imaging (MRI) Chemoprevention
A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis? Bronchial Pneumonia Ineffective Airway Clearance Acute Dyspnea Asthma Attack
Ineffective Airway Clearance
A nurse is caring for a patient whose diagnosis of cystic fibrosis results in the production of large amounts of sticky mucus. The client has a history of repeated hospital admissions for complications of his disease and receives daily treatments to mobilize the secretions. When planning the care of this client, what nursing diagnosis is most plausible?
Ineffective Airway Clearance related to respiratory secretions Increased respiratory secretions create a risk for ineffective airway clearance. The client's breathing rate is likely to be affected, but the increased secretions are the essence of the client's challenge. Mucous membranes are unlikely to be affected. There is no explicit statement that the client possesses readiness for enhanced breathing patterns, although this is likely. (less)
A client is admitted to the health care facility with reports of chest pain, elevated blood pressure, and shortness of breath with activity. The nurse palpates the carotid arteries as 1+ bilaterally and a weak radial pulse. A Grade 3 systolic murmur is auscultated. Which nursing diagnosis can the nurse confirm based on this data?
Ineffective Tissue Perfusion The nurse assesses a decrease in the carotid pulses (1+ is considered weak) and a weak radial pulse is present. The client also has a murmur. These findings allow the nurse to confirm the diagnosis of Ineffective Tissue Perfusion. There are not enough criteria to confirm the diagnosis of Impaired Breathing Pattern, Activity Intolerance, or Ineffective Health Maintenance. (less)
The nurse has completed a focused ear and hearing assessment and gathered the following data: the client speaks very softly, denies hearing loss, and has never had and cannot afford additional hearing tests; the client fails the whisper test. Which nursing diagnosis would be most appropriate?
Ineffective health maintenance related to denial of hearing problem and inadequate resources for additional testing A nursing diagnosis of ineffective health maintenance would be most appropriate based on the data. There is nothing to suggest that the client is having difficulty with social interaction. A soft speaking voice does not indicate a problem with impaired verbal communication. The client has a problem, so a health promotion diagnosis of readiness for enhanced communication would be inappropriate. (less)
INTERSTITIAL FLUID
Interstitial fluid is the fluid that surrounds tissue cells and includes lymph
The following data are gathered: speaks very softly, denies hearing loss, has never had and cannot afford additional hearing tests, fails whisper test. Which nursing diagnosis would be most appropriate?
Ineffective health maintenance, related to denial of hearing problem and inadequate resources for additional testing A nursing diagnosis of ineffective health maintenance would be most appropriate based on the data. There is nothing to suggest that the client is having difficulty with social interaction. A soft-speaking voice does not indicate a problem with impaired verbal communication. The client has a problem, so a wellness diagnosis of readiness for enhanced communication would be inappropriate. (less)
A nurse cares for a client who suffered a myocardial infarction 2 days ago. A high-pitched, scratchy, scraping sound is heard that increases with exhalation and when the client leans forward. The nurse recognizes this sound as a result of what process occurring within the pericardium?
Inflammation of the pericardial sac A high pitched, scratchy, scraping sound that increases with exhalation and when the client leans forward is called a pericardial friction rub. This is caused by inflammation of the pericardial sac. Increased pressure within the ventricles may cause a decrease in cardiac output. Inability of the atria to contract can be caused by any problem that causes the sinoatrial node not to fire. An incompetent mitral valve would cause a systolic murmur. (less)
After a symptom is recognized, the first effort at treatment is often self-care. Which of the following statements about self-care is true? Self-care is:
Influenced by the accessibility of over-the-counter medicines."
The review of systems provides the nurse with:
Information regarding health promotion practices
The nurse is performing an ear assessment of an adult client. Which of the following actions constitutes the correct procedure for using an otoscope when examining the client's ears?
Inserting the speculum down and forward into the ear canal The nurse should insert the speculum gently down and forward into the canal. Using the dominant hand, the nurse should position the hand holding the otoscope against the client's head or face. The largest speculum that fits comfortably into the client's ear canal is used. (less)
Which of the following denotes the correct procedure for using an otoscope when examining the ears of a 32-year-old client?
Inserting the speculum down and forward into the ear canal The nurse should insert the speculum gently down and forward into the canal. Using the dominant hand, the nurse should position the hand holding the otoscope against the client's head or face. The largest speculum that fits comfortably into the client's ear canal is used. (less)
A client presents to an ambulatory clinic with purulent, bloody drainage of the ear. Which of the following should the nurse assess first?
Inspect the client's external ear canal. Purulent, bloody drainage suggests external otitis, an infection of the external ear canal. Therefore the nurse would need to inspect the external auditory canal. Assessing the tympanic membrane would be appropriate if the client has purulent drainage, pain, and complained of a popping sensation, which is associated with otitis media and tympanic perforation. Palpation of the tragus is not an immediate priority in cases of suspected external otitis. Hearing assessments may later be indicated, but these would not be performed at the beginning of the assessment. (less)
CARDIAC ASSESSMENT OBJECTIVE DATA Comprehensive physical examination
Inspection Palpation Auscultation Jugular venous Jugular venous pressure Hepatojugular reflux Carotid arteries Auscultation of the precordium Split heart sound Identify rate and rhythm Identify S1 and S2 Extra sounds Pericardial friction rub Murmurs Lifespan considerations Documenting abnormal findings
The nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis? Select all that apply
Inspiratory wheezes noted in left lower lobes Nonproductive cough Patient reports dyspnea upon exertion Rate of respirations 16 breaths per minute
The nurse assesses the motor system as part of the full neurological examination. In order to effectively assess this system, which of the following instructions should be given to the client?
Instruct the client to flex and extend the right elbow Instructing the client to flex and extend the right elbow is assessing strength, which is a part of the motor system assessment. Instructing the client to state the current date and place is part of the mental status assessment. Instructing the client to smile and close the eyes is part of the cranial nerve assessment. (less)
A nurse cares for a client who suffered a cerebrovascular accident and demonstrates the inability to speak clearly. The nurse recognizes that injury has occurred to what portion of the brain?
Instruct the client to flex and extend the right elbow Instructing the client to flex and extend the right elbow is assessing strength, which is a part of the motor system assessment. Instructing the client to state the current date and place is part of the mental status assessment. Instructing the client to smile and close the eyes is part of the cranial nerve assessment.
A 57-year-old maintenance worker comes to the office for evaluation of pain in his legs. He is a two-pack per day smoker since the age of 16, but he is otherwise healthy. The nurse is concerned that the client may have peripheral vascular disease. Which of the following is part of common or concerning symptoms for the peripheral vascular system?
Intermittent claudication Intermittent claudication is leg pain that occurs with walking and is relieved by rest. It is a key symptom of peripheral vascular disease. This symptom is present in only about one third of clients with significant arterial disease and, if found, calls for more aggressive management of cardiovascular risk factors. Screening with ankle-brachial index can help detect this problem. (less)
The nurse is caring for a client who speaks a language other than English and is using an interpreter to communicate. What would be the best way to choose an interpreter for this client? -Interpreter should always make direct eye contact -Interpreter should understand the health care system -Interpreter should conduct the conversation quickly to avoid misinterpretation -Interpreter should speak in a loud voice
Interpreter should understand the health care system
The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment?
Intracellular Intracellular is the fluid within cells, constituting about 70% of the total body water. Extracellular is all the fluid outside the cells, accounting for about 30% of the total body water. Interstitial fluid is part of the extracellular compartment. Intravascular is also part of the extracellular compartment. (less)
A patient who was in an automobile accident a week ago is at home recovering from her injuries. She contacts her primary care provider's office to report that she still has severe pain in her back, resulting from an injury to that region, that has not been lessened by two different pain relievers that the physician had prescribed for her. The nurse recognizes this as which type of pain?
Intractable Intractable pain is pain that is highly resistant to pain relief, which appears to be the case in this situation. Referred pain is perceived in body areas away from the pain source; because the pain this client is experiencing is due to an injury to the back, this does not seem to be referred pain. Chronic pain is pain that persists longer than 6 months. Visceral pain is pain experienced in a deep organ, typically in the abdominal cavity, thorax, or cranium. (less)
INTRAVASCULAR
Intravascular fluid, or plasma, is the liquid component of the blood (i.e., fluid found within the vascular system)
A nursing student is completing a clinical placement in a hospital setting and is aware of the need to generate positive rapport with a newly admitted patient and his family. Which of the following actions should the nurse perform in order to achieve this goal? Select all that apply. A. Introduce herself to the family by name when first meeting them. B. Reassure the patient that his illness will be successfully treated by the care team. C. Identify herself as a "student nurse" when entering the patient's room. D. Briefly teach the family about the importance of honest communication. E. Knock before entering the patient's room.
Introduce herself to the family by name when first meeting them. Identify herself as a "student nurse" when entering the patient's room. Knock before entering the patient's room.
Two nurses have disagreed about the role of intuition in nursing practice, with one nurse characterizing it as "hocus-pocus" and the other nurse advocating it as a superior problem-solving strategy. Which of the following statements best conveys the role of intuition in nurses' problem solving? -In experienced nurses, intuition can be a valid replacement for scientific problem solving -Intuition is an unreliable mode of thinking that should be avoided -Intuition is reliable when those nurses implementing it have a special gifting -Intuition can be a clinically useful adjunct to logical problem solving
Intuition can be a clinically useful adjunct to logical problem solving
The nursing student talks with the student's family about an AIDS client from the clinical experience. Which tort has the student committed? A. Invasion of privacy B. Fraud C. Assault D. Slander
Invasion of privacy
When the nurse informs a client's employer of his autoimmune deficiency disease, the nurse is committing the tort of: A. Breach of contract B. Assault C. Invasion of privacy D. Battery
Invasion of privacy
When the nurse reports for duty, she finds out her neighbor is admitted to one of units in her facility. The nurse asks a coworker about the neighbor's condition. The coworker is uncomfortable with the nurse's request and confers with the charge nurse. The charge nurse informs the coworker of which potential tort violation she could be charged with if she honors the nurse's request for client information? A. Invasion of privacy B. Negligence C. Assault D. Defamation of character
Invasion of privacy
Neuroanatomy of Pain
Involves both: Peripheral and Central Nervous System Peripheral nervous system Two main types of nerve fibers involved in pain transmission - Sensory/Afferent A-delta& C fibers These are known as nociceptors and carry pain signal to the central nervous system.
If a patient reports a recent breast infection, then the nurse should expect to find_______node enlargement.
Ipsilateral axillary
The nurse is performing the Denver II screening test on a 12-month-old infant during a routine well-child visit. The nurse should tell the infants parents that the Denver II:
Is a screening instrument designed to detect children who are slow in development.
The nurse is nearing the end of an interview. Which statement is appropriate at this time?
Is there anything else you would like to mention?
During an interview, a woman says, I have decided that I can no longer allow my children to live with their fathers violence, but I just cant seem to leave him. Using interpretation, the nurses best response would be:
It sounds as if you might be afraid of how your husband will respond.
A nurse obtains a blood pressure on an elderly client of 160/70 mm Hg. The nurse knows that the term for this condition is what?
Isolated systolic hypertension The elderly are prone to isolated systolic hypertension (systolic greater than 140 but diastolic under 90) due to arteriosclerosis that makes blood vessels stiff and less compliant. Orthostatic hypotension is a blood pressure that drops when a client changes positions. Stage 1 hypertension is a blood pressure reading of 140 to 159/90 to 99 mm Hg. Hypertension is not normal for any client. (less)
A nurse obtains a blood pressure on an elderly client of 160/70 mm Hg. The nurse knows that the term for this condition is what?
Isolated systolic hypertension The elderly are prone to isolated systolic hypertension (systolic greater than 140 but diastolic under 90) due to arteriosclerosis that makes blood vessels stiff and less compliant. Orthostatic hypotension is a blood pressure that drops when a client changes positions. Stage 1 hypertension is a blood pressure reading of 140 to 159/90 to 99 mm Hg. Hypertension is not normal for any client. (less)
A nurse is caring for an Appalachian client following her hysterectomy. Which of the following Appalachian values and beliefs should be considered when planning nursing care for this client? Select all that apply. -They may be fatalistic about losses and deaths -Isolation is considered as a way of life -Dependence and self-determination are valued -There is a deep love, respect, and affection between people and the land -Lifestyle is more revered than compliance with health care issues
Isolation is considered as a way of life, They may be fatalistic about losses and deaths
Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume?
Isotonic fluids have an osmolarity of 250-375 mOsm/L, which is the same osmotic pressure as that found within the cell.
A nursing student is working a 7 a.m. to 3 p.m. shift with a preceptor and is caring for three patients independently. When the preceptor asks if the student has completed charting all her assessments, the student informs the preceptor that she is going to do batch charting. The preceptor informs the student of which of the following about batch charting?
It contributes to many potential errors. Batch charting, which is waiting until the end of a shift or until all patients have been assessed to document, is not recommended. It contributes to many potential errors. Waiting to chart may also contribute to forgetting important information or charting assessment data on the wrong patient.
A client asks the nurse about the function that the lymph system plays in the body. Which of the following would be most appropriate for the nurse to include when responding to the client?
It filters harmful substances from the body. The lymphatic system's primary function is to drain excess fluid and plasma proteins, not capillary blood, from body tissues and return them to the venous system. The system contains lymph nodes that filter microorganism, foreign materials, dead blood cells, and abnormal cells and trap and destroy them. Antibodies and T lymphocytes are produced by the immune system. (less)
Because metabolism continually produces acids, maintenance of pH within these incredibly narrow limits depends on two processes: buffering and compensation. Which statement describes a function of buffering?
It helps to prevent large changes in pH by absorbing or releasing H+ ions.
The nurse is completing an initial assessment of a client who is new to the ambulatory clinic. Before assessing the client's blood pressure, a nurse asks him what his usual blood pressure is. The nurse bases this action primarily on what rationale?
It indicates the client's involvement in his health care. When a client knows his or her usual blood pressure, it shows that the client has been involved in health care through check-ups or self-monitoring. Although it may reveal information about a client's memory or ability to recall facts, the information provides the nurse with valuable information about the client's involvement in health promotion and maintenance activities. (less)
A nursing instructor is describing the nursing process to a class. Which of the following would the instructor include as a characteristic of the nursing process? -It is a framework for providing care -It is independent of other disciplines -It can be used in hospital settings -It involves general care of all clients
It is a framework for providing care
mean arterial pressure (MAP)
It is defined as the average arterial pressure during a single cardiac cycle. FORMULA MAP = SYSTOLIC BLOOD PRESSURE + (2*DIASTOLIC BLOOD PRESSURE)/3 =120+2*80/3
A female nurse is interviewing a male patient who is near the same age as the nurse. During the interview, the patient makes an overtly sexual comment. The nurses best reaction would be:
It makes me uncomfortable when you talk that way. Please stop.
A nurse documents a client's radial pulse as 2+, indicated which of the following?
It occludes with moderate pressure. The amount of pressure required to occlude the pulse is rated at a 1+ (easy to occlude) to 3+ (requires firm pressure to occlude). A radial pulse of 2+ is average (normal) and requires moderate pressure to occlude. (less)
Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation?
It provides quick access to abnormal findings. Charting by exception provides quick access to abnormal findings as it does not describe normal and routine information. When using the PIE charting method, assessments are documented on separate forms. The PIE charting method, not charting by exception, records progress under problems, intervention, and evaluation. The client's problems are given a corresponding number in the PIE charting method, which is used in the progress notes when referring to interventions and the client's responses. (less)
A nurse obtains the blood pressure in a client who is lying down. Which of the following would the nurse expect?
It will be slightly lower than standing readings. When a client lies down there is a decrease in peripheral vascular resistance, which will cause the blood pressure to be slightly lower than when the client is standing.
A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having black stools for the last 24 hours. How would the nurse best document his reason for seeking care?
J.M. is a 59-year-old man who states that he has been having black stools for the past 24 hours.
A young nurse is reviewing growth and development to improve assessment skills. When reviewing culture, the nurse remembers that various cultures consider children differently. For instance, some cultures have rites of passage that mark the transition from childhood to adulthood. Which of the following is the best example of a rite of passage:
Jewish Bar Mitzvah In some cultures, rites of passage mark the transition from childhood to adulthood. One of these is the Jewish ritual of Bar Mitzvah for boys. Catholics recognize confirmation, not first communion, as a rite of passage. Christian baptism frequently occurs at an early age and is not usually a rite of passage from childhood to adulthood. Graduation from grade school occurs at an early age and also is not considered a rite of passage by society. (less)
The U.S. government has created guidelines for health care providers caring for clients in pain. Which of the following reflect these guidelines?
Joint Commission Standards for Pain Management. Joint Commission Standards for Pain Management were revised and published in 2000-2001. The standards require health care providers and organizations to improve pain assessment and management for all patients. (less)
The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain?
Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain.
The nurse is preparing to examine a 6-year-old child. Which action is most appropriate?
Keep in mind that a child this age will have a sense of modesty.
In addition to noting the physical characteristics of the thyroid gland, which of the following signs would be most important to consider in determining if the client has hypothyroidism? A. Increased heart rate B. Increased blood pressure C. Laboratory tests D. Feeling anxious
Laboratory tests
Which term refers to a wound produced by the tearing or splitting of body tissue, usually from blunt impact over a bony surface?
Laceration
What was one barrier to the development of the nursing profession in the United States after the Civil War? -Lack of influence from nursing leaders -Hospital-based schools of nursing -Lack of educational standards -Independence of nursing orders
Lack of educational standards
A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye? A. Vitreous chamber B. Aqueous chamber C. Lacrimal apparatus D. Sinus
Lacrimal apparatus
The nurse is reviewing the development of culture. Which statement is correct regarding the development of ones culture? Culture is:
Learned through language acquisition and socialization.
A nurse obtains a client's blood pressure (BP) on admission in both arms: Right arm BP 130/75 mmHg and left arm BP 140/80 mmHg. Which arm should the nurse use for subsequent blood pressure reading?
Left arm Blood pressure should be taken in the dominant arm first. When assessing for the first time, BP should be measured in both arms. Subsequent readings should be taken in the arm with the highest measurement. (less)
A nurse performs the Trendelenburg test for a client with varicose veins. Which action should the nurse take when performing this test?
Legs should be elevated for 15 seconds When performing the Trendelenburg test, the nurse should elevate the client's leg for 15 seconds to empty the veins. The tourniquet should be put on after leg elevation. The client should stand upright with the tourniquet on the leg. The client is not asked to sit with the leg hanging down when performing the Trendelenburg test. (less)
A client informs the nurse that he wants to discontinue his treatment and go home. Later, the nurse finds the client dressed to leave. Which action should the nurse take in this situation? A. Let the client go after signing a document stating he is going against medical advice. B. Restrain the client until his medical treatment is over. C. Call the physician and get his discharge paper signed. D. Warn the client that he may not be able to access health care again.
Let the client go after signing a document stating he is going against medical advice.
The community environment affects the well-being of the individual and the family. Which of the following is the health responsibility of the family? -Facilitate health care services -Provide educational facilities -Provide recreational services -Maintain a healthy lifestyle
Maintain a healthy lifestyle
The nurse is caring for a client who perceives time differently. What action should the nurse take for this client? A. Set all interventions to be done at specific times. B. Maintain flexibility when the client requests interventions at specific times. C. Have the client set all times for the interventions. D. Perform interventions at random times during shift.
Maintain flexibility when the client requests interventions at specific times.
An Arab client has been admitted to the health care facility with varicose veins. What should the nurse avoid while conducting the interview of the client? -Giving a light handshake -Maintaining eye contact -Asking about the client's personal life -Asking about the client's medial history
Maintaining eye contact
CL- FUNCTIONS
Major component of interstitial and lymph fluid; gastric and pancreatic juices, sweat, bile, and saliva Acts with sodium to maintain the osmotic pressure Role in the body's acid-base balance; combines with hydrogen ions to produce hydrochloric acid
A student nurse is learning how to write a nursing diagnosis for a client. Which actions are accurate guidelines when formulating nursing diagnoses? Select all that apply. Include the medical diagnosis in the nursing diagnosis. Make sure the client problem precedes the etiology. Write the diagnosis in legally advisable terms. Phrase the nursing diagnosis as a client need rather than alteration. Be sure the problem statement indicates what is unhealthy about the client. Make sure defining characteristics follow the etiology.
Make sure the client problem precedes the etiology. Write the diagnosis in legally advisable terms. Be sure the problem statement indicates what is unhealthy about the client. Make sure defining characteristics follow the etiology.
When using hand gel to clean the hands, what must the nurse do before touching a client's eyes?
Make sure the hands are completely dry If using hand gel, the nurse should ensure that the hands are completely dry before touching the client's eye. The nurse does not have to rewash hands with soap and water. The nurse would not start by assessing visual acuity or color blindness. (less)
A patient is newly diagnosed with benign breast disease. The nurse recognizes which statement about benign breast disease to be true? The presence of benign breast disease:
Makes it hard to examine the breasts.
The nurse is presenting an educational event for a local civic group about the risk factors for neck cancer. What would the nurse list? (Select all that apply.) Female gender Male gender Coffee drinker Tobacco use Age older than 50 years
Male gender Tobacco use Age older than 50 years
A client has a prescription for amoxicillin (Amoxil) 500 mg P.O. (by mouth) every 8 hours. The nurse administers the medication via the intravenous route. Based on the nurse's action, the client develops a pulmonary embolus, experiences respiratory distress, and is transferred to the intensive care unit. The client's family files a lawsuit against the facility and the nurse. While reviewing the case, which legal action has the nurse attorney identified that meets the criteria for the client's lawsuit? A. Negligence B. Malpractice C. Assault D. Battery
Malpractice
While caring for an infant, the nurse hears another child screaming in the next room. She rushes to the other room to check on the screaming child, forgetting to put the side rails up on the infant's crib. She returns to the room to find the infant has fallen out of the crib and sustained a head injury. Based on the nurse's action, which tort is the nurse liable for? A. Defamation B. Malpractice C. Assault D. Battery
Malpractice
During reporting, the nurse hears that a patient is experiencing hallucinations. Which is an example of a hallucination?
Man believes that his dead wife is talking to him.
Receiving is a part of the communication process. Which receiver is most likely to misinterpret a message sent by a health care professional?
Man whose wife has just been diagnosed with lung cancer
A nurse observes that a young man's arm span appears to be greater than his height. Which condition should the nurse suspect in this client?
Marfan's syndrome Arm span is greater than height and pubis to sole measurement exceeds pubis to crown measurement in Marfan's syndrome. In gigantism, there is increased height and weight with delayed sexual development. Extreme weight loss is seen in anorexia nervosa. Central body weight gain with excessive cervical obesity (Buffalo's hump), also referred to as endogenous obesity, is seen in Cushing's syndrome. (less)
A new mother calls the clinic to report that part of her left breast is red, swollen, tender, very hot, and hard. The nurse notices that she has been breastfeeding for 1 month. From her description, what condition does the She has a fever of 38.3 C. She also has had symptoms of influenza, such as chills, sweating, and feeling tired. nurse suspect?
Mastitis
If an American Indian woman has come to the clinic to seek help with regulating her diabetes, then the nurse can expect that she:
May also be seeking the assistance of a shaman or medicine man
The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient:
May take a little longer to respond, but his general knowledge and abilities should not have declined.
The nurse is using a multidimensional pain assessment tool that combines indices measuring pain intensity, mood, pain location (via body diagram), and verbal descriptors, and which includes questions about medication efficacy. Which of these tools is a multidimensional pain assessment tool?
McGill Pain Questionnaire The MPQ was developed to measure pain in experimentally induced circumstances, following procedures, and with several medical-surgical conditions. It consists of a set of verbal descriptors used to capture the sensory aspect of pain, a VAS scale, and a present pain intensity rating made up of words and numbers. The tool has been found reliable and valid, and has been translated into several languages. (less)
Based on her knowledge of the Health Information Technology for Economic and Clinical Health Act of 2009, a nurse understands that the health care clinic that she works in could face penalties if it does not demonstrate which of the following by 2015?
Meaningful use of electronic health records Since the Health Information Technology for Economic and Clinical Health Act of 2009 was adopted, there has been a slow but steady increase in use of EHRs by health care agencies and primary health care providers. To encourage the use of EHRs, Medicare and Medicaid began to offer federal incentive payments of $2 million or more to health care providers and hospitals to use EHR technologies. In addition, penalties will be applied to providers unable to demonstrate meaningful use of EHRs by 2015. (less)
A nurse is caring for a 78-year-old male patient who has been hospitalized following a stroke. Which nursing action has the highest priority for this patient? A. Ensuring that the patient has family and friends visit him B. Helping the patient to fill out an advanced directives form C. Finding a safe environment for the patient upon discharge D. Measuring the patient's I&O during recovery
Measuring the patient's I&O during recovery
THORACIC CAVITY Contains 2 Spaces
Mediastinal Space or Cavity & 2.Pleural Space or Cavity 1. Mediastinal Space or Cavity A. contains trachea, pulmonary, lymph & great vessels, & esophagus B. extends from sternum to vertebrae C. sandwiched between right and left lung lobes 2. Pleural Space or Cavity A. contains the right & left lung B. extends from sternal & vertebral borders to the right & left chest wall C. sandwiched by the mediastinal cavity & the rib cage
ANATOMY OF THE HEART
Mediastinum Landmarks on anterior thoracic wall intercostal spaces (ICSs) sternal lines midclavicular line (MCL) base= TOP apex= BOTTOM
The nurse assesses a client who is postoperative day 1 following a total abdominal hysterectomy. Assessment data includes BP 150/88 mm Hg, HR 100/bpm, RR 22/min with a pain scale of 8 out of 1-10. The abdominal dressing in clean, dry, and intact. The client's orders indicate ambulation today. Which is the priority nursing action? A. Notify the healthcare provider of the client's condition. B. Assist the client out of bed to walk in the hall. C. Medicate the client for pain. D. Remove the abdominal dressing and assess the incision.
Medicate the client for pain.
What is the central theme of Florence Nightingale's nursing theory? -Meeting the personal needs of the client within the environment -Nursing is a therapeutic, interpersonal, and goal-oriented process -Humans are in a constant relationship with stressors in the environment -Nursing is an art
Meeting the personal needs of the client within the environment
A client presents to the emergency department with reports of neck pain and a sudden onset of a headache. Upon examination, the nurse finds that the client has an increased temperature and neck stiffness. The nurse recognizes these findings as most likely to be caused by what condition? A. Migraine headache B. Meningeal inflammation C. Trigeminal neuralgia D. Parkinson's disease
Meningeal inflammation
The nurse is taking a family history. Important diseases or problems about which the patient should be specifically asked include:
Mental illness.
The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status?
Mental status functioning is inferred through the assessment of an individuals behaviors.
When performing an assessment of the nervous system, it is most appropriate for a nurse to complete it in which sequence? A. Cranial nerves, motor/cerebellar, sensory, reflexes, mental status B. Motor/cerebellar, sensory, reflexes, cranial nerves, mental status C. Reflexes, sensory, motor/cerebellar, cranial nerves, mental status D. Mental status, cranial nerves, motor/cerebellar, sensory, reflexes
Mental status, cranial nerves, motor/cerebellar, sensory, reflexes
A client has the following arterial blood gas results: pH: 7.33 PaCO2: 42 mm Hg HCO3: 19 mEq/L PaO2: 95 mm Hg Which imbalance would the nurse suspect?
Metabolic acidosis The results reveal metabolic acidosis, which is characterized by a pH lower than 7.35 and a plasma HCO3 concentration lower than 22 mEq/L. Respiratory acidosis is indicated by a low pH accompanied by an increased arterial concentration of carbon dioxide, which often is clinically defined as a PaCO2 of greater than 45 mm Hg. Respiratory alkalosis is present when a high pH is accompanied by a blood carbon dioxide concentration lower than 35 mm Hg. Metabolic alkalosis is characterized by a pH higher than 7.45 and a plasma HCO3 concentration above 26 mEq/L.
The nurse is reviewing the client's arterial blood gas results. The test reveals a pH of 7.52, a PaO2 level of 49 mmHg and an HCO3 level of 28 mEq/L, the nurse suspects the client is most likely experiencing which condition?
Metabolic alkalosis Metabolic alkalosis occurs when there is excessive loss of body acids or with unusual intake of alkaline substances. It can also occur in conjunction with an ECF deficit or potassium deficit (known as "contraction alkalosis"). Vomiting or vigorous nasogastric suction frequently causes metabolic alkalosis. Endocrine disorders and ingestion of large amounts of antacids are other causes. The loss of stomach acid or taking in of base causes H+ shifts in the blood, and pH increases. (less)
A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing?
Metabolic alkalosis Endocrine disorders and ingestion of large amounts of antacids cause metabolic alkalosis.
A nurse is providing care to a client who has been vomiting for the past 2 days. The nurse would assess this client for which imbalance? Select all that apply.
Metabolic alkalosis • Hypokalemia Explanation: If sufficient gastric juice (ECF with additional acid) is lost from the stomach, then consequently hydrogen, sodium, and chloride ions are depleted, increasing the risk of ECF volume deficit and/or metabolic alkalosis. Gastric fluid also is high in potassium, and excessive losses may contribute to hypokalemia. Respiratory acidosis would be more likely to occur with an underlying lung disorder, such as asthma or emphysema. Vomiting leads to a loss of sodium, so elevated sodium levels would be unlikely. Imbalances of calcium are not typically associated with imbalances associated with vomiting.
MG2+ FUNCTIONS
Metabolism of carbohydrates and proteins Activator for many intracellular enzyme systems Role in neuromuscular function Acts on cardiovascular system, producing vasodilation
In Jean Piaget's formal operations stage, what does the adolescent use for the first time to allow the adolescent to "think about thinking?"
Metacognition For the first time, those in the formal operations stage can use metacognition or the ability to "think about thinking." The other words are not terms used in the area of developmental psychology. (less)
A group of students is reviewing the various levels of illness prevention. The students demonstrate understanding when they identify which of the following as a goal of tertiary prevention of illness? -Minimizing complications -Preventing disease or illness -Improving general well-being -Providing prompt treatment
Minimizing complications
The event producing the first heart sound (S1) is closure of which of the following valves?
Mitral Closure of the mitral valve produces S1.
The nurse is giving a talk to a local community group on the harms of smoking. The nurse tells the group that a risk factor is something that increases a person's chances for illness or injury. What type of risk factor is smoking? -Nonmodifiable -Modifiable -Secondary -Primary
Modifiable
A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes that:
More information should be gathered to decide whether her dress is appropriate.
Which of the following is a characteristic of nursing practiced from early civilization to the 16th century? -The physician was the priest who treated disease with prayer -Most early civilizations believed that illness had supernatural causes -The nurse was a nun committed to caring for the needy and homeless -Nursing changed from a spiritual focus to an emphasis on knowledge expansion
Most early civilizations believed that illness had supernatural causes
What task should a nurse ask a client to perform to assess the function of cranial nerve XII?
Move the tongue from side to side Asking the client to move the tongue from side to side assesses function of the hypoglossal nerve, cranial nerve XII. The function of cranial nerve XI can be assessed by asking the client to shrug the shoulders against resistance. The nurse asks the client to swallow water to assess the function of cranial nerves IX and X. Asking the client to walk in heel-to-toe fashion helps in assessment of balance. (less)
What task should a nurse ask a client to perform to assess the function of cranial nerve XII?
Move the tongue from side to side Asking the client to move the tongue from side to side assesses function of the hypoglossal nerve, cranial nerve XII. The function of cranial nerve XI can be assessed by asking the client to shrug the shoulders against resistance. The nurse asks the client to swallow water to assess the function of cranial nerves IX and X. Asking the client to walk in heel-to-toe fashion helps in assessment of balance.
A man has been admitted to the observation unit for observation after being treated for a large cut on his forehead. As the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, I quit smoking after my wife died 7 years ago. However, the nurse notices an open pack of cigarettes in his shirt pocket. Using confrontation, the nurse could say:
Mr. K., you have said that you dont smoke, but I see that you have an open pack of cigarettes in your pocket.
A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data?
Mr. Y., I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain?
A woman has just entered the emergency department after being battered by her husband. The nurse needs to get some information from her to begin treatment. What is the best choice for an opening phase of the interview with this patient?
Mrs. H., my name is Mrs. C. Ill need to ask you a few questions about what happened.
In auscultating a client's heart sounds, a nurse hears a swooshing sound over the pre cordium. The nurse recognizes this sound as which of the following?
Murmur Blood normally flows silently through the heart. There are conditions, however, that can create turbulent blood flow in which a swooshing or blowing sound may be auscultated over the pre cordium; this sound is known as a murmur. S1, the first heart sound, sounds like "lub," and S2, the second heart sound, sounds like "dubb." Ventricular gallop is a name for the third heart sound, S3, which is not a swooshing sound over the pre cordium. (less)
Mr. Jones is admitted to your unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L. For what manifestations will you be alert?
Muscle weakness, fatigue, and dysrhythmias Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Manifestations of hypercalcemia include nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech. Diminished cognitive ability and hypertension may result from hyperchloremia. Constipation is a sign of hypercalcemia. (less)
PART 2 = DIAGNOSIS
Must be supported by the clinical information found in Part 1 of the assessment. NANDA Dx labels and describes a patient problem that the nurse can professionally and legally manage. NANDA= NORTH AMERICAN NURSING DIAGNOSIS ASSOCIATION
Mr. Clyde presents at the clinic with a complaint of weakness that is made worse with repeated effort and improves with rest. Mr. Clyde's complaint is consistent with what health problem?
Myasthenia gravis Weakness made worse with repeated effort and improved with rest suggests myasthenia gravis.
A nurse is working with a client who recently suffered a heart attack. As a result, the client has experienced the death of the muscle tissues that make up the thickest layer of the heart. This layer of muscle is known as which of the following?
Myocardium The myocardium is the thickest layer of the heart and is made up of contractile cardiac muscle cells. The pericardium is a tough, inextensible, loose-fitting, fibroserous sac that attaches to the great vessels and surrounds the heart. A serous membrane lining, the parietal pericardium, secretes a small amount of pericardial fluid that allows for smooth, friction-free movement of the heart. This same type of serous membrane covers the outer surface of the heart and is known as the epicardium. The endocardium is a thin layer of endothelial tissue that forms the innermost layer of the heart and is continuous with the endothelial lining of blood vessels. (less)
PHANTOM PAIN (AMPUTATION OF AN EXTREMITY) IS A TYPE OF
NEUROPATHIC PAIN & IS TREATED WITH PAIN MEDICATIONS.
Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing?
Narrowing or partial obstruction of an airway passage The auditory characteristics of wheezing result from narrowing of the lumen of a respiratory passage. Fluid in the alveoli results in crackles, and complete obstruction causes an absence of breath sounds. Decreased lung compliance compromises ventilation but does not necessarily result in wheezes. (less)
Which of the following national nursing organizations serves as a primary source of research data about nursing education, and is the professional organization for nurse educators? -National League for Nursing (NLN) -Sigma Theta Tau International -American Association of Colleges of Nursing (AACN) -American Nurses Association (ANA)
National League for Nursing (NLN)
When patients report pain, it is important to find the source. When patients describe pain as "burning, painful numbness, or tingling," the source is more than likely:
Neuropathic Visceral pain originates from abdominal organs and is often described as crampy or gnawing. Somatic pain originates from the skin, muscles, bones, and joints. Referred pain originates from a specific site, but the patient experiencing the pain feels it at another site along the innervating spinal nerve. Neuropathic pain is described as burning, painful numbness, or tingling. (less)
A client with an amputated arm tells a nurse that sometimes he experiences throbbing pain or a burning sensation in the amputated arm. What kind of pain is the client experiencing?
Neuropathic pain The client is experiencing neuropathic pain or functional pain. Neuropathic pain is often experienced days, weeks, or even months after the source of the pain has been treated and resolved. The client is not experiencing cutaneous, visceral, or chronic pain. In cutaneous pain, the discomfort originates at the skin level. In visceral pain, the discomfort arises from internal organs caused from a disease or injury. In chronic pain the discomfort lasts longer than 6 months. (less)
A nurse performs an initial health history on a client admitted for new onset of chest pain. Which data is considered subjective for the cardiovascular system?
No current medications or treatments Subjective data is data collected from the client. No current medications or treatments is information the nurse obtained from the client. Apical heart rate 70 beats per minute, no edema of extremities noted, and apical impulse palpated at 5 intercostal space on left are examples of objective data collected by the nurse upon physical examination. (less)
A nurse is creating a concept map of the pathophysiology of pain. The nurse should identify which of the following as being responsible for transmitting pain sensations to the central nervous system?
Nociceptors The source of pain stimulates peripheral nerve endings or nociceptors, which transmit the sensations to the central nervous system. Transduction begins when a mechanical, thermal, or chemical stimulus results in tissue injury or damage, stimulating the nociceptors. Modulation inhibits the pain message and involves the body's own endogenous neurotransmitters in the course of processing the pain stimuli. Cytokines are released due to an inflammatory process resulting from the painful stimulus. (less)
A pregnant woman states, I just know labor will be so painful that I wont be able to stand it. I know it sounds awful, but I really dread going into labor. The nurse responds by stating, Oh, dont worry about labor so much. I have been through it, and although it is painful, many good medications are available to decrease the pain. Which statement is true regarding this response? The nurses reply was a:
Nontherapeutic response. By providing false reassurance, the nurse actually cut off further discussion of the womans fears.
TEMPERATURE
Normal range depends on the route used for measurement Rectal and temporal artery measurements are 0.4ºC to 0.5ºC (0.7ºF to 1ºF) higher than oral measurements Axillary temperatures average 0.5ºC (1ºF) lower than oral temperatures Diurnal cycle Electronic thermometers Documentation
NA+ SOURCES AND LOSSES
Normally enters the body through the gastrointestinal tract from dietary sources, such as salt added to processed foods, sodium preservatives added to processed foods Lost from gastrointestinal tract, kidneys, and skin
CL- REGULATION
Normally paired with sodium; excreted and conserved with sodium by the kidneys Regulated by aldosterone alongside sodium Low potassium level leads to low chloride level
Two nurses collaborate in assessing an apical-radial pulse on a patient. The pulse deficit is 16 beats/min. What does this indicate?
Not all of the heartbeats are reaching the periphery. A difference between the apical and radial pulse rates is the pulse deficit and signals that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated. (less)
A health care agency has been asked to compensate a client as per a lawsuit filed against it for not following the Health Insurance Portability and Accountability Act (HIPAA) regulations. Which of the following situations is a HIPAA violation?
Not informing a client in writing of the purpose of sharing his or her personal details. Under HIPAA regulation, health care agencies need to submit a written notice to all clients identifying the uses and disclosures of their health information, such as to third parties for use in treatment or payment for services. The physicians, auditors, and the health authorities do not have the right to share any client information without the client's written consent. (less)
The nurse palpates a client's auricles and notes an elarged lymph node on one ear. No redness is observed, and the client denies pain or tenderness. What is the nurse's best action?
Notify the healthcare provider about the finding. Lymph tissue should not be palpable on the ears. Enlarges lymph nodes indicate pathology or inflammation; and the healthcare provider should be notified. Ear drops are not indicated since the node is on the auricle, not in the canal. An audiogram is indicated for hearing loss. (less)
A client complains of a unilateral headache near the scalp line and double vision. The nurse palpates the space above the cheekbone near the scalp line on the affected side, and the client complains of tenderness on palpation. What is the nurse's next action? A. Notify the healthcare provider immediately. B. Administer intravenous pain medication. C. Palpate the carotid pulses bilaterally at the same time. D. Prepare the client for a temporal artery biopsy.
Notify the healthcare provider immediately.
A client presents to the clinic complaining of sudden visual loss in the left eye. What is the nurse's priority action? A. Assess cranial nerve function. B. Notify the healthcare provider immediately. C. Ask the client if protective eyewear was worn. D. Perform the Allen test and report the findings urgently.
Notify the healthcare provider immediately.
The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action? Notify the physician for additional orders. Document the client's level of consciousness. Consult with another nurse to validate the assessment. Decrease stimulation and allow the client to rest.
Notify the physician for additional orders.
A nurse monitoring a client's IV infusion auscultates the client's lung sounds and finds crackles in the bases of lungs that were previously clear. What would be the appropriate intervention in this situation?
Notify the primary care provider immediately for possible fluid overload. Explanation: If the client's lung sounds were previously clear, but now some crackles in the bases are auscultated, notify the primary care provider immediately. The client may be exhibiting signs of fluid overload. Be prepared to tell the health care provider what the past intake and output totals were, as well as the vital signs and pulse oximetry findings of the client
A family that consists of two homosexual parents and three children living in the same house is an example of which type of family? A. Nuclear B. Extended C. Blended D. Single-parent
Nuclear
During a busy shift, Nurse R. admitted a postsurgical patient who is obese. Nurse R. used the standard size of blood pressure cuff available on the unit, despite the fact that the patient's upper arms have a high circumference. What are the potential consequences of Nurse R.'s action?
Nurse R. may obtain a blood pressure reading that is higher than actual blood pressure. If a blood pressure cuff is too narrow, the reading could be erroneously high because the pressure is not evenly transmitted to the artery. This occurs when an average-sized cuff is used on an obese person. This mismatched cuff will not, however, make it particularly difficult to inflate the cuff and brachial occlusion is not a significant risk. (less)
A nursing student wants to take up an advanced specialty nursing role. Which of the following roles is included in advanced specialty nursing? -Nurse midwives care for women with complicated pregnancies -Nurse anesthetists are registered nurses -Nurse midwives are licensed practice nurses -Nurse anesthetists can have independent practices
Nurse anesthetists are registered nurses
Symptoms, such as pain, are often influenced by a persons cultural heritage. Which of the following is a true statement regarding pain?
Nurses need to recognize that many cultures practice silent suffering as a response to pain
Which of the following represents the basic framework of the research process? -Qualitative data -Nursing theory -Quantitative data -Nursing Process
Nursing Process
What is the best explanation for the way evidence based practice (EBP) has changed the way nursing care is delivered? -Nurses now have to take part in research -Nurses now spend time looking up the best way to give nursing care -Nursing care now incorporates research studies into client care -Nursing care now uses EBP as a means of ensuring quality care
Nursing care now uses EBP as a means of ensuring quality care
What is the central theme of Hildegard Peplau's nursing theory? -Nursing is an art -Nursing is a therapeutic, interpersonal, and goal-oriented process. -Meeting the personal needs of the client within the environment -Humans are in a constant relationship with stressors in the environment
Nursing is a therapeutic, interpersonal, and goal-oriented process.
A nurse is conducting client assessments in a long-term care facility. The manager of the facility has requested that the clinical staff use assessment forms that allow them to compare nursing data across clinical populations, settings, geographic areas, and time, so that they can compare their results with other long-term care facilities in the nation. Which form should the nurse use?
Nursing minimum data set The nursing minimum data set establishes comparability of nursing data across clinical populations, settings, geographic areas, and time. Open-ended forms, cued or checklist forms, and integrated cued checklists do not provide such comparability of nursing data. (less)
Nurses in an ICU noticed that their clients required less interventions for pain when the ICU was quiet. They then asked a researcher to design a study about the effects of noise on the pain levels of hospitalized clients. How does this demonstrate the ultimate goal of expanding the nursing body of knowledge? -Nursing research involves clients in their care while hospitalized -Nursing research helps improve ways to promote and maintain health -Nursing research explains ongoing medical studies to clients, and asks for participation. -Nursing research draws conclusions about the quality of client care
Nursing research helps improve ways to promote and maintain health
10 PAIN ASSESSMENT TOOLS PAIN ASSESSMENT TOOLS
ONE DIMENSION PAIN SCALES 1. VISUAL ANALOG SCALE- 0-10 scale 2. VERBAL DESCRIPTOR SCALE VDS 3. NUMERIC PAIN INTENSITY SCALE (NPI) 4. COMBINES THERMOMETER SCALE 5. MULTIDIMENSIONAL PAIN SCALE 6. MCGILL PAIN QUESTIONNAIRE (mpq) 7. BRIEF PAIN INVENTORY (BPI) 8. BRIEF PAIN IMPACT QUESTIONNAIRE (BPIQ) 9. WONG--BAKER FACES Pain RATING SCALE
A nurse is assessing a client for possible dehydration. Which of the following should the nurse do?
Observe for a decrease in jugular venous pressure Decrease in jugular venous pressure can occur with dehydration secondary to a decrease in total blood volume, so the nurse should observe for a decrease in jugular venous pressure. Assessing the difference in the apical and radial pulses would help the nurse assess for pulse deficit. Differences in the amplitude or rate of the carotid pulse may indicate stenosis. A split S1 occurs when the left and right ventricles contract at different times (asynchronous contraction). (less)
A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation?
Observe for the use of accessory muscles The tripod position is often assumed by the client with chronic obstructive pulmonary disease (COPD) in order to help elevate the diaphragm during inspiration. This is often accompanied by the use of accessory muscles of the neck. Crackles are present in pneumonia or fluid in the lungs. Tactile fremitus helps to assess for the presence of a consolidation such as pleural effusion or pneumonia. Diaphragmatic excursion assesses the movement of the diaphragm.
During an examination, the nurse can assess mental status by which activity?
Observing the patient and inferring health or dysfunction
When attempting to assess a client's pain, which of the following actions should the nurse perform first?
Obtain a client self-report. The nurse should always try to get a self-report, but note if unable and go on to the other items such as searching for potential causes of pain, observing client behaviors, and obtaining information from surrogates such as family members, parents, and caregivers. (less)
A comprehensive definition of family is that it is a social group with members who share common values, interact over time, and ... -Participate in religious rituals -Maintain order and safety -Evolve psychologically over time -Occupy specific positions
Occupy specific positions
The nurse performs the action shown when assessing a client's eyes. What is the nurse assessing? A. Near vision B. Distance vision C. Ocular alignment D. Color discrimination
Ocular alignment
The nurse is caring for an 85-year-old, female client hospitalized for dehydration. The nurse notices that the patient is shivering and takes the client's temperature. She notes an oral temperature of 97.8°:F (36.6°:C). The client also says that she is "chilly." What action, if taken by the nurse, is most appropriate? A. Notify the physician. B. Offer the client an extra blanket. C.Increase the client's oral fluid intake. D. Assess the client's respiratory rate.
Offer the client an extra blanket.
A nurse is providing care to a client who is on fluid restriction. Which action by the nurse would be most appropriate?
Offer the client sugar-free candy to help combat thirst. To minimize thirst for clients on fluid restriction, offer sugar-free candy and gum to help minimize thirst. Salty or very sweet fluids should be avoided. Rinsing the mouth with water and then having the client spit it out before swallowing may be helpful. Alcohol-based mouthwashes should be avoided because they have a drying effect. A water-based gel, not petroleum based, can be applied to the client's lips to moisten and prevent drying and cracking.
Risk factors for hypothermia
Older age. Older adults are more vulnerable to hypothermia for a number of reasons. ... Very young age. Children lose heat faster than adults do. ... Mental problems. ... Alcohol and drug use. ... Certain medical conditions. ... Medications.
In the hot/cold theory, illnesses are believed to be caused by hot or cold entering the body. Which of these patient conditions is most consistent with a cold condition?
Older man with gastrointestinal discomfort
The nurse is preparing to perform the Rinne test on a client. The nurse should place the tuning fork at which location first?
On the client's mastoid process For the Rinne test, the tuning fork base is place on the client's mastoid process and then it is moved to the front of the external auditory canal when the client no longer hears the sound. The tuning fork is placed in the center of the client's forehead or head for the Weber test. (less)
The nurse is preparing to perform the Rinne test on a client. The nurse would place the tuning fork at which location first?
On the mastoid process For the Rinne test, the tuning fork base is place on the client's mastoid process and then it is moved to the front of the external auditory canal when the client no longer hears the sound. The tuning fork is place in the center of the client's forehead or head for the Weber test. (less)
Where should a nurse place the hands to palpate the submandibular lymph nodes? A. On the medial border of the mandible B. At the angle of the mandible on the anterior edge C. At the posterior base of the skull bone D. A few centimeters behind the tip of the mandible
On the medial border of the mandible
PAIN
One of the most common reasons patients seek help from health care professionals Does not respect gender, age, or ethnicity Can occur at any time, to anyone Can profoundly affect 1. Quality of life 2. Interactions with family and friends 3. Sense of well-being and self-esteem 4. Financial resources
A 54-year-old man comes to the clinic with a horrible problem. He tells the nurse that he has just discovered a lump on his breast and is fearful of cancer. The nurse knows which statement about breast cancer in men is true?
One percent of all breast cancers occurs in men.
The nurse asks, I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here. This question is found at the __________ phase of the interview process.
Opening or Introduction
A client who just underwent hip replacement surgery reports pain at a 10 on a scale of 0 to 10 and receives 4 mg of morphine. A nurse on the orthopedic unit enters the client's room and finds that the client has a respiratory rate of 7 breaths/min. The client is groggy and hard to arouse. What could be contributing to the client's findings?
Opiates, which may cause hypoventilation Explanation: Opiates may reduce the ability of the brain to trigger breathing, causing hypoventilation (slow breathing). This scenario does not describe a reaction to anesthesia, and it is not a normal finding following surgery.
When performing a client's ophthalmoscopic exam, the nurse observes a round shape with distinct margins. The nurse would document this as which of the following?
Optic disc The optic disc is round to oval with sharp, well-defined borders. The physiologic cup appears on the optic disc as slightly depressed and a lighter color than the disc. Arteriole retinal vessels appear bright red, and venules appear darker red and larger, with both progressively narrowing as they move away from the optic disc. The fovea is a small area of the retina that provides acute vision. (less)
When performing an ophthalmoscopic exam, a nurse observes a round shape with distinct margins. The nurse would document this as which of the following?
Optic disc The optic disc is round to oval with sharp, well-defined borders. The physiologic cup appears on the optic disc as slightly depressed and a lighter color than the disc. Arteriole retinal vessels appear bright red, and venules appear darker red and larger, with both progressively narrowing as they move away from the optic disc. The fovea is a small area of the retina that provides acute vision. (less)
ORTHOSTATIC BLOOD PRESSURE (ORTHOSTATIC HYPOTENSION) OR POSTURAL HYPOTENSION
Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position.Sep 1, 2011
A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure?
Over the client's thigh The nurse should measure the blood pressure over the client's thigh or the popliteal artery behind the knee. It is inadvisable post-mastectomy to assess blood pressure at the normal site, which is over the brachial artery at the inner aspect of the elbow. In normal cases, the blood pressure may also be assessed at the lower arm and radial artery. (less)
DURING THE GENERAL SURVEY, WHAT DO YOU ASSESS? 9 THINGS
Overall appearance Hygiene and dress Skin color Body structure and development Behavior Facial expression Level of consciousness Speech Mobility
The Diagnosis contains PES format:
P= PROBLEM E= ETIOLOGY S=SIGNS AND SYMPTOMS
In interviewing a client about his heart rate, the nurse asks whether he has noticed any alteration to his heartbeat. The client responds that he sometimes feels his heart race even when he has not been exerting himself physically. This alteration is known as which of the following?
PALPITATION Explanation: An alteration in heartbeat felt by a client is called a palpitation and can be caused by various circumstances including thyroid dysfunction, medication reaction, or alteration in fluid volume. Dyspnea is difficulty breathing. Pulse pressure is the difference between systolic and diastolic blood pressures. Apical beats are simply the beats of the heart palpated directly over the apex of the heart, on the chest.
5. PERCEPTION
PERCEPTION of pain is the end result of the neuronal activity of pain transmission and where pain becomes a conscious multidimensional experience. The multidimensional experience of pain has affective-motivational, sensory-discriminative, emotional and behavioural components. When the painful stimuli are transmitted to the brain stem and thalamus, multiple cortical areas are activated and responses are elicited.
The nurse has measured from the tip of the client's nose to his earlobe and then down to the diploid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which of the following components of the nursing process has the nurse demonstrated? -Planning; implementing -Assessing; diagnosing -Diagnosing; implementing -Implementing; evaluation
Planning; implementing
EDEMA dema is the swelling resulting from fluid accumulation in body tissues. It is most commonly found in the lower extremities (such as feet, ankles, and legs). TWO KINDS OF EDEMA
PITTING (leaves an indentation after you press))AND NON-PITTING (no indentation left) Grade 1+ Edema: A pit of 2 mm or less; presents as slight pitting with no distortion. Pitting disappears immediately. Grade 2+ Edema: A deeper pit measuring between 2 mm and 4 mm. It will have no easily discernible distortion and the pitting will disappear in 10 - 15 seconds. Grade 3+ Edema: A noticeably deep pit measuring between 4 mm and 6 mm. The area affected will look distinctly fuller and swollen. The indentation will take as long as 1 minute before it disappears. Grade 4+ Edema: A very deep pit is seen which will last between 2 to 5 minutes before it disappears. This indentation will measure 6 - 8 mm in depth and the body part affected by the edema will look gross and distorted.
ISOTONIC FLUID REMAINS IN THE INTRAVASCULAR COMPARTMENT, WHAT IS AN EXAMPLE OF INTRAVASCULAR FLUID
PLASMA
PMI
POINT OF MAXIMAL IMPULSE (the apex beat) .. the place where the apical pulse is palpated as strongest, often in the fifth intercostal space of the thorax, just medial to the left midclavicular line.
Diuretics, commonly given to treat high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes including
POTASSIUM CALCIUM MAGNESIUM
Objective Data Collection
PREPARATION Environment: warm, comfortable and relaxing, well lit Equipment: Scale Height bar Stethoscope Thermometer Watch with 2nd hand Sphygmomanometer Pulse oximeter Tape measure (for infants
SUPINE POSITION
PT LIES FLAT ON BACK ARMS AT SIDE LEGS EXTENDED (FOR PALPATIION OF EXTERNAL ORGANS) no gi track pts, (45 degree angle for them, bcus they may aspirate, suck food particles or fluids into the lungs.airway) THE TUBE NEEDS TO STAY LOW WITH GRAVITY.
DORSAL RECUMBENT POSITION
PT LIES FLAT ON BACK WITH KNEES BENT, AND FLAT FEET (EXAMINING VAGINA, RECTUM, OR BOTH.
SIMS POSITION (SIMS=SIDE SLEEPER)
PT ON SIDE WITH TOP LEG OVER BOTTOM LEG BENT (EXAMINE THE RECTUM, AND RECTAL TEMPERATURE)
FOR PULSES NOTE.....
PULSE RATE PULSE RHYTHM PULSE DEFICITS AMPLITUDE ELASTICITY
Verbal Communication Patterns
Pace (speed of speech) Paralanguage (volume, tone, pitch) Articulation (pronunciation) Content (generational colloquialism) Foreign language or limited English
Which of the following principles should the nurse integrate into the pain assessment and pain management of pediatric patients?
Pain assessment may require multiple methods in order to ensure accurate pain data. It is often necessary to use more than one technique for pain assessment in children. Though their neurological system is indeed developing, children feel pain acutely, and it is inappropriate to withhold analgesics until they are a "last resort." It is simplistic to specify a numeric pain scale for all patients above a certain age; the assessment tool should reflect the patient's specific circumstances, abilities, and development. (less)
OBJECTIVE DATA COLLECTION OF PAIN INCLUDES
Pain has objective effects Stress response Inadequately treated pain Observable behavioral responses such as: breathing pattern; facial expressions; body language; and vocalizations
SOMATIC PAIN
Pain in the skin, muscles, bones, (BURN VICTIMS) SKIN LAYERS CUTANEOUS-->DERMIS--->EPIDERMIS (SUBCUTANEOUS TISSUES)
A nurse is working with an elderly Jewish man who is experiencing excruciating pain from a severe burn that he suffered earlier in the day. Given his cultural background, which expression of pain should the nurse most expect to find in this client?
Pain is expressed openly, with much complaining Those of a Jewish background tend to believe that pain should be expressed openly, with much complaining. Asians and Asian Americans tend to think of pain as being natural and honorable and that it should be dealt with by using mind over body and positive thinking. African Americans tend to think of pain as a challenge to be fought, as inevitable, and to be endured. Hindus tend to believe that pain must be endured as part of preparing for the next life in the cycle of reincarnation. (less)
Risk Assessment and Health Teaching
Pain is not a benign experience Acute pain that is undertreated or untreated Teaching patients Patient refusal of pain medications
PLEAURA
Pair of serous membranes lining the thorax and enveloping the lungs in humans and other mammals.
The nurse is preparing to assess a client's carotid arteries. Which of the following actions would be most appropriate?
Palpate each artery individually to compare. When assessing a client's carotid arteries, the nurse should palpate each artery individually because bilateral palpation could result in reduced cerebral blood flow. Auscultation should be done before palpation because palpation may increase or slow the heart rate, changing the strength of the carotid pulse heard. The nurse should use the bell of the stethoscope to auscultate the arteries and have the client hold the breath for a moment so breath sounds do not conceal any vascular sounds. (less)
A patient states during the interview that she noticed a new lump in the shower a few days ago. It was on her left breast near her axilla. The nurse should plan to:
Palpate the unaffected breast first.
Assessment of the pulse amplitude is accomplished by which of the following?
Palpating the flow of blood through an artery The pulse amplitude describes the quality of the pulse in terms of its fullness and reflects the strength of left ventricular contraction. It is assessed by the feel of the blood flowing through an artery. (less)
While performing an assessment of a client who sustained a chest injury, which physical examination technique should the nurse use to elicit crepitus?
Palpation The nurse should use the palpation technique to elicit crepitus. Crepitus is a crackling sensation that occurs when air passes through fluid or exudate. Auscultation, percussion, and inspection cannot elicit crepitus because it is air trapped into the tissue around the lungs. (less)
In interviewing a client about his heart rate, the nurse asks whether he has noticed any alteration to his heartbeat. The client responds that he sometimes feels his heart race even when he has not been exerting himself physically. This alteration is known as which of the following?
Palpitation An alteration in heartbeat felt by a client is called a palpitation and can be caused by various circumstances including thyroid dysfunction, medication reaction, or alteration in fluid volume. Dyspnea is difficulty breathing. Pulse pressure is the difference between systolic and diastolic blood pressures. Apical beats are simply the beats of the heart palpated directly over the apex of the heart, on the chest. (less)
A nurse observes the gait of an elderly client admitted for surgery. The client's gait is stiff with rigid movements. The nurse should ask this client questions about which disease?
Parkinson's disease A stiff, shuffling, rigid gait is seen in persons with Parkinson's disease due to the destruction of dopamine receptors in the brain that maintain balance between contraction and relaxation of the muscles. COPD clients have no problems with gait except that activity makes them short of breath. Lordosis of the spine is seen in pregnant women and occurs in the lumbar area of the spine due to the weight of the developing fetus. Multiple sclerosis causes muscle weakness, not rigidity. (less)
Upon inspection of a client with reports of a fever, the nurse notices that the client's earlobes are asymmetrical in appearance. The nurse recognizes that the most common cause for the asymmetry of the earlobes is what condition? Bell's palsy Acute pharyngitis Thyroid enlargement Parotid enlargement
Parotid enlargement
A triage nurse is working in the emergency department of a busy hospital. Four patients have recently been admitted. Patient A has an arrhythmia diagnosed as atrial fibrillation; Patient B is in chronic congestive heart failure; Patient C is assessed and found to have a probable pulmonary embolism; Patient D complains of chest pain relieved by nitroglycerin and rest. Which patient would be the nurse's highest priority?
Patient C Cardiac emergencies that necessitate rapid assessment and intervention include acute coronary syndromes, acute decompensated heart failure, hypertensive crisis, cardiac tamponade, unstable cardiac arrhythmias, cardiogenic shock, systemic or pulmonary embolism, and aortic dissection. (less)
Which of these statements represents subjective data the nurse obtained from the patient regarding the patients skin?
Patient denies any color change
Which situation is most appropriate during which the nurse performs a focused or problem-centered history?
Patient in an outpatient clinic has cold and influenza-like symptoms
A client states, "I must be in poor health because I am a senior citizen. That's what my neighbor says and she is older than I am." This statement is based on which of the following factors? -Age -Gender -Peer Influence -Illness factors
Peer Influence
The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique, if used by the new nurse, indicates that more review is needed?
Percussing once over each area
A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurses best course of action
Perform a complete mental status examination.
A nurse in the surgical daycare department has called a client in from the waiting room and is meeting the client for the first time. The nurse immediately observes that the client has a noticeably "stooped" posture. How should the nurse best follow up this abnormal assessment finding?
Perform a focused assessment of the client's musculoskeletal system If you observe abnormalities during the first meeting, you may need to perform an in-depth assessment of the body area that appears to be affected. Abnormal posture would warrant musculoskeletal assessment. Referral would be premature, and there is no pressing need to inform the anesthesiologist. The family history is unlikely to be relevant to an abnormality in posture. (less)
On a health history, a client reports no visual disturbances, last eye exam being 2 years ago, and not wearing glasses. The nurse notices that the client squints when signing the consent for treatment form and holds the paper close to the face. What should the nurse do next? A. Document the findings in the client's record B. Perform both the distant and near visual acuity tests C. Test the pupils for direct and consensual reaction to light D. Obtain a referral to the ophthalmologist for a complete eye exam
Perform both the distant and near visual acuity tests
On a health history, a client reports no visual disturbances, last eye exam two years ago, and does not wear glasses. The nurse notices that the client squints when signing the consent for treatment form and holds the paper close to the face. What should the nurse do next? A. Document the findings in the client's record B. Perform both the distant and near visual acuity tests C. Test the pupils for direct and consensual reaction to light D. Obtain a referral to the ophthalmologist for a complete eye exam
Perform both the distant and near visual acuity tests
CA2+ REGULATION
Primarily excreted by gastrointestinal tract; lesser extent by kidneys Regulated by parathyroid hormone and calcitonin High serum phosphate results in decreased serum calcium level; low serum phosphate leads to increased serum calcium
On a health history, a client reports no visual disturbances, last eye exam two years ago, and does not wear glasses. The nurse notices that the client squints when signing the consent for treatment form and holds the paper close to the face. What should the nurse do next?
Perform both the distant and near visual acuity tests The first thing the nurse should do is perform both the distant and near visual acuity exams to assess for loss of far and near vision. Testing the pupil is important to assess reaction to light. The findings must be documented in the client's record. If abnormalities are found upon assessment, the client should be referred for a complete eye examination. (less)
A client complains of pain in the calves, thighs, and buttocks whenever he climbs more than a flight of stairs. This pain, however, is quickly relieved as soon as he sits down and rests. The nurse should suspect which of the following conditions in this client?
Peripheral arterial disease Intermittent claudication is characterized by weakness, cramping, aching, fatigue, or frank pain located in the calves, thighs, or buttocks but rarely in the feet with activity. These symptoms are quickly relieved by rest but reproducible with same degree of exercise and may indicate peripheral arterial disease (PAD). Leg pain that awakens a client from sleep is often associated with advanced chronic arterial occlusive disease. A lack of pain sensation may signal neuropathy in such disorders as diabetes. Heaviness and an aching sensation aggravated by standing or sitting for long periods of time and relieved by rest are associated with venous disease. (less)
A client reports pain in the legs that begins with walking but is relieved by rest. Which condition should the nurse assess the client for?
Peripheral vascular problems The nurse should assess the client for peripheral vascular problems in both the legs. Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system. In case of an acute obstruction, the leg pain would persist even when the client stopped walking. Diabetes can cause pain as a result of diabetic neuropathy, which is unrelated to walking. Low calcium level may cause leg cramps but would not necessarily be related to walking. (less)
The nurse is comparing the concepts of religion and spirituality. Which of the following is an appropriate component of ones spirituality?
Personal effort made to find purpose and meaning in life
iv complications
Phlebitis and thrombus present as local acute tenderness, redness, warmth, and slight edema of the vein above the site. Sepsis manifests as a red and tender insertion site with fever, malaise, and other vital sign changes. Infiltration or the escape of fluid into the subcutaneous tissue manifests as swelling, pallor, coldness, or pain around the infusion site and significant decrease in the flow rate. The signs of speed shock are pounding headache, fainting, rapid pulse rate, apprehension, chills, back pains, and dyspnea.
Non-Verbal Communication Patterns
Physical Appearance and Dress Body Movement and Posture Touch Facial Expressions Eye Behavior
A nurse is a wellness center is presenting a class on integrating holistic therapies with traditional health care. The nurse talks about the trend in health care to treat each client in a manner that reconnects their total being. Which of the following would best be considered a holistic approach to health? -Emotional and sexual contact -Financial success and post-secondary education -Healthy work environment -Physical, emotional, and spiritual well-being
Physical, emotional, and spiritual well-being
When performing a pain assessment the client should be asked to provide all the following information except:
Physiological classification While the effects of pain on activities of daily living and past experiences and future expectations for treatment should be elicited from the client, he or she would not be expected to classify pain according to physiology. (less)
A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient has dysarthric speech and is lethargic. The nurses best approach regarding this examination is to
Plan to defer the rest of the mental status examination
Your community outreach class is giving a presentation on seat belts and child safety seats at the local firehouse every weekend in October. What level(s) of health promotion is this an example of? -All three levels -Secondary -Tertiary -Primary
Primary
A 47-year-old receptionist comes to the office with fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only worsened despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol level. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. Examination reveals a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated at 101 degrees Farenheit. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examination are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms?
Pneumonia Pneumonia is usually associated with dyspnea, cough, and fever. On auscultation there can be coarse or fine crackles heard over the affected lobe. Percussion over the affected area is dull, and there is often an increase in fremitus. Egophony and pectoriloquy are heard because of increased sound transmission of high-pitched components of sounds. The multiple air-filled chambers of the alveoli usually filter out these higher frequencies. (less)
A 25-year-old male patient is brought to the emergency department by ambulance after being involved in a motor vehicle accident. You find that he has decreased breath sounds over the left lung fields. What might you suspect is the cause?
Pneumothorax Breath sounds may be decreased when air flow is decreased (as in obstructive lung disease or muscular weakness) or when the transmission of sound is poor (as in pleural effusion, pneumothorax, or COPD). (less)
A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte?
Potassium Diuretics, commonly given to treat high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes including potassium, calcium, and magnesium.
The nurse is teaching parents of children, and states that children in this stage believe inanimate objects have life-like qualities. Which stage of Piaget's theory of cognitive development is the nurse describing?
Preoperational The child in Piaget's preoperational stage believes inanimate objects have life-like qualities. Piaget's concrete operation stage refers to cognitive development of school-age children. Adolescence is the beginning of formal operations. Cognitive expertise is developed in middle adults. (less)
A 66-year-old client states that he has increasing difficulty hearing high-pitched sounds. The patient's statement most likely suggests that he has what diagnosis?
Presbycusis Presbycusis, a gradual hearing loss that often begins with a loss of the ability to hear high-frequency sounds, is common after age 50. Vertigo refers to a true spinning motion. Otalgia refers to ear pain. Tinnitus refers to ringing in the ears. (less)
A nurse notices a middle-aged client in the waiting room pick up a magazine to read while she waits to be seen. She opens the magazine and then extends her arms to move it further from her eyes. Which condition does the nurse most suspect in this client? A. Exotropia B. Esotropia C. Strabismus D. Presbyopia
Presbyopia
Upon assessment of a client's pulse, a nurse notices that the amplitude of the pulse varies between beats. Which other finding should the nurse assess for in this client?
Presence of an S3 Changes in the amplitude (or strength) of a client's pulse from beat to beat is called pulsus alternans. This is usually seen in heart failure. The nurse should assess the client for the presence of an S3 and an S4, which indicate a noncompliant ventricle. Diminished heart sounds can be present in an obese client or with hypovolemia, shock, or decreased cardiac output. A pulse that changes with respirations is called a paradoxical pulse and seen in cardiac tamponade or obstructive lung disease. A split S2 does not change the amplitude of a client's pulse. (less)
When assessing a client's respirations, what is most important to include in the documentation?
Presence of dyspnea The presence of dyspnea is the most important of the choices listed to include in the documentation. Dyspnea can be an indicator of potential respiratory distress. The presence of pain and position of the client can impact the client's respiratory status, but are not the primary piece of information to include in the documentation. Assessment of pedal pulses is a component of a circulatory assessment. (less)
The nurse recognizes that a child is most likely in Piaget's preoperational stage of development when observing which activity?
Pretend play Using language and pretend play are characteristics of the preoperational stage. Seriation refers to the ability to arrange objects by quantitative dimensions, characteristic of the concrete operational stage. Formal operations also include verbal problem-solving skills. The adolescent who uses formal operations can be presented verbally with "A = B, B = C, A ? C" and substitute the "=" for the question mark without having to see the written problem. The amygdala (that part of the brain involved in processing emotional information) matures sooner than the prefrontal cortex (Santrock, 2012). This finding may partially explain why teens frequently react emotionally before weighing the consequences of such behavior and why they may do things and not realize beforehand what the consequences might be- formal operations stage. (less)
A client reports severe pain in the posterior region of the neck and difficulty turning the head to the right. What additional information should the nurse collect? A. Previous injuries to the head and neck B. Difficulty with swallowing C. Changes in sleeping habits D. Stiffness in the right shoulder
Previous injuries to the head and neck
The Heart
Primary function of Heart is to supply the body with blood to meet its metabolic demands. t pumps about 55-80 ml (1/3 cup) of blood with each beat for adults and around 25-85 ml per beat for children. An adult heart pumps about 6,000-7,500 liters (1,500-2,000 gallons) of blood daily. The average adult body contains about five quarts of blood which continually circulates throughout the body.
What level of prevention is noted when the nurse educates a group of mothers of school-age children on self breast examinations? -Tertiary prevention -Secondary prevention -Educational prevention -Primary prevention
Primary prevention
A nurse, new to the hospital, is attending orientation with the nurse educator who is discussing the use of PIE charting in the documentation of patient care. How would the nurse educator best describe PIE charting?
Problem, Interventions, and Evaluation The PIE format includes problem ( P) , interventions ( I) , and evaluation ( E) .
What is the main issue that a nurse should consider when choosing a pain assessment tool to collect objective data?
Produce accurate results each time it is used The main issues in choosing a pain assessment tool are its reliability and validity. The tool should be clear and understandable to the client and require little effort from the client and the nurse. Populations will vary in the ability to understand and interpret pain tools depending on culture and language. Pain should be described in the client's terms and is always subjective in nature. Various types of pain will b e described differently depending upon whether the pain is acute or chronic. (less)
During a family assessment, a teenage girl alludes to the fact that her grandfather used to touch her in a sexual manner. What is the nurse's primary responsibility when learning this information? A. Elicit more detail to corroborate the girl's claims. B. Make arrangements to protect the girl's future safety. C. Promptly report the allegations to authorities. D. Confirm the girl's statement with other family members.
Promptly report the allegations to authorities.
A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that including cultural information in his health assessment is important to:
Provide cultural health rights for the individual.
Which intervention performed by the nurse is most appropriate for assisting a client in meeting safety and security needs based on Maslow's Hierarchy of Needs? A. Cutting up food and opening drink containers for the client. B. Providing the mother the phone number for the Poison Control Center C. Seeking input from the client regarding their preferences for a snack. D. Assisting the client to validate their feelings regarding treatment options.
Providing the mother the phone number for the Poison Control Center
The nurse is assessing hospitalized post-operative pain and has asked the client to rate his pain, describe it, state the location and onset of when it started. What other question should the nurse include in this pain assessment?
Provoking and alleviating factors The nurse is conducting a focused pain assessment of a hospitalized client. Some burses prefer to use mnemonics to remember the elements of pain assessment. One of these is OPQRST : O: Onset P: Provocative or palliative Q: Quality R: Region and radiation S: Severity T: Timing The availiability of medication, past medications, and client's financial resources are not the most pertinent questions to include at this time. (less)
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?
Psychosocial stress has a major influence on health in many domains. Stress can have physical, emotional, social, cognitive, and/or spiritual consequences on a person. Stress does not necessarily preclude development, however, nor does it always drive the process of development. Stress influences the character and content of the health interview, but it does not necessarily "distort" the data obtained. (less)
PULMONONARY CIRCULATION
Pulmonary circulation is the portion of the cardiovascular system which carries deoxygenated blood away from the heart, to the lungs, and returns oxygenated (oxygen-rich) blood back to the heart. while pulmonary circulation, the smaller loop involves blood flow from the heart to the lungs and back again.
You are caring for an 80-year-old Hispanic woman who is 48 hours postop from the repair of a fractured hip. She has a sudden onset of dyspnea without pain. What disease process would you suspect?
Pulmonary embolism Risk factors for pulmonary embolism include postpartum or postoperative periods, prolonged bed rest, congestive heart failure, chronic lung disease, fractures of hip or leg, and deep venous thrombosis (often not clinically apparent). (less)
When testing the near reaction, an expected finding includes which of the following? A. Pupillary dilation on near gaze; dilation on distant gaze B. Pupillary dilation on near gaze; constriction on distant gaze C. Pupillary constriction on near gaze; dilation on distant gaze D. Pupillary constriction on near gaze; constriction on distant gaze
Pupillary constriction on near gaze; dilation on distant gaze
The nurse is performing a review of systems on a 76-year-old patient. Which of these statements iscorrect for this situation?
Questions that are reflective of the normal effects of aging are added.
The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client?
RENAL FAILURE ( condition where the kidneys loose the ability to remove wastes and balance fluids Excess fluid volume may result from increased fluid intake or from decreased excretion, such as occurs with progressive renal disease.
Which of the following statements best conveys the relationship between race and ethnicity? -Race and ethnicity are both culturally determined concepts -Race denotes physical characteristics while ethnicity is rooted in a common heritage -Race is based on an individual's cultural history and is independent of ethnicity -Race and ethnicity can be considered to be synonymous in the context of health care
Race denotes physical characteristics while ethnicity is rooted in a common heritage
A young adult client has just had X-rays and computed tomography scanning of the head and neck following a mountain bicycling accident. All results are negative. What should the nurse assess for next? A. Range of motion of the neck B. Headache C. Shortness of breath D. Range of motion of the arms and shoulders
Range of motion of the neck
The nurse is taking care of a female client who is scheduled for a mastectomy. The client tells the nurse that she is apprehensive about the operation and asks the nurse to read a passage from the Koran to help her prepare herself for surgery. Which action by the nurse is the most appropriate? A. Read the Koran passage to the client. B. Gently inform the client that nurses cannot practice religion with clients. C. Ask the client if she would like to call a minister to pray with her. D. Ask if someone else on staff is the same religion as the client.
Read the Koran passage to the client.
The nurse identifies the UAP recorded the client's blood pressure as 78/52. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse?
Reassess blood pressure The nurse can delegate the monitoring and documenting of specific assessments to UAPs; but the nurse always retain the responsibility to interpret delegated assessment data to evaluate the patient's condition. The nurse should retake the blood pressure immediately as it is abnormally low for this patient. Having the UAP retake the blood pressure does not allow the nurse to evaluate the client or assess the accuracy of the UAP's ability to take a blood pressure. The physician should not be notified until the blood presser has been reassessed. (less)
A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not ____ four unrelated words ____.
Recall; after a 30-minute delay
The nurse is aware the when assessing a patient's language development, it is important to include which of the following?
Receptive and productive language All human societies use language as a means to communicate. Language development consists of two parts. Receptive language is the understanding of spoken or written words. Productive language is the use of spoken or written words. Subjective and objective are terms nurses use when describing assessment data, while negative and positive are values that can be assigned to many different events. Motor and sensory are diffferent areas of a person's growth and development, not related to language
A nurse is taking a patient's temperature and wants the most accurate measurement, based on core body temperature. What site should be used?
Rectal Heat is generated by metabolic processes in the core tissues of the body, transferred to the skin surface by the circulating blood, and then dissipated to the environment. Core body temperatures may be measured at rectal or tympanic sites. (less)
A nurse is taking a rectal temperature on an unconscious patient. What reading would reflect temperature within the normal range?
Rectal temperatures are 0.4° to 0.5°C (0.7° to 1°F) higher than oral temperatures.
Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media?
Red, bulging, with an absent light reflex A client with acute otitis media would have a red, bulging eardrum, with absent light reflex. A pearly, translucent membrane, with no bulging is a normal finding in the tympanic membrane. A yellowish, bulging membrane, with bubbles is seen in serous otitis media. A gray, translucent membrane, with no retraction is a normal finding in the tympanic membrane. (less)
The results of a client's Rinne test suggest that bone conduction and air conduction are both reduced. Which of the following would be most appropriate?
Refer the client for further evaluation. Bone conduction greater than air conduction suggest a conductive hearing loss. When data suggest signs and symptoms requiring diagnosis and treatment, the client should be referred to a physician for further evaluation. Taking a swab for culture testing is irrelevant; infection does not cause this change in hearing function. Repeat testing is unlikely to yield differing results. (less)
A patient in the Emergency Department is diagnosed with a myocardial infarction (heart attack). The patient describes pain in his left arm and shoulder. What name is given to this type of pain?
Referred pain Referred pain is pain that is perceived in an area distant from the point of origin. Pain associated with a myocardial infarction is frequently referred to the neck, shoulder, or arm. (less)
The patient comes to the emergency department reporting indigestion and left arm pain. The physician orders an EKG along with drawing of cardiac enzymes. When the results are back, the patient is informed of the diagnosis of heart attack. The indigestion and arm pain are examples of which of the following?
Referred pain Referred pain originates from a specific site, but the person feels the pain at another site site along the innervated spinal nerve. An example is cardiac pain that the person experiences as arm pain and indigeston. Visceral pain originates from abdominal organs. Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues. Somatic pain originates from skin, muscles, bones, and joints. (less)
PARATHYROID GLANDS INCREASE PTH CAUSES WHAT 2 THINGS DECREASED PTH CAUSES WHAT 2 THINGS
Regulate calcium (Ca2+) and phosphate (HPO42−) balance by means of parathyroid hormone (PTH); PTH influences bone reabsorption, calcium absorption from the intestines, and calcium reabsorption from the renal tubules. Increased secretion of PTH causes: a. Elevated serum calcium concentration b. Lowered serum phosphate concentration Conversely, decreased secretion of PTH causes: a. Lowered serum calcium concentration b. Elevated serum phosphate concentration
KIDNEYS
Regulate extracellular fluid (ECF) volume and osmolality by selective retention and excretion of body fluids Regulate electrolyte levels in the ECF by selective retention of needed substances and excretion of unneeded substances Regulate pH of ECF by excretion or retention of hydrogen ions Excrete metabolic wastes (primarily acids) and toxic substances Normally filter 180 L of plasma daily in the adult, while excreting only 1.5 L of urin
K+ REGULATION
Regulated by aldosterone Eliminated by the kidneys (no effective method of conserving potassium) Additional regulation via transcellular shift between the ICF and ECF compartments
A nursing instructor is teaching students about the pain experience. The instructor informs the students that a patient experiencing pain will have a stress repsonse. The students are aware that this stress repsonse causes the following:
Release of epinephrine, cortisol, and norepinephrine The nurse must assess objective data as well as subjective data when assessing the patient for pain. Pain will induce a stress response that causes the release of epinephrine, cortisol, and norepinephrine. These hormones will have a metabolic and neuroendocrine response. Some of these effects are increased oxygen demand and consumption, as well as increased blood glucose and lactate levels and ketones. Muscle tension may also increase from the stress response. (less)
A geriatric client is observed smoking a cigarette and lowering the oxygen nasal prongs away from the nostrils. Which is the priority action of the nurse? A. Instruct the client to switch to chewing tobacco B. Remind the client to avoid smoking during oxygen therapy C. Accept the client has lung cancer and will die one way or another D. Request a prescription for a smoking cessation program for the client
Remind the client to avoid smoking during oxygen therapy
LUNGS
Remove approximately 300 mL of water daily through exhalation (insensible water loss) in the normal adult Eliminate about 13,000 mEq of hydrogen ions (H+) daily, as opposed to only 40 to 80 mEq excreted daily by the kidneys Act promptly to correct metabolic acid-base disturbances; regulate H+ concentration (pH) by controlling the level of carbon dioxide (CO2) in the extracellular fluid as follows: Metabolic alkalosis causes compensatory hypoventilation, resulting in CO2 retention (increases acidity of the extracellular fluid). Metabolic acidosis causes compensatory hyperventilation, resulting in CO2 excretion (decreases acidity of the extracellular fluid).
A nurse in the emergency department assesses a 3 year old child with a fractured femur, a hematoma on the back of his head, and multiple 1-cm round scabs and blisters on his upper back. The parents state that their child sustained the injuries by falling out of his high chair. What is the best action for the nurse to take? -Document the suspected child abuse in the child's health care record -Report the suspected child abuse to Child Protective Services -Refer the child and the family to social services for follow up -Ask the physician to question the parents about the suspected child abuse.
Report the suspected child abuse to Child Protective Services
During the admission assessment of a female client age 40 years with a suspected mandibular fracture, the client discloses to the nurse that her injury came as a result of her husband hitting her. Which action should the nurse prioritize when responding to this disclosure? A. Reporting the abuse to the appropriate authorities B. Ensuring the client's statement is confirmed by another nurse C. Performing an assessment to confirm the client's statement D. Informing the client of her right to keep this information private
Reporting the abuse to the appropriate authorities
The nurse is reviewing aspects of substance abuse in preparation for a seminar. Which of these statements illustrates the concept of tolerance to an illicit substance? The person:
Requires an increased amount of the substance to produce the same effect.
When percussing the posterior lung fields, which of the following findings is expected?
Resonance over all lung fields All lung tissue is expected to be resonant on percussion. Hyperresonance and tympany suggest a hyperinflated lung or pneumothorax. Dullness is expected in structures below the level of the diaphragm, but dullness in the bases of the lungs themselves would be considered pathological. (less)
A client is being discharged home. The discharge note that the nurse writes for this client provides information for what purpose?
Resources and strategies for managing the client at home Discharge assessment information is used to identify necessary resources and strategies for successful home management. This information is useful for social work, physical and occupational therapies, and follow-up care by the nurse and provider when returning to the outpatient setting. Discharge assessments do not provide information that is only used in internal audits; they are not summaries of the medical course of the hospitalized client, nor are they used for maintaining an accurate list of medications the client has taken. (less)
The nurse employs interpersonal skills of communication when caring for and interacting with clients. Which of the following is the best example of establishing a therapeutic nurse-client relationship? -Approach the client as part of your job, and complete nursing care quickly to promote comfort -Introduce yourself, and then accomplish nursing care actives efficiently to allow the client to rest. -Respect for the client, and engaging in open communication in getting to know the client -Recognize how your approach affects client care, and describe why you have to do things the nursing way
Respect for the client, and engaging in open communication in getting to know the client
The nurse employs interpersonal skills of communication when caring for and interacting with clients. Which of the following is the best example of establishing a therapeutic nurse-client relationship? -Respect for the client, and engaging in open communication in getting to know the client -Introduce yourself, and then accomplish nursing care activities efficiently to allow the client to rest -Approach the client as part of your job, and complete nursing care quickly to promote comfort Recognize how your approach affects client care, and describe why you have to do things the nursing way
Respect for the client, and engaging in open communication in getting to know the client
Mrs. Helms is admitted to your unit with an exacerbation of COPD. When you enter her room to do your initial assessment, you note that she is sitting on the side of the bed, leaning forward, with her arms on the bedside table. What would this indicate to you?
Respiratory distress Cardiac or respiratory distress is evidenced by clutching the chest, pallor, diaphoresis, labored breathing, wheezing, cough, shortness of breath, or the tripod position.
The patient with a cognitive impairment sometimes cannot rate pain on a scale of 0 to 10. In such a case, the nurse is aware of other cues to assess the patient's pain. Which of the following is correct?
Restlessness, guarding When a patient has a cognitive impairment, it becomes more difficult for nurses to assess pain. Nurses may use behavioral observations such as restlessness, guarding, pacing to assess pain, but these are not pain specific and may represent repsonses to other conditions. Difficult personalities, yelling, loss of appetite, and decreased urine output do not necessarily mean that the patient is in pain. Changes in vital signs with pain would be increased blood pressure and pulse, not decreases in these indicators. (less)
The nurse is taking routine vital signs toward the end of shift. A client's BP reads 204/148. The client's baseline BP has been in the 130's systolic. What should the nurse do first?
Retake the blood pressure. When encountering an abnormal value, obtain the vital sign(s) again to assess accuracy. It would be inappropriate to notify the physician immediately, give PRN blood pressure medications, or document the findings before rechecking the reading. (less)
During a breast examination on a female patient, the nurse notices that the nipple is flat, broad, and fixed. The patient states it started doing that a few months ago. This finding suggests:
Retracted nipple.
RHONCHI
Rhonchi are continuous low pitched, rattling lung sounds that often resemble snoring. Obstruction or secretions in larger airways are frequent causes of rhonchi. They can be heard in patients with chronic obstructive pulmonary disease (COPD), bronchiectasis, pneumonia, chronic bronchitis, or cystic fibrosis. RHONCHI are also called low-pitched wheezes. They are often caused by secretions in larger airways or obstructions.
BLOOD FLOW
Right Atrium Step Two - Deoxygenated Tricupid Valve Step Three - Deoxygenated Right Ventricle Step Four - Deoxygenated Pulmonary Semilunar Valve Step Five - Deoxygenated Pulmonary Artery Step Six - Deoxygenated Lungs Step Seven - becomes Oxygenated Pulmonary Vein Step Eight - Oxygenated Left Atrium Step Nine - Oxygenated Bicuspid Valve Step Ten - Oxygenated Left Ventricle Step Eleven - Oxygenated Aortic Semilunar Valve Step Twelve - Oxygenated Aorta Step Thirteen - Oxygenated To the Body Step Fourteen - body consumes oxygens blood becomes deoxygenated BL
A client's patellar reflex is normal for the right side but diminished on the left. Using the scale for grading reflexes, how should the nurse document this finding? A. Right knee +1; Left knee 0 B. Right knee +2; Left knee +1 C. Right knee +3; Left knee +2 D. Right knee +4; Left knee +3
Right knee +2; Left knee +1
The nurse is assessing an elderly client's blood pressure and finds it to be high. Which of the following characteristics should the nurse suspect to find in respect to this client's arteries?
Rigid The older client's artery may feel more rigid, hard, and bent. More rigid, arteriosclerotic arteries account for higher systolic blood pressure in older adults. Normal arteries should feel resilient, straight, and springy. (less)
The nurse is assessing an elderly client's blood pressure and finds it to be high. Which of the following characteristics should the nurse suspect to find in respect to this client's arteries?
Rigid. The older client's artery may feel more rigid, hard, and bent. More rigid, arteriosclerotic arteries account for higher systolic blood pressure in older adults. Normal arteries should feel resilient, straight, and springy. (less)
A client admitted for a surgical procedure tells the nurse, "I am very worried because I am allergic to latex. I want to make sure that everyone knows this." In order to assure the safety of the client, what nursing diagnosis would the nurse address? Anxiety related to surgical procedure Knowledge Deficit related to surgical procedure Risk for Allergy Response related to latex allergy Risk for Injury related to latex allergy
Risk for Allergy Response related to latex allergy
A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. The client states that he almost ran into a parked car yesterday because he misjudged the distance from the bumper of his own car. He works for a computer software company and has noticed he is experiencing difficulty reading the manuals that accompany the software he installs for companies. What nursing diagnosis can the nurse confirm based on this data? A. Ineffective Individual Coping B. Disturbed Self Concept C. Self-Care Deficit D. Risk for Injury
Risk for Injury
A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. The client states that he almost ran into a parked car yesterday because he misjudged the distance from the bumper of his own car. He works for a computer software company and has noticed he is experiencing difficulty reading the manuals that accompany the software he installs for companies. What nursing diagnosis can the nurse confirm based on this data?
Risk for Injury The only nursing diagnosis that can be confirmed with these data is Risk for Injury. The client is aware of the dangers of driving due to changes in his vision. There is not enough data to support the other diagnoses. (less)
A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. Client states he almost ran into a parked car yesterday because he misjudged the distance from the bumper of his own car. He works for a computer software company and has noticed he is experiencing difficulty reading the manuals that accompany the software he installs for companies. What nursing diagnosis can the nurse confirm based on this data?
Risk for Injury The only nursing diagnosis that can be confirmed with this data is Risk for Injury. The client is aware of the dangers of driving due to changes in his vision. There is not enough data to support the other diagnosis. (less)
In some cultures, "the avenue through which adolescents gain access to sacred adult practices, to knowledge, and to sexuality" is commonly referred to as what?
Rite of passage Rites of passage mark the transition from childhood to adulthood. Examples include the Jewish ritual of bar mitzvah for boys and bat mitzvah for girls, Catholic confirmation, and the Hispanic girl's quinceanera. The Bar Mitzvah is a specific rite of passage, but the question does not give information regarding the specifics of this event. In the United States, these rites do not necessarily give adolescents status as adults in the community outside their faith or ethnic communities. Graduation from high school may or may not lead to adulthood; the graduate may go on to a vocational school, college, or the world of work but may continue to live with or be economically dependent on parents for some years after. (less)
PO4- FUNCTIONS
Role in acid-base balance as a hydrogen buffer Promotes energy storage; carbohydrate, protein, and fat metabolism Bone and teeth formation Regulation of hormone and coenzyme activity Role in muscle and red blood cell function
CA2+ FUNCTIONS
Role in blood coagulation and in transmission of nerve impulses Helps regulate muscle contraction and relaxation Activates enzymes that stimulate essential chemical reactions in the body Major component of bones and teeth
An examiner is using an ophthalmoscope to examine a patients eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would indicate that the examination is being correctly performed
Rotating the lens selector dial to bring the object into focus
When describing the cardiac cycle to a group of students, the instructor correlates heart sounds with events of the cycle. Which heart sound would the instructor explain as being associated with systole?
S1 The S1 heart sound is associated with systole, while the S2, S3, and S4 heart sounds are associated with diastole.
The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication?
SBAR Verbal communication of a change in a client's condition would be most effective if the nurse used SBAR as it provides a standardized format and structure for communication. PIE, DAR and SOAP are all types of progress notes. (less)
HEATH RECORDS ARE WHAT SOURCE? WHAT KIND OF DATA DO THEY PROVIDE TO THE NURSE?
SECONDARY DATA SOURCE PROVIDE BOTH SUBJECTIVE AND OBJECTIVE DATA
ORTHOPNEA
SHORTNESS OF BREATH (DYSPNEA) THAT OCCURS WHEN LYING FLAT, WHICH CAUSES THE PERSON TO HAVE TO SLEEP PROPPED UP IN BED, OR SITTING IN A CHAIR. UNABLE TO BREATHE LYING DOWN.
HYPERTONIC SOLUTION HAS A GREATER OSMALARITY AND CAUSES CELLS TO FLUID MOVES OUT OF THE INTRACELLULAR SPACE, AND INTO THE INTRAVASCULAR COMPARTMENT, SO CELLS
SHRINK
HEARTS CONDUCTION SYSTEM... SA NODE?
SINOATRIAL NODE (SA NODE) THE PACEMAKER/ELECTRICAL IMPULSE MAKER OF THE HEART LOCATED IN THE RIGHT ATRIUM.
A patient arrives in the emergency department in diabetic ketoacidosis. What assessment finding would the nurse expect in this patient?
Sweet-smelling breath Sweet-smelling breath may indicate diabetic ketoacidosis.
When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nursing implementing?
SOAP charting The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress. Focus charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation. (less)
ELECTROLYTES IN THE Extracellular fluid (ECF)
SODIUM+ CHLORIDE- CALCIUM+ BICARBONATE-
5 EXAMPLES OF CATIONS ( SOME PEOPLE CAN'T HAVE MILK)
SODIUM+ POTASSIUM+ CALCIUM+ HYDROGEN+ MAGNESIUM+
Systolic blood pressure (SBP) & Diastolic blood pressure (DBP)Systolic blood pressure (SBP) & Diastolic blood pressure (DBP)
SYSTOLIC BLOOD PRESSURE (TOP NUMBER) MEASURES THE PRESSURE IN THE ARTERIES WHEN THE HEART BEATS/contracts. *THE MAXIMAL ARTERIAL PRESSURE DURING THE CONTRACTION OF THE LEFT VENTRICLE The blood pressure when the heart is contracting. It is specifically the maximum arterial pressure during contraction of the left ventricle of the heart. The time at which ventricular contraction occurs is called systole. In a blood pressure reading, the systolic pressure is typically the first number recorded. For example, with a blood pressure of 120/80 ("120 over 80"), the systolic pressure is 120. By "120" is meant 120 mm Hg (millimeters of mercury).
The nurse performs and assessment of the client and the family to have a better understanding of client and family needs. Which of the following is an individual need? -Socialization -Education -Safety -Political
Safety
The nurse is conducting a home assessment and suggests that the client's family remove scatter rugs from the home and increase the lighting. Which basic human need is being addresses by the nurse's suggestions? -Physiologic -Self-actualization -Safety and securing -Self-esteem
Safety and securing
The nurse provides the mother of a toddler with the phone number for the Poison Control Center. Which level of Maslow's hierarchy of needs is the nurse addressing? -Loving and belonging needs -Safety and security needs -Self-actualization needs -Physiologic needs
Safety and security needs
The nurse is determining a site for an IV infusion. What guideline should the nurse consider?
Scalp veins should be selected for infants because of their accessibility. Potential sites for neonates and children include: veins of the scalp (neonates under 6 months) because of the accessibility, and dorsal veins of the foot (toddlers). The antecubital veins are not a good choice for infusion because flexion of the client's arm can displace the IV catheter. The veins in the leg of an adult should not be used, unless other sites are inaccessible, because of the danger of stagnation of peripheral circulation and possible serious complications, such as deep vein thrombosis. Veins in surgical areas are not recommended and would not increase the potency of medication. (less)
A woman over the age of 40 years has an annual mammogram. What level of prevention does this represent? -Tertiary prevention -Medical prevention -Secondary prevention -Primary prevention
Secondary prevention
Following the identification of a researchable problem, what must the nurse do? -Evaluate the number of ways to collect data -Determine a source appropriate to collect data -Obtain a list of possible outcomes -Select literature relevant to the problem
Select literature relevant to the problem
The community health nurse working at the local church is developing a program to address the issue of diabetic management. The nurse recognizes what church activity could adversely affect the health of the diabetic parishioners? A. Serving doughnuts, fruit juice, and coffee after church services on Sunday B. Eating at the pot luck dinner for the returning veterans C. Staffing a daycare center for the working mothers of the church D. Volunteering to construct a new playground for the children
Serving doughnuts, fruit juice, and coffee after church services on Sunday
A client from a severe motor vehicle accident arrives in the emergency department. The nurse observes irregular respirations of varying depth and rate followed by periods of apnea. Which of the following would the nurse suspect?
Severe brain damage The respiratory pattern observed is Biot's respirations, which may be seen with meningitis or severe brain damage. Diabetic ketoacidosis would reveal Kussmaul's respirations, which are characterized by an increased rate and depth. Renal failure would reveal Cheyne-Stokes respirations characterized by a regular pattern of alternating deep and rapid breathing with periods of apnea. A narcotic overdose would reveal hypoventilation or possibly Cheyne-Stokes respirations. (less)
A nurse is assessing a 24-year-old client in terms of her psychosocial development, following Erikson's approach. Which of the following would the nurse most likely identify as an abnormal finding in this client?
Sexual promiscuity Although this stage focuses on the desire for a special and permanent love relationship, it also includes the ability to have close, caring relationships with friends of both genders and a variety of ages. Having established an identity apart from the childhood family, the young adult is now able to form adult friendships with parents and siblings. However, the young adult will always be a son or daughter. If the young adult cannot express emotion and trust enough to open up to others, social and emotional isolation may occur. Loneliness may cause the young adult to turn to addictive behaviors such as alcoholism, drug abuse, or sexual promiscuity. (less)
A group of students is reviewing information about pain transmission and the fibers involved. The students demonstrate understanding when they state that A-delta primary afferent fibers transmit pain that is felt as which of the following?
Sharp A-delta primary afferent fibers transmit fast pain to the spinal cord that is felt as a pricking, sharp, or electric-quality sensation. C-fibers transmit slow pain felt as burning, throbbing, or aching. (less) The nurse is using the Verbal Descriptor Scale to assess a client's pain. The nurse will prioritize which of the following data?
A woman has just learned that she is pregnant. What are some things the nurse should teach her about her breasts?
She can expect her areolae to become larger and darker in color.
A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true?
She can see at 20 feet what a normal person could see at 100 feet. The denominator of an acuity score represents the line on the chart the client can read. In the example above, the client could read the larger letters corresponding with what a normal person could see at 100 feet. (less)
A female American Indian has come to the clinic for follow-up diabetic teaching. During the interview, the nurse notices that she never makes eye contact and speaks mostly to the floor. Which statement is true regarding this situation
She is showing that she is carefully listening to what the nurse is saying.
While completing the cardiovascular system health history, a client reports difficulty falling asleep unless she is in an upright position. Which of the following potential problems should the nurse further investigate?
Shortness of breath Shortness of breath, also called orthopnea, is dyspnea that occurs while the client is lying flat and improves when the client sits up. The client would not experience relief from chest pain, palpitations or edema by sitting upright. For this reason, these options are incorrect. (less)
The nursing student is studying Erikson's eight stages and understands that generativity is related to which of the following?
Showing a concern for establishing and guiding the next generation Generativity vs. stagnation occurs during the middle-adult ages and includes productivity and creativity. Generativity is primarily the concern with establishing and guiding the next generation. Coming to terms with one's life choices is done during the integrity vs. despair stage of late adulthood. During this time, older adults express feelings that time is short. Separating oneself from others to prevent commitment is during the early adult stage of intimacy vs. isolation, and this occurs when a person is unsuccesssful in establishng intimacy. (less)
What task should a nurse ask a client to perform to assess the function of cranial nerve XI?
Shrug shoulders against resistance The function of cranial nerve XI can be assessed by asking the client to shrug his or her shoulders against resistance. Asking the client to move the tongue from side to side assesses function of the hypoglossal nerve, Cranial nerve XII. The nurse asks the client to swallow water to assess the function of cranial nerves IX and X. Asking the client to walk in heel-to-toe fashion helps in assessment of balance.
In which position should the nurse place the toddler when examining the ear?
Sitting on the parent's lap with parent steadying the head The toddler should sit on the parent's lap with the parent steadying the head. Preschoolers often need to be held down on the examination table in a supine position with the head turned toward the parent. Older children can sit on the examination table. (less)
A student in the vascular surgery clinic is asked to perform a physical examination on a client with known peripheral vascular disease in the legs. Which of the following aspects are most important to note?
Size, symmetry, and skin colour Size, symmetry, and skin colour are important aspects to note in physical examination. Swelling in the legs, cyanosis, and lack of appropriate hair growth are all signs of peripheral vascular disease. (less)
Which of the following occurs in respiratory distress?
Skin between the ribs moves inward with inspiration. This description is consistent with retractions, which occur with respiratory distress. Other features include speaking in short sentences, use of accessory muscles, leaning forward to gain mechanical advantage for the diaphragm, and pursed lip breathing in which the client exhales against the lips, which are pressed together.
The nurse is presenting an educational event for gardeners. When discussing the ears, what would be an important topic to cover?
Skin cancer prevention Many melanomas develop near or on the helix of the ear. Teaching clients how to protect themselves from unnecessary sun exposure increases the likelihood of preventative behaviors. Otalgia is an earache. Tinnitus is ringing in the ears. Sound control would be related to environmental loud noises. None of the three would be a topic for gardeners. (less)
A nurse, while off-duty, tells the physiotherapist that a client who was admitted to the nursing unit contracted AIDS due to exposure to sex workers at the age of 18. The client discovers that the nurse has revealed the information to the physiotherapist. With what legal action could the nurse be charged? A. Libel B. Slander C. Negligence D. Malpractice
Slander
Lymphedema
Swelling in an arm or leg caused by a lymphatic system blockage. pregnant women are more at risk due to the pressure of the fetus on the blood vessels and veracose veins.
Which of these clinical manifestations are physiologic responses to pain? Select all that apply.
Sleeplessness • Perspiration • Increased heart rate Sleeplessness, perspiration, and increased heart rate are physiologic responses to pain. Pain elicits a stress response in the human body triggering the sympathetic nervous system. Decreased, not increased, intestinal motility and insulin are physiologic responses to pain.
The nurse is performing a breast examination. Which of these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? Have the woman:
Slowly lift her arms above her head, and note any retraction or lag in movement.
The nurse is observing a client's posture and facial expression for evidence of pain. Which of the following would most likely lead the nurse to suspect that the client may be experiencing pain?
Slumped posture A slumped posture indicates that the client is disturbed or uncomfortable, suggesting pain. Attentive listening and eye contact are normal findings suggesting no pain. Excessive changes in position would suggest possible pain. (less)
FACTORS THAT INFLUENCE BLOOD PRESSURE
Smoking Being overweight or obese Lack of physical activity Too much salt in the diet Too much alcohol consumption (more than 1 to 2 drinks per day) Stress Older age Genetics Family history of high blood pressure Chronic kidney disease Adrenal and thyroid disorders Sleep apnea
A 52-year-old man is skeptical about the potentially harmful effect of his smoking on his heart, citing the fact that both his father and grandfather lived long lives despite being lifelong smokers. Which of the following facts would underlie the explanation that the nurse provides the client?
Smoking increases the heart's workload and contributes to atherosclerosis. Smoking increases cardiac workload and contributes to hypertension, plaque build-up, and blood clots. It does not directly affect contractility or cardiac conduction, and it is not a component of metabolic syndrome. (less)
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?
Social isolation The central task of young adulthood in Erikson's framework is intimacy versus isolation. Failure to achieve this task results in isolation. The other listed diagnoses may or may not accompany this developmental deficit. (less)
During the nursing assessment, the client shares that the family attends church nearly every Sunday. Which function of the family does this represent? -Economic -Socialization -Physical -Reproductive
Socialization
The nurse is assessing the communication style of the client. Communication is an example of which dimension of the individual? A. Physical dimension B. Environmental dimension C. Sociocultural dimension D.Emotional dimension
Sociocultural dimension
A nurse is teaching a client about his newly prescribed diuretic and how it affects his fluid and electrolyte balance. In addition to water, the nurse would explain that the drug also affects which electrolyte? Select all that apply.
Sodium Chloride Potassium Magnesium Diuretics are prescribed to increase the excretion of sodium, chloride, and water in clients with high blood pressure or with chronic heart, renal, or liver problems. At times, the medications may remove too much ECF from the body, resulting in a deficit. Diuretics, except for the potassium-sparing diuretics, also promote the excretion of potassium and magnesium from the body, increasing the risk of electrolyte deficits as well. Imbalances of calcium and phosphate are usually not associated with diuretic therapy.
What does SpO2 mean? What is a normal SpO2 level? SaO2 can be measured either by ABG analysis or by pulse oximetry. SaO2 refers to the amount of oxygen bound to hemoglobin in arterial blood. SpO2 simply means that the SaO2 was measured using pulse oximetry.
SpO2 stands for peripheral capillary oxygen saturation, an estimate of the amount of oxygen in the blood. More specifically, it is the percentage of oxygenated haemoglobin (haemoglobin containing oxygen) compared to the total amount of haemoglobin in the blood (oxygenated and non-oxygenated haemoglobin). SpO2 is an estimate of arterial oxygen saturation, or SaO2, which refers to the amount of oxygenated haemoglobin in the blood. Haemoglobin is a protein that carries oxygen in the blood. It is found inside red blood cells and gives them their red colour. SpO2 can be measured by pulse oximetry, an indirect, non-invasive method (meaning it does not involve the introduction of instruments into the body). It works by emitting and then absorbing a light wave passing through blood vessels (or capillaries) in the fingertip. A variation of the light wave passing through the finger will give the value of the SpO2 measurement because the degree of oxygen saturation causes variations in the blood's colour. This value is represented by a percentage. If your Withings Pulse Ox™ says 98%, this means that each red blood cell is made up of 98% oxygenated and 2% non-oxygenated haemoglobin. Normal SpO2 values vary between 95 and 100%.
A nurse measures a client's blood pressure at 174/102 mm Hg. The nurse recognizes this as what classification of blood pressure measurement according to the JNC VII guidelines?
Stage 2 Hypertension The client's blood pressure falls between the ranges of 160 to 179 systolic or 100 to 109 diastolic. Therefore, the blood pressure of the client can be classified as Stage 2 Hypertension. Normal blood pressure measurement should be less than 130 systolic and less than 85 diastolic. Stage 1 Hypertension measurement should be between 140 to159 systolic and 90 to 99 diastolic. Stage 3 Hypertension measurements should be greater than or equal to180 systolic and greater than or equal to 110 diastolic. (less)
A client who has been admitted to the hospital for the treatment of a gastrointestinal bleed requires a transfusion of packed red blood cells. Which of the following aspects of the nurse's execution of this order demonstrates technical skill? -Ensuring that informed consent has been obtained and properly filed in the client's chart -Explaining the process that will be involved in preparing and administering the transfusion -Starting a new, large-gauge intravenous site on the client, and priming the infusion tubing -Understanding the Rh system that underlies the client's blood type
Starting a new, large-gauge intravenous site on the client, and priming the infusion tubing
PITUITARY GLAND LIST FUNCTIONS OF ADH HORMONE
Stores and releases the antidiuretic hormone (ADH) (manufactured in the hypothalamus), which acts to allow the body to retain water. It acts chiefly to regulate sodium and water intake and excretion. Functions of ADH include: Maintains osmotic pressure of the cells by controlling renal water retention or excretion a. When osmotic pressure of the ECF is greater than that of the cells (as in hypernatremia—excess sodium—or hyperglycemia), ADH secretion is increased, causing renal retention of water. b. When osmotic pressure of the ECF is less than that of the cells (as in hyponatremia), ADH secretion is decreased, causing renal excretion of water. Controls blood volume (less influential than aldosterone) a. When blood volume is decreased, an increased secretion of ADH results in water conservation. b. When blood volume is increased, a decreased secretion of ADH results in water loss.
A nurse instructor is observing a nursing student assess a client's capillary refill. Which action by the student indicates the proper technique?
Student compresses the client's nail bed until it blanches. Capillary refill is assessed by compressing the nail bed until it blanches and then releasing the pressure, noting the time it takes for the color to return. Gentle compression of the wrist area on the thumb side is appropriate when taking a radial pulse. Applying firm pressure to note indentation tests for pitting edema. Having the client turn his or her hands over and back allows for inspection of hand color. (less)
A 12-year-old presents to the clinic with his father for evaluation of a painful lump in the left eye. It started this morning. The client denies any trauma or injury. There is no visual disturbance. Upon physical examination, there is a red raised area at the margin of the eyelid that is tender to palpation; no tearing occurs with palpation of the lesion. Based on this description, what is the most likely diagnosis?
Stye A hordeolum or stye is a painful, tender, erythematous infection in a gland at the margin of the eyelid.
PART 1= ASSESMENT (DATA COLLECTION)
Subjective Data: Non-measurable, it is what the patient states Objective Data: Measurable, it is what you find performing inspection, palpation, percussion and auscultation
A nurse has documented the nursing history and physical examination of a client. This health information is best described as which of the following?
Subjective data and objective data The nursing history and physical examination are also known as subjective and objective data. The nurse interprets this information and draws inferences from it. Observation and inspection are techniques used to perform the physical exam. Data are the information obtained from assessment; the results would be similar to the outcomes achieved by a client. (less)
The results of a client's ECG and D-dimer levels suggest a pulmonary embolism. Which of the following history and examination findings would the nurse expect in light of this diagnosis?
Sudden onset of dyspnea The arterial occlusion that results in pulmonary embolism normally manifests as a sudden onset of dyspnea, which deep breathing is unlikely to relieve, because part of the pulmonary arterial tree is occluded. A history of heart failure is not a notable risk factor. Absent breath sounds, not crackles, are an expected finding on auscultation. (less)
A client explains that she has been feeling stress at work lately because her boss has been asking her to perform accounting measures that went against her conscience. According to Freud, which component of the personality is associated with the conscience?
Superego Freud's theory includes three basic structures in the anatomy of the personality: the id, ego, and superego. The id is completely unconscious and is an inherited system. Containing the basic motivational drives for such entities as air, water, warmth, and sex, it seeks instant gratification and supplies the psychic energy for the ego and the superego. The ego emerges to initially act as an intermediary between the id and the external world, or reality. It includes many processes such as learning, perceptions, memory, problem solving and decision making. The superego, often referred to as the moral component of personality (or in lay terms, one's "conscience"), provides feedback to the person regarding how closely the person's behavior conforms to the external value system. There is no "super id." (less)
A client is in a persistent vegetative state. The client has no immediate family and is a ward of the state. Under these circumstances, who will speak on this client's behalf? A. Surrogate decision maker B. Church-appointed guardian C. A significant other D. Her best friend
Surrogate decision maker
A nurse is working with a client who is victim of a gun shooting. The client has an increased pulse rate and pupil dilation and is clearly in stress. The nurse recognizes the "fight-or-flight" response in this client and understands that this represents an activation of which of the following?
Sympathetic nervous system The sympathetic nervous system ("fight-or-flight" system) is activated during stress and elicits responses such as decreased gastric secretions, bronchiole dilatation, increased pulse rate, and pupil dilatation. The parasympathetic nervous system functions to restore and maintain normal body functions, for example, by decreasing heart rate. The somatic nervous system mediates conscious, or voluntary, activities, whereas the autonomic nervous system (comprising the sympathetic and parasympathetic systems) mediates unconscious, or involuntary, activities. The central nervous system (CNS) encompasses the brain and spinal cord, which are covered by meninges, three layers of connective tissue that protect and nourish the CNS.
During an examination of a 3-year-old child, the nurse will need to take her blood pressure. What might the nurse do to try to gain the childs full cooperation?
Tell the child that by using the blood pressure cuff, we can see how strong her muscles are.
Normal vital signs for teens
Temperature 96.4-99.5 Pulse 55-105 Respirations 12-22 Blood-pressure 112/64
The nurse is teaching a client with diabetes, who is frequently admitted to the hospital due to elevated blood sugars, how to better control the blood sugar level and recognize the symptoms associated with both hyperglycemia and hypoglycemia. This teaching is an example of which of the following levels of health promotion? -Tertiary -Primary -Secondary -Chronic
Tertiary
Which of the following assessments is most likely to provide insight into the function of the client's CN VIII?
Test the client's hearing for lateralization and bone and air conduction. CN VIII is the acoustic nerve; function is thus tested by assessing the client's hearing. Shoulder shrugging tests CN XI; frowning and closing the eyes depend on CN VII. CN I is tested by assessing the client's ability to identify smells. (less)
Which of the following assessments is most likely to provide insight into the function of the client's CN VIII?
Test the client's hearing for lateralization and bone and air conduction. CN VIII is the acoustic nerve; function is thus tested by assessing the client's hearing. Shoulder shrugging tests CN XI; frowning and closing the eyes depend on CN VII. CN I is tested by assessing the client's ability to identify smells.
The nurse is conducting a class on BSE. Which of these statements indicates the proper BSE technique?
The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period
The younger nurses who seem to adapt easily to the new technology presented are perceived as threatening by two nurses who have worked on the unit for years. The older nurses begin to ridicule the younger nurses, saying, "You might be able to work a computer, but we know how to provide real care." How should the charge nurse respond? A. The charge nurse should discuss the concept of cultural conflict and help both parties see their respective value to the unit. B. The charge nurse should demonstrate cultural blindness and pretend that the issue does not exist. C. The charge nurse should understand that this is stereotyping in the form of racism and intervene immediately. D. The charge nurse should recognize that this is cultural imposition and the younger nurses are forcing new technology on the older nurses.
The charge nurse should discuss the concept of cultural conflict and help both parties see their respective value to the unit.
As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test? A. Client's consensual pupil constricts in response to indirect light B. Eyes converge on an object as it is moved towards the nose C. Direct light shown into the client's pupils results in constriction D. The client and the examiner see the examiner's finger at the same time
The client and the examiner see the examiner's finger at the same time
As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test?
The client and the examiner see the examiner's finger at the same time The observation that the client and examiner see the examiner's finger at the same time indicates normal peripheral vision. The client not seeing the examiner's finger and a delay in seeing indicates reduced peripheral vision. Client's consensual pupils constrict in response to indirect light as well as direct light shown into the client's pupils resulting in constriction is observed when testing the pupils for reaction to light. Eyes converge on an object as it is moved towards the nose tests for accommodation. (less)
As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test? A. Client's consensual pupil constricts in response to indirect light. B. Eyes converge on an object as it is moved towards the nose. C. Direct light shown into the client's pupils results in constriction. D. The client and the examiner see the examiner's finger at the same time.
The client and the examiner see the examiner's finger at the same time.
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?
The client describes herself as lonely and isolated. According to Erikson, the young adult should have achieved self-efficacy during adolescence and is now ready to open up and become intimate with others. Loneliness and isolation suggest a failure to achieve this task. Erikson did not emphasize employment, psychiatric illness, or childbearing as central focuses of young adult development. (less)
The thoracic cavity contains WHAT ORGANS
Thoracic cavity: The chest; contains trachea, bronchi, lungs, esophagus, heart and great blood vessels, thymus gland, lymph nodes, and nerves. Contains smaller cavities, too: Pleural cavities surround each lung. Pericardial cavity contains the heart.
A new client comes to the primary care clinic and asks for help treating head lice. The nurse assesses that the client lives in low-income housing, and nine other people live with the client in a one-bedroom apartment. Which consideration is the priority nursing concern? A. The client does not have running water. B. The client has no hope for the future. C. The client receives government assistance. D. The client does not have air-conditioning.
The client does not have running water.
A nurse is interviewing a 15-year-old girl who is morbidly obese. The client explains that she eats because it brings her comfort. According to Freud, which of the following would explain this client's eating habits?
The client has an oral fixation. Freud proclaimed that people who overeat are orally fixated and that those who deny themselves food are using oral zone control. Behavior being guided by punishment and reward is characteristic of the preconventional level of Kohlberg. Establishing identity versus role confusion is the primary task of adolescence, according to Erikson. Piaget stated that during the attainment of concrete operations, a person develops the ability to conserve (realize that certain properties still exist in spite of transformations) weight. (less)
The nurse receives an 8-year-old girl in the pediatric unit following a tonsillectomy. Which assessment finding requires immediate intervention by the nurse? A. The client makes a rattling noise when she breathes through her mouth. B. The client is sleepy from the anesthesia, but arouses to her name. C. The client tells the nurse that her throat hurts. D. The client cries to the nurse that she wants to go home.
The client makes a rattling noise when she breathes through her mouth.
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?
The client makes decisions without considering the impact on others. Within Kohlberg's framework, the young adult who continues to make decisions and behave for sole satisfaction has not attained the conventional level of development. Kohlberg emphasizes moral behavior, and this is a more central focus than trust, being manipulated, or having difficulty with decision making. (less)
In addressing health promotion for a client who is a member of another culture, the nurse should be guided by which of the following principles? -The nurse should avoid performing health promotion education if this is not a priority in the client's culture -The client may have a very different understanding of health promotion -Health promotion is a concept that is largely exclusive to American culture -A culture's conceptualization of health promotion is a result of that culture's level of socioeconomic development
The client may have a very different understanding of health promotion
In addressing health promotion for a client who is a member of another culture, the nurse should be guided by which principle? A. The client may have a very different understanding of health promotion. B. Health promotion is a concept that is largely exclusive to Western cultures. C. A culture's conceptualization of health promotion is a result of that culture's level of socioeconomic development. D. The nurse should avoid performing health promotion education if this is not a priority in the client's culture.
The client may have a very different understanding of health promotion.
A client diagnosed with advanced lung cancer has a nursing diagnosis of Ineffective Coping. What assessment data would provide evidence to the nurse for this diagnosis? The client asks about hospice services. The client makes funeral plans. The client states, "I am sure the doctors have misdiagnosed me." The client states, "I hope that I am able to attend my daughter's wedding."
The client states, "I am sure the doctors have misdiagnosed me."
The nurse has identified a nursing diagnosis of "Risk for Impaired Parenting" for a client who has recently learned of her pregnancy. What assessment data would be appropriate to lead the nurse to select this diagnosis? The client states, "I am shocked to find out that I am pregnant." The client states, "I do not plan to tell my family about my pregnancy right away." The client states, "I do not know how to take care of a baby." The client states, "I know that I will have to make some changes in my life."
The client states, "I do not know how to take care of a baby."
A nurse convinces a client who is a Jehovah's Witness that receiving blood products is more important than the legalistic components of religion. What client reaction may be expected following this mandated change? A. The client states, "I feel like I abandoned my religion." B. The client states, "I am glad that nurse told me what to do." C. The client states, "I can't get over my feelings of legalism as a Jehovah's Witness." D. The client states, "Why isn't blood administration forced on all who need that treatment?"
The client states, "I feel like I abandoned my religion."
A client has sustained a brain stem injury and is being treated in the intensive care unit. Which of the following would the nurse need to consider when assessing this client's respiratory status?
The client will have a loss of involuntary respiratory control. The brain stem contains the medulla and the pons, which control involuntary respiratory effort. The negative response to stimuli is unrelated to the client's respiratory function. Cheyne-Stokes respirations are an abnormal pattern of rhythmic breathing. The client's breathing will not be characterized by increased effort. (less)
A Hispanic woman is seeking care at the local clinic. The nurse is completing a cultural assessment. Which would demonstrate cultural assimilation? A. The client speaks only Spanish and requires a translator. B. The client's daughter, who is with her, learned the dominant lanuguage as her second language. C. The client and her daughter cook traditional Hispanic foods for the family. D. The client enjoys watching television from the home country in Spanish.
The client's daughter, who is with her, learned the dominant lanuguage as her second language.
The nurse is using the Verbal Descriptor Scale to assess a client's pain. The nurse will prioritize which of the following data?
The client's explanation of how her pain feels The Verbal Descriptor Scale rates pain from no pain up to the worst possible pain with mild, moderate, severe, and very severe in between the two endpoints. The Faces Pain Scale uses facial expressions to rate pain. A numeric pain intensity scale rates pain using a 0 to 10 number scale. A visual analog scale rates pain along a 10 cm line from no pain to pain as bad as it could possibly be. (less)
The nurse is applying the blood pressure cuff on a client's arm. Which action would be most appropriate?
The cuff is placed about 1 inch above the antecubital area. Placed so that the midline of the bladder is over the arterial pulsation, the cuff is wrapped smoothing and snugly around the upper arm 1 inch above the anticubital space, so that there is enough room to place the bell of the stethoscope. The bladder cuff should encircle 80% of the arm circumference in adults. (less)
Diaphragm vs. Bell
The diaphragm is best for higher pitched sounds, like breath sounds and normal heart sounds. The bell is best for detecting lower pitch sounds, like some heart murmurs, and some bowel sounds. It is used for the detection of bruits, and for heart sounds (for a cardiac exam, you should listen with the diaphragm, and repeat with the bell). If you use the bell, hold it to the patient's skin gently for the lowest sounds, and more firmly for the higher ones.
When making client rounds, the charge nurse observes which action by a staff nurse that would constitute battery? A. The elderly client refuses the intramuscular injection, but the staff nurse administered it. B. The staff nurse threatens to restrain the client if she did not take her medication. C. While bathing a client behind pulled curtains, two nurses are discussing a different client. D. The nurse tells the client she cannot leave the hospital because she is seriously ill.
The elderly client refuses the intramuscular injection, but the staff nurse administered it.
The nurse is conducting a family assessment of a traditional family. Which assessment data cue describes the socioeconomic status of the family? -The family members vacation together every year at a beach resort -The father is an engineer and the mother is an elementary school teacher -The family consults their rabbi and synagogue members during times of stress -The family celebrates Hanukkah and Passover with special meals
The father is an engineer and the mother is an elementary school teacher
The nurse is assessing a new patient's blood pressure using a manual sphygmomanometer. Which of the following sounds constitutes the patient's systolic blood pressure?
The first appearance of faint but distinctive tapping sounds Explanation: The systolic blood pressure reading occurs during phase I, which is characterized by the appearance of faint but clear tapping sounds that gradually increase in intensity.
1. TRANSDUCTION
The first phase, transduction, begins when a painful or noxious stimulus causes tissue damage. The damaged cells release substances that lead to the generation of an action potential. Prostaglandins, bradykinin, serotonin, substance P, and histamine are some of the substances released in response to tissue damage.
A 14-year-old girl is anxious about not having reached menarche. When taking the health history, the nurse should ascertain which of the following? The age that:
The girl began to develop breasts.
THERE ARE FOUR CHAMBERS OF THE HEART
The heart has four chambers: two atria and two ventricles. 1. The right atrium receives oxygen-poor blood from the body and pumps it to the right ventricle. 2.The right ventricle pumps the oxygen-poor blood to the lungs. 3. The left atrium receives oxygen-rich blood from the lungs and pumps it to the left ventricle. 4. The left ventricle pumps the oxygen-rich blood to the body.
The nurse is using the danger assessment (DA) tool to evaluate the risk of homicide. Which of these statements best describes its use
The higher the number of yes answers, the more serious the danger of the womans situation.
The nurse is caring for a client who speaks a differnt language than herself and is using an interpreter to communicate. What would be the best way to choose an interpreter for this client? A. The interpreter should speak in a loud voice. B. The interpreter should conduct the conversation quickly to avoid misinterpretation. C. The interpreter should understand the health care system. D. The interpreter should always make direct eye contact.
The interpreter should understand the health care system.
A laboratory assistant who is trying to view the electronic record of a client's personal history gets an error message, "You are not authorized to view this information." What is the reason for this message?
The laboratory assistant can only retrieve medical records but cannot view the details. As per HIPAA regulations, it is important to block the type of information that personnel in various departments can retrieve. Laboratory assistants can retrieve information from the medical records, but they cannot view information in the client's personal history. Even if the laboratory assistant had the correct access number and the password or was trying to view archived data, he or she would not have been able to access a client's personal history. (less)
A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye?
The lacrimal apparatus (which consists of the lacrimal gland, punctum, lacrimal sac, and nasolacrimal duct) protects and lubricates the cornea and conjunctiva by producing and draining tears. (less)
A nurse performs the Snellen test on a client and obtains these results: OD 20/40, OS 20/30. What conclusion can the nurse make in regards to the client's vision based on these results? Vision is worse in the left eye than the right eye The larger the bottom number, the worse the visual acuity Client is legally blind in the left eye Glasses are needed by the client for near vision
The larger the bottom number, the worse the visual acuity
A nurse performs the Snellen test on a client and obtains these results: OD 20/40, OS 20/30. What conclusion can the nurse make in regards to the client's vision based on these results?
The larger the bottom number, the worse the visual acuity. OD = right eye, OS = left eye. Therefore, the client has worse vision in the right eye because the larger the number on the bottom, the worse the visual acuity. A client is considered legally blind when the vision in the better eye with corrective lens is 20/200 or less. Snellen test is to test for distant vision (far) not near vision. (less)
All the following are characteristics of wisdom except?
The level of knowledge, judgment, and advice reflected in wisdom is inferior Wisdom, an expert knowledge system, focuses on important and difficult matters often associated with the meaning of life and the human condition. The level of knowledge, judgment, and advice reflected in wisdom is superior. The knowledge associated with wisdom has extraordinary scope, depth, and balance and is applicable to specific situations. Wisdom combines mind and virtue (character) and is employed for personal well-being, as well as for the benefit of humankind. (less)
In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. The reason for this is that the upper outer quadrant is:
The location of most breast tumors.
what do the lungs do in the carbonic acid sodium bicarbonate buffer system
The lungs help by regulating the production of carbonic acid (h2co3-) resulting from the combination of carbon dioxide and water.
The nurse is reviewing and analyzing data from the initial assessment of a newly admitted client who is a 79-year-old man. What assessment finding most clearly indicates a need for further data?
The man has a diffuse rash on his torso. The nurse should know the onset, precipitating factors, and course of the rash in order to plan appropriate interventions and referrals. The other data do not suggest an immediate need for more data. (less)
COLLOID FLUIDS
The most commonly used crystalloid fluid is normal saline, a solution of sodium chloride at 0.9% concentration, which is close to the concentration in the blood (isotonic). Ringer's lactate or Ringer's acetate is another isotonic solution often used for large-volume fluid replacement.
CLUBBING OF FINGERS/TOES
The nail widening that characterizes clubbing occurs because the tissue under the nail plate becomes thicker. This can be caused by a number of conditions that lead to a decrease in the amount of oxygen in your blood, such as lung disease and heart disease.
A nurse is assessing an 82-year-old client in terms of his psychosocial development, following Piaget's approach. Which of the following would the nurse most likely identify as an abnormal finding in this client?
The need for assistance in correctly taking daily medication Normally, the older adult, who has seen much change, can demonstrate flexibility. This person is capable of making realistic decisions regarding pacing of activities, planning self-care, making living arrangements, providing for transportation, adhering to medical regimen, and managing finances. Older adults are capable of gradually transferring social/civic responsibilities to others. The older adult who does not possess formal operational thinking (an abnormal finding), however, eventually profits from assistance from others, especially in obtaining help with activities of daily living, correctly taking medication, and maintaining one's highest level of wellness. (less)
A nurse assesses the pulse rate of an athletic client during a routine checkup. The nurse should anticipate the pulse rate to be in what range of beats per minute?
The normal pulse rate of a well-conditioned athletic client is often 45-60 beats per minute because of the conditioning of the cardiovascular system. A pulse rate ranging between 60 and 100 beats/min is normal for adults. A pulse rate of more than 100 beats/min would indicate tachycardia
The nursing instructor is discussing assessment of the head and neck with the class. What identifying characteristic would the instructor use for the thyroid cartilage? A. Its position just below the mandible B. The curve on its inferior edge C. Its relation to the cricoid cartilage D. The notch on its superior edge
The notch on its superior edge
Which action by the nurse is consistent with Weber's test?
The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears. Using Weber's test, the nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears to differentiate the cause of unilateral hearing loss. In Rinne's test, the nurse strikes the tuning fork and places it on the patient's mastoid process to measure bone conduction. When examining the inner ear, the nurse uses a bulb insufflator attached to an otoscope to observe movement of the tympanic membrane. In the Whisper test, the nurse shields their mouth and whispers a simple sentence approximately 18 inches from the patient's ear. (less)
The health care facility is involved in litigation by four clients. When reviewing the cases, which legal case would the nurse attorney identify to best describe malpractice? A. The nurse applies an ice pack to a client's lower back without an order and he feels better. B. The nurse using proper mechanics assists a client to a locked bed. He slips and breaks his left femur. C. The nurse administers amoxicillin (Amicar) to a client with known allergies to penicillin. The client has a seizure with resulting respiratory arrest. D. The nurse administered the wrong medication to the client, who had one episode of vomiting 5 minutes after consuming the medication with no further adverse reactions.
The nurse administers amoxicillin (Amicar) to a client with known allergies to penicillin. The client has a seizure with resulting respiratory arrest.
The nursing student is taking an examination on Nursing Ethics and Law. Which choice selected by the student would indicate to the nursing faculty that the student has a good understanding of negligence? A. The nurse advises a visitor to avoid bringing fresh fruit to a client with neutropenia. B. The nurses assesses for collateral circulation (Allen's test) before preforming an arterial blood gas (ABG). C. The nurse auscultates breath sounds every 8 hours on a client receiving enteral feedings. D. The nurse assesses distal pulses on a client three hours after a femoral arteriography.
The nurse assesses distal pulses on a client three hours after a femoral arteriography.
In which of the following situation would the nurse be most justified in implementing trial-and-error problem solving? -The nurse is attempting to landmark an obese client's apical pulse The nurse is attempting to determine a post stroke client has a swallowing deficit -The nurse is attempting which PRN analgesic to offer a client who is in pain -The nurse is attempting to determine the range of motion of a client's hip joint following hip surgery
The nurse is attempting to landmark an obese client's apical pulse
A nurse wishes to advance his or her career and work as a clinical nurse specialist. Which of the following should the nurse keep in mind? -The nurse oversees the care coordination of a group of clients -The nurse may teach advanced education for nurses -This requires at least a doctoral degree education -The nurse practices only with a private practitioner
The nurse may teach advanced education for nurses
Legal safeguards are in place in the nursing practice to protect the nurse from exposure to legal risks as well as to protect the client from harm. What are examples of legal safeguards for the nurse? Select all that apply. A. The nurse obtains informed consent from a client to perform a procedure. B. The physician is responsible for administration of a wrongly prescribed medication. C. The nurse educates the client about The Patient Care Partnership. D. The nurse executes physician orders without questioning them. E. The nurse documents all client care in a timely manner. F. The nurse claims management is responsible for inadequate staffing leading to negligence.
The nurse obtains informed consent from a client to perform a procedure. The nurse educates the client about The Patient Care Partnership. The nurse documents all client care in a timely manner.
Which example may illustrate a breach of confidentiality and security of patient information?
The nurse provides information over the phone to the patient's family member who lives in a neighboring state Providing information over the phone to a family member without knowing whether or not the patient wants the family member to know the information is a breach of confidentiality and security of patient information. Providing information to a caregiver involved in the care of a patient is not a breach in confidentiality, while providing information to a professional not involved in the care of the patient is a breach in confidentiality. Patient information should not be discussed in public areas, such as elevators or the cafeteria. Logging off a computer that displays patient data is an appropriate method of protecting patient confidentiality and information. (less)
The nurse is implementing care for several clients. Which of the following clients is the nurse helping to reach the highest level of Maslow's hierarchy of basic human needs? -The nurse teaches the daughter how to do a finger-stick blood sugar for her mother -The nurse provides privacy for the client and family during times of prayer -The nurse allows family to sit quietly at the client's bedside after visiting hours. -The nurse teaches the son how to perform passive range of motion with his father
The nurse provides privacy for the client and family during times of prayer
A physician is called to see a client with angina. During the visit the physician advises the nurse to decrease the atenolol to 12.5 mg. However, since the physician is late for another visit, she requests that the nurse write down the order for her. What should be the appropriate nursing action in this situation? A. The nurse should ask the physician to come back and write the order. B. The nurse should write the order and implement it. C. The nurse should inform the client of the change in medication. D. The nurse should remind the physician later to write the work order.
The nurse should ask the physician to come back and write the order.
A client is unhappy with the health care provided to him. He approaches the nurse and informs her that he is leaving the facility. The client has not been discharged by the physician. The nurse finds that the client has dressed and is ready to go. What would the nurse's action be in this situation? A. The nurse should get the client restrained and call the physician. B. The nurse should let the client go because she cannot do anything. C. The nurse should call the nursing supervisor and inform her about the situation. D. The nurse should warn the client that he cannot come to the hospital again.
The nurse should call the nursing supervisor and inform her about the situation.
Which statement is best for the nurse to use when preparing to administer the Abuse Assessment Screen?
We need to ask the following questions because domestic violence is so common in our society
When reviewing the client's history, the nurse notes that it has been recorded that the client's last bowel movement was 2 days ago. Before the nurse identifies a diagnosis of "Constipation," what assessment must the nurse make? The nurse should assess the client's dietary habits. The nurse should assess the client's bowel sounds. The nurse should determine the client's normal bowel elimination pattern. The nurse should determine the standard bowel elimination pattern for the client's age.
The nurse should determine the client's normal bowel elimination pattern.
During morning report, the night nurse tells the day nurse that the client refused to allow the technician to draw blood for laboratory testing. What step would be essential for the day nurse to complete before selecting a nursing diagnosis to address this issue? The nurse should determine the length of time the client has been in the hospital. The nurse should determine what laboratory tests are critical at this time. The nurse should determine the reason for the client's refusal. The nurse should determine the client's last laboratory results.
The nurse should determine the reason for the client's refusal.
A non-English-speaking client has been admitted to the health care facility with complaints of chest pain. Since the assigned nurse does not know the client's language, what would be the most appropriate solution in this case? -The nurse should get a language dictionary and translate -The nurse should request the help of a professional interpreter -The nurse should ask the supervisor for a different assignment -The nurse should communicate with the client non-verbally
The nurse should request the help of a professional interpreter
A nurse is writing a letter to a U.S. Congressman to support the promotion of health care issues. Which guidelines would ensure a properly written letter? (Select all that apply.) A. The nurse should state the purpose of the letter briefly and clearly in the first paragraph. B. The nurse should name the city and state where he or she lives and votes. C. The nurse should avoid using specific examples from the workplace to support the position. D. The nurse should restate exactly what the legislator should do at the end of the letter. E. The nurse should try to keep the letter to two pages and include a cover page with contact information. F. The nurse should address the letter to as many legislators as possible
The nurse should state the purpose of the letter briefly and clearly in the first paragraph. The nurse should name the city and state where he or she lives and votes. The nurse should restate exactly what the legislator should do at the end of the letter.
During an assessment, the nurse uses the CAGE test. The patient answers yes to two of the questions. What could this be indicating?
The nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment.
A female nurse is interviewing a man who has recently immigrated. During the course of the interview, he leans forward and then finally moves his chair close enough that his knees are nearly touching the nurses knees. The nurse begins to feel uncomfortable with his proximity. Which statement most closely reflects what the nurse should do next?
The nurse should try to relax; these behaviors are culturally appropriate for this person.
A nurse is meeting for the first time a 42-year-old client whose visit to the clinic has been prompted by her chief complaint of ongoing lower back pain. Which of the following approaches to pain assessment should the nurse use when assessing the client's pain?
The nurse should use a pain assessment tool that is simple but still addresses the major parameters of pain. Pain assessment requires an instrument that is easy to use, clinically valid, and easy to evaluate. An instrument that is too detailed is a liability; while the nurse should be responsive to the client's priorities and identified needs, it would inappropriate to wholly delegate the character and direction of assessment to the client. Pain assessment is highly dependent on subjective data, and these findings would not be minimized or discounted. (less)
Which action by the nurse is consistent with the Rinne test?
The nurse strikes the tuning fork and places it on the patient's mastoid process to measure bone conduction. In the Rinne test, the nurse strikes the tuning fork and places it on the patient's mastoid process to measure bone conduction. Using Weber's test, the nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears to differentiate the cause of unilateral hearing loss. When examining the inner ear, the nurse uses a bulb insufflator attached to an otoscope to observe movement of the tympanic membrane. In the Whisper test, the nurse shields their mouth and whispers a simple sentence approximately 18 inches from the patient's ear. (less)
A nurse is caring for a Native American/First Nations woman who is receiving chemotherapy for breast cancer. Which nursing action is the best example of providing culturally sensitive care? A. The nurse does not include the family in the nursing care plan. B. The nurse makes direct eye contact when examining the client. C. The nurse uses a low tone of voice when explaining the care plan to the client. D. The nurse provides materials for the client to take notes about the care plan.
The nurse uses a low tone of voice when explaining the care plan to the client.
After reporting to work for a night shift, the nurse learns that the unit will be understaffed because two RNs called out sick. As a result, each nurse on the unit will need to provide care for an additional four acute clients, in addition to her regular client assignment. Which statement is true for this nurse when working in understaffed circumstances? A. The nurse will be legally held to the same standards of care as when staffing levels are normal. B. Understaffing constitutes an extenuating circumstance that creates a temporarily lower expectation for care for the nurse. C. The nurse must document that float staff, nurses on overtime, and part-time staff were contacted in an effort to fill the gaps in care. D. The nurse is legally obliged to refuse to provide care when understaffing creates the potential for unsafe conditions.
The nurse will be legally held to the same standards of care as when staffing levels are normal.
A client arrives at a health care facility complaining of pain in the abdomen and diarrhea. The physician diagnoses the client with colitis, an acute illness. Why is colitis considered an acute illness? -It is not curable -It lasts for a long time -It is difficult to treat -The onset is sudden
The onset is sudden
A group of nursing students has attended a presentation about the National Student Nurses' Association (NSNA). Which statement by the group indicates that they have understood the information presented? -The organization is funded by the national government -The NSNA contributes to the improvement of public health -The NSNA is run by a group of registered nurses -The organization provides programs of current professional interest
The organization provides programs of current professional interest
The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland?
The parathyroid gland secretes parathyroid hormone, which regulates the level of calcium and phosphorus. Removal of the parathyroid gland will cause calcium and phosphorus imbalances
An elderly woman has been admitted to the hospital for the treatment of an acute illness and has received only one visitor in the several days since admission. The student nurse asks the patient about her relationship to this individual and the patient states, "In reality, she's my best friend but I consider her to be my family, even though I have a daughter somewhere." What foundational belief of family nursing should most influence the student's interactions with the patient? A. The student should choose interventions that facilitate reconnection with estranged family members. B. The patient can define who is and who is not part of her family. C. Many individuals exist without a family and adopt substitutes as needed. D. Family is more important to individuals who have large numbers of people in their families.
The patient can define who is and who is not part of her family.
The nurse is evaluating the effectiveness of the patient's pain medication and notes the patient is hard to arouse. The nurse interprets this as:
The patient may be over-sedated. The patient is over-sedated; this is not an expected behavior following administration of pain medication. Although the patient may be tired from lack of sleep, the nurse should be able to arouse them from sleep. Signs and symptoms of an allergic reaction would include difficulty breathing, appearance of a rash or wheals, and itching. (less)
PERIPHREAL VASCULAR SYSTEM
The peripheral vascular system consists of the veins and arteries not in the chest or abdomen (i.e. in the arms, hands, legs and feet). The peripheral arteries supply oxygenated blood to the body, and the peripheral veins lead deoxygenated blood from the capillaries in the extremities back to the heart.
where is the phosphate buffer system active?
The phosphate buffer system is active in intracellular fluids, especially in the renal tubules.
PULSE PRESSURE
The pulse pressure is calculated by subtracting the diastolic pressure from the systolic pressure. In other words, it is the change in pressure from the diastolic level to the systolic level. It is determined by two factors, the stroke volume and the compliance of the arterial system. The stroke volume, of course, is the amount of the blood injected into arteries by each heart beat. The compliance is determined by the elasticity of the arterial system. Flexible arteries that expand easily have a high compliance. Stiff arteries have a low compliance.
A nurse uses an infusion pump to administer the IV solution to a client. The nurse is aware that an infusion pump adjusts the pressure according to the resistance it meets and there is a possibility that the needle may get displaced. How would a change in the needle's position affect the infusion pump?
The pump will continue to infuse fluid even when the needle is displaced.
A patient reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. What opioid neuromodulator may be responsible for this increased level of comfort?
The release of endorphins Endorphins and enkephalins are opioid neuromodulators that are powerful pain-blocking chemicals that have prolonged analgesic effects and produce euphoria. It is thought that certain measures such as skin stimulation and relaxation techniques release endorphins. (less)
The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs?
The right lung has three lobes, while the left lung has two lobes. The right lung is made up of three lobes, whereas the left lung contains only two lobes. The sizes of the lungs are not identical but do not differ by one-third. The lower lobes of both lungs are primarily located toward the posterior surface of the chest wall. (less)
PEAR DI ORANGE "SKIN OF AN ORANGE"
The skin may also have ridges or appear pitted, like the skin of an orange (called peau d'orange), which is caused by a buildup of fluid and edema (swelling) in the breast. Other symptoms include heaviness, burning, aching, increase in breast size, tenderness, or a nipple that is inverted (facing inward).
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?
The student is having difficulty creating an identity. During adolescence, Erikson emphasized the need to establish an identity. He did not prioritize the role of sexuality, empathy, or moral behavior at this stage of development.
A 52-year-old patient fails the Romberg test. The nurse explains that this might indicate a dysfunction in what part of the ear?
The vestibular portion of the inner ear Failure of the Romberg test may indicate dysfunction in the vestibular portion of the inner ear, semicircular canals, and vestibule.
LAYERS OF THE HEART WALL
The wall of the heart is composed of three layers , the thin outer epicardium, the thick middle myocardium, and the very thin inner endocardium. 1. PERICARDIUM=The pericardial sac is a folded fibrous connective tissue layer that encompasses the entire heart and the roots of the great vessels 2. EPICARDIUM= The epicardium is the layer of muscle found covering the external surfaces of the heart he epicardium is a thin layer of connective tissue and fat, and serves as an additional layer of protection for the heart, under the pericardium. The epicardium is a thin layer of connective tissue and fat, and serves as an additional layer of protection for the heart, under the pericardium. 3. MYOCCARDIUM= The myocardium is the muscle tissue of the heart, composed of cardiac muscle cells called cardiomyocytes, which contract like other muscle cells, but also conduct electricity to coordinate contraction. 4. ENDOCARDIUM= Endocardium is composed of endothelial cells and lines the inner surface of the heart.
A nurse is preparing a class for a group of parents about ear infections and measures to prevent them. The nurse is planning to address the reasons why children are more susceptible to this infection than adults. Which of the following would the nurse include?
Their eustachian tube is shorter, straighter, and narrower. The fact that children are more susceptible than adults to otitis media is due mostly to the shorter, straighter, narrower eustachian tubes of children. Otitis media in children is not associated with putting things in their ears, immature immune systems, or poor hand-washing techniques. (less)
A 65-yetr-old patient remarks that she just cannot believe that her breasts sag so much. She states it must be from a lack of exercise. What explanation should the nurse offer her? After menopause:
Thelandular and fat tise arophies, causing breast size and clasticity to diminish, resuliting in breasts that sag.
Of the following, which best explains the importance of theoretic frameworks? -Theoretic frameworks guide physiologic nursing care -Theoretic frameworks guide psychosocial nursing care -Theoretic frameworks advance the ethical aspects of practice -Theoretic frameworks advance nursing knowledge and practice
Theoretic frameworks advance nursing knowledge and practice
During a Weber test, the client reports lateralization of sound to the good ear. The nurse interprets this as which the following?
There is a sensorineural hearing impairment. With the Weber test, lateralization of sound to the good ear suggests sensorineural hearing loss because of the limited perception of sound due to nerve damage in the affected ear, making sound seem louder in the unaffected ear. Lateralization to the poor ear suggests conductive hearing loss. (less)
A nurse is assessing the blood pressure of a client using the Korotkoff's sounds technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record?
There is an auscultatory gap An auscultatory gap is a period during which sound disappears. An auscultatory gap can range as much as 40 mm Hg. A widening in the diameter of the artery takes place in the phase II of the Korotkoff's sounds technique. An adult diastolic pressure takes place in the phase IV of the Korotkoff's sounds technique. (less)
A client has sustained a brainstem injury. Which of the following would the nurse need to keep in mind about this client's respiratory effort?
There is loss of involuntary respiratory control. The brainstem contains the medulla and the pons, which control involuntary respiratory effort. The negative response to stimuli is unrelated to the client's respiratory effort. The client's breathing patterns will change according to cellular demands. The levels of carbon dioxide and oxygen in the blood also will vary based on the client's respiratory efforts as well as interventions used to sustain these efforts. (less)
Why are middle-aged adults usually more adept at solving practical problems than younger people?
They have more experience with such problems Middle-aged adults are usually more adept at solving practical problems than younger age groups because of their years of experience in doing so. They have encountered everyday problems dozens of time. While these problems remain irritating, a person in his or her 40s or 50s knows that they are solvable, what strategies to use to handle them, and how to survive them. (less)
Which statement demonstrates the safest way to document assessment findings of drainage noted in both eyes of a client? Thick, purulent drainage is noted at inner corner of OD. Thick, purulent drainage is noted at inner corner of OS. Thick, purulent drainage is noted at inner corner of OU. Thick, purulent drainage is noted at inner corner of both eyes.
Thick, purulent drainage is noted at inner corner of both eyes.
While performing a routine check-up on an 81-year-old retired grain farmer in the vascular surgery clinic, the nurse notes that he has a history of chronic arterial insufficiency. Which of the following physical examination findings of the lower extremities would be expected with this disease?
Thin, shiny, atrophic skin Thin, shiny, atrophic skin is more commonly seen in chronic arterial insufficiency; in chronic venous insufficiency the skin often has a brown pigmentation and may be thickened.
The nurse is providing instructions to newly hired graduates for the minimental state examination (MMSE). Which statement best describes this examination?
This examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness.
PART 5= EVALUATION
This is where you determine if your plan of care worked. i.e. did the patient meet the specified goals and outcomes. If patient did not, you need to revise your plan of care.
PART 4= IMPLENTATION/ INTERVENTION
This is where you put your care plan into action and monitor patient progress All actions are focused on solving the patient's nursing problems and meeting their health care needs This is also where you will collaborate with other health professionals to meet your plan of care.
A patient is describing his symptoms to the nurse. Which of these statements reflects a description of the setting of his symptoms?
This pain happens every time I sit down to use the computer.
INTER-ARTERIAL PATHWAY TO THE HEART SAB RL P
This pathway is made up of 5 elements: The sino-atrial (SA) node The atrio-ventricular (AV) node The bundle of His The left and right bundle branches The Purkinje fibres
During a follow-up visit, the nurse discovers that a patient has not been taking his insulin on a regular basis. The nurse asks, Why havent you taken your insulin? Which statement is an appropriate evaluation of this question?
This question may place the patient on the defensive.
The nurse makes this comment to a patient, I know it may be hard, but you should do what the doctor ordered because she is the expert in this field. Which statement is correct about the nurses comment?
This type of comment promotes dependency and inferiority on the part of the patient and is best
During an examination, the nurse notes a supernumerary nipple just under the patients left breast. The patient tells the nurse that she always thought it was a mole. Which statement about this finding is correct?
This variation is normal and not a significant finding
The nurse elicits a positive Homans' sign in a client's right leg. Which of the following might the nurse suspect?
Thrombophlebitis A positive Homans' sign may indicate deep vein thrombosis or superficial thrombophlebitis. However further testing, such as ultrasound of the legs, and referral are indicated for a definitive diagnosis. Homans' sign does not suggest arterial occlusion, venous insufficiency, or varicose veins. (less)
During a pharmacology class the students are told that some drugs need to be closely monitored. What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?
Tinnitus and sensorineural hearing loss It is important that nurses are knowledgeable about the ototoxic effects of certain medications such as salicylates, loop diuretics, quinidine, quinine, and aminoglycosides. Signs and symptoms of ototoxicity include tinnitus and sensorineural hearing loss. Hypotension, reduced urinary output, and impaired facial movement are not signs of ototoxicity. (less)
The nurse is caring for a patient with a terminal illness. What would be the purpose of convening a family care conference?
To coordinate all aspects of the patient's care When working with patients who have complex health problems (e.g., end-of-life care), you may request or help facilitate a family care conference. Family members and all members of the health care team meet to discuss how best to provide and coordinate care in challenging situations. (less)
A nurse needs to select a venipuncture site to administer a prescribed amount of IV fluid to a client. The nurse looks for a large vein when using a needle with a large gauge. Which of the following reasons explains the nurse's action?
To prevent compromising circulation The nurse looks for a large vein when using a needle with a large gauge to prevent compromising circulation. To reduce the potential for blood clots and restrict a client's mobility, the nurse does not use foot or leg veins. The nurse avoids using veins on the inner surface of the wrist to prevent pain and discomfort. (less)
The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history?
To provide a database of subjective information about the patients past and current health
Why are nursing organizations important for the continued development and improvement of nursing as a whole? -To regulate work activities for members -To provide socialization and networking for members -To provide information to nurses about legal requirements -To set standards for nursing education and practice
To set standards for nursing education and practice
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as
Total Pareneteral Nutrition Total parenteral nutrition is a hypertonic solution containing 20% to 50% dextrose, proteins, vitamins, and minerals that is administered into the venous system.
Which action by the nurse demonstrates correct assessment of the corneal reflex of a client during an eye examination? A. Touch the cornea with a wisp of cotton B. Shine a penlight on the eye in a darkened room C. Ask the client to read the Snellen chart D. Test the cornea of the eye with an ophthalmoscope
Touch the cornea with a wisp of cotton
TRANSCELLULAR FLUID
Transcellular fluids include cerebrospinal, pericardial, synovial, intraocular, and pleural fluids, as well as sweat and digestive secretions
Which of the following statements is true regarding Piaget's concept of transductive thinking?
Transductive thinking can be used by formal operational thinkers. In transductive reasoning, thinking occurs from specific to specific; if two things are alike in one aspect, the child thinks they are alike in all aspects.
A nurse is inspecting a client's eyes to assess for the possibility of detached retinas. The nurse is aware that which of the following is the function of the retina? Refracts light rays onto the posterior surface of the eye Controls the amount of light entering the eye Transforms light rays into nerve impulses that are conducted to the brain Permits the entrance of light to the eye
Transforms light rays into nerve impulses that are conducted to the brain
Water in the body functions primarily to
Transport nutrients to cells and wastes from cells Transport hormones, enzymes, blood platelets, and red and white blood cells Facilitate cellular metabolism and proper cellular chemical functioning Act as a solvent for electrolytes and nonelectrolytes Help maintain normal body temperature Facilitate digestion and promote elimination Act as a tissue lubricant
The nursing process is based upon the process of problem solving. What type of problem solving is the nurse using if she attempts to obtain a blood pressure on the client's right arm, the left arm, the left leg, and then finally the right leg, were a blood pressure is finally obtained? -Critical thinking -Scientific problem solving -Intuitive thinking -Trial-and-error problem solving
Trial-and-error problem solving
A nurse needs to get an accurate fluid output assessment of a client with severe diarrhea. Which action should the nurse perform?
Weigh the client's wet linen or dressing.
When assessing the ears of older adults, it is necessary to remember that physiologic changes take place as people age. What is a physiologic change that takes place in the ear of an older adult?
Tympanic membrane is more opaque The cartilage and skin around the external ear may be less pliable in older adults. The stiff hairs in the canal may require a smaller otoscope tip to separate them and increase visualization of the tympanic membrane. The membrane itself may seem more opaque and less mobile. The cone of light does not become brighter as people age nor does the external ear canal enlarge. (less)
OBJECTIVE DATA IN PERIPHREAL/VASCULAR/LYPHATIC SYSTEM. LOOK, FEEL, LISTEN...FOR
UNILATERAL EDEMA= OCCLUSION BILATERAL EDEMA= USUALLY CHF RELATED, FLUID CLUBBING IN COPD PATIENTS (lack of oxygen in the nails.
Which area of the arm drains to the epitrochlear nodes?
Ulnar surface of the forearm and hand, little and ring fingers, and ulnar middle finger The epitrochlear node receives lymphatic drainage from the ulnar surface of the forearm and hand, little and ring fingers, and ulnar middle finger. More importantly, it is generally a sign of generalized lymphadenopathy as seen in syphilis and HIV infection. (less)
A nursing student is collaborating with an experienced nurse to assess a family using the Calgary Family Assessment Model (CFAM). What will be the primary goal when using the model? A. Understand the interactions between the members of the family. B. Teach the family to build on their current health status. C. Elicit the family's input into planning their care. D. Demonstrate healthy patterns of interactions.
Understand the interactions between the members of the family.
Which statement best describes a proficient nurse? A proficient nurse is one who:
Understands a patient situation as a whole rather than a list of tasks and recognizes the long-term goals for the patient
The nurse manager is explaining culturally competent care during a staff meeting. Which statement accurately describes the concept of culturally competent care? The caregiver:
Understands and attends to the total context of the patients situation.
During a home visit, the nurse notices that an older adult woman is caring for her bedridden husband. The woman states that this is her duty, she does the best she can, and her children come to help when they are in town. Her husband is unable to care for himself, and she appears thin, weak, and exhausted. The nurse notices that several of his prescription medication bottles are empty. This situation is best described by the term:
Unintentional physical neglect.
How can a nurse accurately assess the distant visual acuity of a client who is non-English-speaking? Move an object through the six cardinal positions of gaze Use a Snellen E chart to perform the examination Have the client read from a Jaeger reading card Perform the confrontation test in all four fields
Use a Snellen E chart to perform the examination
How can a nurse accurately assess the distant visual acuity of a client who is non-English speaking?
Use a Snellen E chart to perform the examination If a client does not speak English, is unable to read, or has a verbal communication problem, the Snellen E chart can be used to test the client's distant visual acuity. With this test, the client is asked to indicate by pointing which way the E is open on the chart. The six cardinal positions of gaze test eye muscle function and cranial nerve function. The Jaeger chart tests near visual acuity. Confrontation test is used to test visual fields for peripheral vision. (less)
A nursing instructor is presenting information to nursing students. The instructor addresses the taking of vital signs on clients from other cultures. What would the nurse address about clients from East African cultures?
Use of henna for body decorations Some clients from East African countries apply skin decorations with henna. Black henna causes major errors in oxygen saturation readings, while red henna does not. The presenting nurse would not generally discuss male circumcision, the educational status of the clients, or the environmental influences of the area. (less)
A teenager is brought to the clinic for a sports physical examination. The client states plans to play goalie on the community soccer team. What is the most important teaching opportunity presented for this client? A. Use of safety equipment B. Prevention of knee injuries C. Prevention of head injuries D. Use of correct foot gear
Use of safety equipment
An instructor is reviewing the steps to obtain a radial pulse. The instructor determines that the teaching was successful when the students demonstrate which of the following?
Use of two middle fingers lightly applied to wrist area along the thumb side To obtain the radial pulse, the nurse applies light pressure using the two middle fingers to the radial artery on the lateral aspect of the client's wrist. Light not firm pressure is used. The area is along the lateral aspect of the wrist, which correlates to the same side as the thumb. The bell of the stethoscope is applied to find the brachial pulse when preparing to obtain a client's blood pressure. (less)
A nurse is obtaining a client's radial pulse. Which of the following actions demonstrates correct technique for this assessment?
Use of two middle fingers lightly applied to wrist area along the thumb side To obtain the radial pulse, the nurse applies light pressure using the two middle fingers to the radial artery on the lateral aspect of the client's wrist. Light, not firm, pressure is used. The area is along the lateral aspect of the wrist, which correlates to the same side as the thumb. The bell of the stethoscope is applied to find the brachial pulse when preparing to obtain a client's blood pressure. (less)
A nurse has just discussed with a client the quality, severity, and location of the client's back pain. Which of the following is an appropriate guideline for the nurse to follow when documenting these findings?
Use phrases instead of sentences to record data. The nurse should document assessments using phrases instead of sentences to avoid the use of too many redundant words and to focus only on the essential (information) terms. Errors in documentation should be corrected by drawing one line through the entry, writing "error," and initialing the entry; an eraser should not be used to remove any error in the document. A pencil or pen with erasable ink should never be used in documentation. The nurse needs to record only the data findings, not how the data findings were obtained, in precise terms. All findings should be recorded as per the values obtained during assessment in descriptive terms, even if the finding is normal. (less)
The nurse suspects abuse when a 10-year-old child is taken to the urgent care center for a leg injury. The best way to document the history and physical findings is to:
Use the words the child has said to describe how the injury occurred.
Auscultation
Used to assess air flow (breath sounds) through upper & lower airways Use the diaphragm of the stethoscope Large airways have coarse loud sounds Lower airways have finer softer sounds Listen to both anterior & posterior surfaces bilaterally using a ladder pattern technique
The nurse is using audiometry to screen the hearing of elementary school students. Which best describes audiometry?
Uses headphones and a box that delivers tones to each ear at variable frequencies and volumes. Headphones and a box that delivers tones to each ear at variable frequencies and volumes are used in testing hearing by audiometry. A tuning fork, a U-shaped instrument, is used to assess sound perception through bone and air conduction. An audiologist assesses hearing with an audiogram by placing the individual in a sound-proof booth. An audiologist measures oto-acoustic emissions with a tympanogram. (less)
A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, You dont smoke, drink, or take drugs, do you? This question is an example of:
Using biased or leading questions.
When providing patient education on hearing, patients should be reminded to utilize ear plugs when they are what? (Mark all that apply.)
Using lawnmowers • At train stations • At concerts As nurses, prevention is key, and patients should be reminded to utilize ear plugs when exposed to loud noises in their daily lives (e.g., lawnmowers, leaf blowers, chainsaws, concerts, train stations, battlefields, and sirens) and to limit exposure (iPod buds and cell phones). (less)
Although all of the following are nursing responsibilities, which one would be expected of a nurse with a baccalaureate degree? -Administering medications as prescribed -Providing direct physical care -Using research findings to improve practice -Collaborating with other health care providers
Using research findings to improve practice
When planning care for a client with an inner ear infection, the nurse will need to include interventions for which of the following potential problems?
VERTIGO The labyrinth within the inner ear senses the position and movements of the head and helps to maintain balance. If these structures are infected or inflamed, the patient could develop vertigo. Rhinorrhea, fever, and headache are not potential problems associated with an inner ear infection. (less)
The nurse plans to test which cranial nerve when testing an elderly patient's hearing status?
VIII Cranial nerve VIII contains sensory fibers for hearing and balance.
A nurse is providing care to a client who has been in a motor vehicle accident and who has facial lacerations and a pelvic fracture. How can the nurse best determine the reliability and accuracy of data obtained during a pain assessment?
Validate the assessment data with the client. It is important to validate pain assessment data that are collected with the client. Comparisons to previous assessments and consultation with other members of the care team do not determine the reliability and accuracy of data obtained during a pain assessment. (less)
When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next action should be to:
Validate the data by asking a coworker to listen to the breath sounds
A nurse is comparing the subjective data and objective data obtained from an assessment of a client who is thought to have hepatitis A. This nurse's comparison will achieve what benefit to this client's care?
Validation of data The nurse compares objective and subjective data to determine discrepancies and validate the data obtained to ensure that the information is accurate and complete. Missing data would need to be validated. From this validation, the nurse can then formulate nursing diagnoses. The form used for documentation varies from agency to agency and is unrelated to the comparison of subjective and objective data. (less)
The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse suspects which of the following?
Venous insufficiency Brown discoloration around the ankles occurs with chronic venous stasis resulting from hemosiderin deposits, which are byproducts of red blood cell degradation or iron deposits left behind from the process. There is no evidence of ulceration. Arterial occlusion would be associated with weak or absent pulses. Dependent edema is edema that results from the legs being in a dependent or down position. A brown pigmentation would not be present with dependent edema. (less)
The nurse is preparing to leave the unit for lunch. What type of communication method should the nurse use?
Verbal handoff A verbal handoff is appropriate anytime the nurse transfers the responsibility for the care of a patient to another. This type of handoff reporting would allow the new nurse to ask questions to clarify care. A written handoff is appropriate when the patient is being transferred to another care unit to another. It can also be used for change-of-shift report. A focus note is a type of documentation system, organized by data (D), action (A), and response (R). The Resident Assessment Instrument is a multidisciplinary tool used to track goal achievement of residents in long-term care settings. (less)
The nurse is preparing to auscultate the lung sounds of a young adult. Which sound will the nurse expect to hear over most of the patient's lungs?
Vesicular Vesicular breath sounds are normally heard over most of both lungs. In a young adult, this is the sound that the nurse will most likely hear when auscultating the patient's lungs. Bronchovesicular breath sounds are normally heard in the 1st and 2nd intercostal spaces anteriorly and between the scapulas posteriorly. Bronchial breath sounds are normally heard over the manubrium but may not be heard at all. Tracheal breath sounds are normally heard over the trachea in the neck. (less)
The nurse is caring for a patient following an open reduction, internal fixation of the right hip. The nurse observes the patient moans when being repositioned. What type of pain indicator is moaning?
Vocalization Moaning is a vocalization pain indicator; other examples include groaning, gasping, and screaming. Verbalization would include the expression specific words, such as counting, praying, and swearing. Emotional pain indicators include excessive sleeping, anxiety, fear, and depression. Behavioral pain indicators include massaging, guarding, and immobilizing body parts. (less)
The nursing class has just learned that Healthy People 2020 focuses on health disparities. National trends in efforts to prevent these disparities focus on which of the following groups? Select all that apply. -Vulnerable populations -People with disabilities -Older adults -Men -Those living in poverty -Women
Vulnerable populations,Those living in poverty, Women, Older adults, People with disabilities
UPPER AIRWAY "CONDUCTING AIRWAY" FUNCTION
Warms, moisturize, filters & transports air to lower airways. Includes nasal passages, mouth, pharynx, larynx, bronchi & bronchioles
When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination?
Wash hands before and after every physical patient encounter
The nurse is examining a patients lower leg and notices a draining ulceration. Which of these actions is most appropriate in this situation?
Wash hands, put on gloves, and continue with the examination of the ulceration.
The nurse on the elective surgery floor receives a report that describes the client's abdominal wound dressing as having a moderate amount of yellowish and bloody drainage on it and a very foul smell. In planning for a dressing change, it is most important for the nurse to perform which action? A. Change the abdominal dressing more frequently. B.Apply extra gauze dressings to the wound to absorb the drainage. C. Wash her hands before and after the dressing change. D. Use sterile gloves to change the abdominal dressing.
Wash her hands before and after the dressing change.
The nurse is assessing a client's respiratory rate. Which of the following should the nurse do to ensure accuracy of this assessment?
Watch chest movement before removing the stethoscope after counting the apical beat Because breathing is under voluntary in addition to autonomic control, clients may intentionally or inadvertently alter their breathing rate if they are aware that it is being assessed. To obtain an accurate assessment, observe respirations without alerting the client by watching chest movement before removing the stethoscope after you have completed counting the apical beat. Asking the client to breathe normally may still make the client self-conscious and prevent an accurate measurement. Observing the client's chest movement before calling the client back to the examination room would not be practical due to the distance. Performing the assessment multiple times is unnecessary and time consuming (less)
Which statement most accurately describes the process of osmosis?
Water moves from an area of lower solute concentration to an area of higher solute concentration. Osmosis is the primary method of transporting body fluids, in which water moves from an area of lesser solute concentration and more water to an area of greater solute concentration and less water. Solutes do not move during osmosis and plasma proteins facilitate colloid osmotic pressure, which is related to, but not synonymous with, the process of osmosis. (less)
Which statement most accurately describes the process of osmosis?
Water moves from an area of lower solute concentration to an area of higher solute concentration. Osmosis is the primary method of transporting body fluids, in which water moves from an area of lesser solute concentration and more water to an area of greater solute concentration and less water. Solutes do not move during osmosis and plasma proteins facilitate colloid osmotic pressure, which is related to, but not synonymous with, the process of osmosis.
A nurse has chosen to characterize a new initiative as "wellness promotion" rather than "health promotion." Which of the following statements best describes the difference between the concept of wellness and the concept of health? -Health is a state that can be promoted and protected by nursing practice, whereas wellness is solely dependent on the client. -Wellness is determined by age-related expectations, whereas health is an achievable state at any point in the lifespan -Well is an active state, whereas health is a more passive state dependent on the absence of disease -Wellness is dependent on the resolution of acute and chronic illnesses, whereas health can exist at any stage or condition
Well is an active state, whereas health is a more passive state dependent on the absence of disease
When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American-Indian patient?
What cultural or spiritual beliefs are important to you?
The nurse is responsible for establishing a caring relationship with the client. The nurse could evaluate her priority for caring by asking which self-reflection questions? Select all that apply. -What do I know about the client beyond his physical condition? -When the client's family comes, do I take the time to talk with them? -How does the client need to change in order for me to know him better? -Do I provide care that is individualized, or do I provide care as planned? -How do I decide what the client needs and prioritize my time?
What do I know about the client beyond his physical condition?, Do I provide care that is individualized, or do I provide care as planned?, How do I decide what the client needs and prioritize my time?, When the client's family comes, do I take the time to talk with them?
A nurse assesses a client's orientation. What are the questions that the nurse should ask? Select all that apply? ppts
What is your name? • Where are you? • What is the date today? • Why are you here? Orientation assesses client ability to know who they are (person), where they are (place), what the date is (time), and why they are in the hospital or what the current situation means (situation).
The nurse is conducting a physical examination of a client who reports finding a lump in the neck. Which of the following questions should be included in when the nurse is collecting subjective data? (Select all that apply). A. When did you first notice the lump? B. How recently have you consumed alcohol? C. Do you have family members that experience lumps? D. Has the lump changed? E. Is it painful to touch?
When did you first notice the lump? How recently have you consumed alcohol? Has the lump changed?
A patient with advanced chronic obstructive pulmonary disease (COPD) is very fatigued and has minimal stamina. Clustering of care has become necessary. When should the nurse auscultate this patient's lungs?
When turning the patient A patient may be clinically stable but be unable to fully cooperate in the assessment process because of fatigue. Consider clustering care. Auscultate the lungs when turning the patient or getting the patient up in a chair. (less)
when you breathe in
When you breathe in, or inhale, your diaphragm contracts (tightens) and moves downward. This increases the space in your chest cavity, into which your lungs expand. The intercostal muscles between your ribs also help enlarge the chest cavity. They contract to pull your rib cage both upward and outward when you inhale.
During a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on her breast for approximately 2 weeks. In trying to find the cause of the rash, which question would be important for the nurse to ask?
Where did the rash first appearon the nipple, the areola, or the surrounding skin?
Which tests are appropriate for a nurse to perform to test the cranial nerve VIII?
Whisper test, Rinne, and Weber Cranial nerve VIII is the acoustic/vestibulocochlear which assesses the client's ability to hear. The nurse should perform the whisper test, and the Rinne and Weber test using the tuning fork. The gag reflex, rise of the uvula, and ability to swallow are tests to assess cranial nerves IX (glossopharygeal) and X (vagus). Asking the client to smile, frown, show teeth, and puff out cheeks assess the function of cranial nerve VII (facial). (less)
Which tests are appropriate for a nurse to perform to test the cranial nerve VIII?
Whisper test, Rinne, and Weber Cranial nerve VIII is the acoustic/vestibulocochlear which assesses the client's ability to hear. The nurse should perform the whisper test, and the Rinne and Weber test using the tuning fork. The gag reflex, rise of the uvula, and ability to swallow are tests to assess cranial nerves IX (glossopharygeal) and X (vagus). Asking the client to smile, frown, show teeth, and puff out cheeks assess the function of cranial nerve VII (facial).
In which of the following population should the nurse carefully assess the clients' use of over-the-counter medications? -Asian -White middle class -Hispanic -African American
White middle class
A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination. During the tests of cognitive function, the nurse would expect that he:
Will be oriented to place and person, but the patient may not be certain of the date.
The nursing researcher is studying so-called "unnatural illnesses." What cause of such illnesses would be included in the study? A. Cold air B. Food C. Impurities in water D. Witchcraft
Witchcraft
Which assessment procedure should a nurse institute to test a client for stereognosis?
With eyes closed, ask the client to identify a familiar object that is placed in their hand To test a client for stereognosis, with the eyes closed, the nurse should ask the client to identify a familiar object that is placed in their hand. To test graphesthesia, the nurse should use a blunt instrument to write a number in the client's hand and ask them to identify it. When testing sensitivity to position, the nurse should ask the client to close their eyes then move the finger up or down and ask the direction it is moved. Asking the client to identify the number of points touched with two ends of an applicator at the same time is two-point discrimination. (less)
Which assessment procedure should a nurse institute to test a client for stereognosis?
With eyes closed, ask the client to identify a familiar object that is placed in their hand To test a client for stereognosis, with the eyes closed, the nurse should ask the client to identify a familiar object that is placed in their hand. To test graphesthesia, the nurse should use a blunt instrument to write a number in the client's hand and ask them to identify it. When testing sensitivity to position, the nurse should ask the client to close their eyes then move the finger up or down and ask the direction it is moved. Asking the client to identify the number of points touched with two ends of an applicator at the same time is two-point discrimination.
Nurses are occasionally asked to witness a testator's (person who makes the will) signing of his or her will. Which of the following guidelines is true regarding a nurse's role is witnessing a testator's signature? A. Witnesses to a signature do not need to read the will. B. Witnesses do not need to observe the signing of the will and can sign it at a later time. C. A beneficiary to a will is allowed to act as a witness. D. A single witness is sufficient for a will.
Witnesses to a signature do not need to read the will.
The need for university-based nursing education programs was brought to light during which important historical time? -Spanish American War -Korean War -World War I -World War II
World War II
A 90-year-old patient tells the nurse that he cannot remember the names of the medications he is taking or for what reason he is taking them. An appropriate response from the nurse would be:
Would you have a family member bring in your medications?
During a visit to the clinic, a patient states, The doctor just told me he thought I ought to stop smoking. He doesnt understand how hard Ive tried. I just dont know the best way to do it. What should I do? The nurses most appropriate response in this case would be:
Would you like some information about the different ways a person can quit smoking?
The nurse is teaching a pregnant woman about breast milk. Which statement by the nurse iscorrecr?
You may notice a thick, yellow fluid express from your breast as early as the fourth month of pregnancy
As the nurse enters a patients room, the nurse finds her crying. The patient states that she has just found out that the lump in her breast is cancer and says, Im so afraid of, um, you know. The nurses most therapeutic response would be to say in a gentle manner:
Youre afraid you might lose your breast?
11. The nurse is planning to assess a client for graphesthesia. How will the nurse perform this phase of assessment? A) The client will close the eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object. B) The client is asked to identify the number of points felt when the nurse touches the client with the ends of two applicators at the same time. C) The nurse will simultaneously touch the client in the same area on both sides of the body, and the client will identify where the touch occurred. D) The nurse will briefly touch the client, and the client will identify where the touch occurred.
a
15. During the health history, a client reports a decrease in his ability to smell. During the physical assessment, the nurse would make sure to assess which cranial nerve? A) CN I B) CN II C) CN VII D) CN IX
a
PULMONARY EMBOLISM
a potentially life-threatening complication, is caused by the detachment (embolization) of a bloodclot that travels to the lungs from the leg (ususally) or arm, either extremity. SIGNNS= ACUTE DYSPENEA,(difficult or labored brething) CHEST PAIN, INCREASED HR, SWEATING, ANXIETY " I'M DYING"
spasm
a sudden involuntary muscular contraction or convulsive movement.
The nurse has developed a strong therapeutic partnership with a 44-year-old electrician who suffered severe burns while working on an industrial site. Which of the nurse's following actions most directly addresses the patient's self-actualization needs? a) Discussing the patient's strengths and dialoguing with him about his body image. b) Encouraging the patient to talk about his previous accomplishments and his goals for the future. c) Reorganization of his care and facilitating a day pass so the patient can spend Thanksgiving with his family. d) Encouraging the patient's friends and family to take an active role in his care at the hospital.
a) Discussing the patient's strengths and dialoguing with him about his body image. Aspects of self-actualization include focusing on patient's strengths and fostering a positive body image. Addressing accomplishments and goals is likely to meet patients' self-esteem needs. Facilitating contact and connection between patients and their families is an action that promotes love and belonging needs.
The nurse who is caring for a child admitted after an automobile accident recognizes the importance of including the child's family in the plan of care. Inclusion of the family meets which of Maslow's basic human needs? a) Love and belonging. b) Physiologic. c) Self-actualization. d) Self-esteem
a) Love and Belonging: Love and belonging needs include the understanding and acceptance of others in both giving and receiving love, and the feeling of belonging to families, peers, friends, a neighborhood, and a community. The inclusion of family and friends in the care of a patient is a nursing intervention to meet this need.
The nurse has arranged for a stroke patient to participate in a daily group rehabilitation program that aims to improve the mobility, independence, and activities of daily living (ADLs) of participants. This program is likely to address which of the following needs? Select all that apply. a) Physiologic needs b) Safety and security needs c) Love and belonging needs d) Self- esteem needs e) Self-actualization needs
a) Physiologic needs b) Safety and security needs c) Love and belonging needs d) Self-esteem needs e) Self-actualization needs A rehabilitation program is likely to be multidimensional, addressing the physiology of the patient's movement while prioritizing and ensuring safety. Improving independence and ADLs is likely to benefit the patient's self-esteem and self-actualization after the effects of stroke. The group format of the program is likely to provide some measure of belonging with those who have had similar experiences, thus preventing isolation.
A couple with adolescent children is most likely to focus on which of the following developmental tasks? a) Strengthening marital relationships. b) Establishing a mutually satisfying marriage. c) Coping with loss of energy and privacy. d) Adjusting to retirement
a) Strengthening marital relationships: The couple in a family with adolescents and young adults likely has a developmental task to strengthen marital relationships. Establishing a mutually satisfying marriage and coping with the loss of energy and privacy are tasks for a couple with young children. Adjusting to retirement is a developmental task for older adults.
19. When reviewing the neural pathways, a group of students is identifying sensations that travel via the spinothalamic tract. Select all the sensations that are carried by this tract. A) Pain B) Temperature C) Position D) Vibration E) Light touch
abe
The functional reflex that allows the eyes to focus on near objects is termed A. pupillary reflex. B. accommodation. C. refraction. D. indirect reflex.
accommodation
The functional reflex that allows the eyes to focus on near objects is termed
accommodation. Accommodation is a functional reflex allowing the eyes to focus on near objects. This is accomplished through movement of the ciliary muscles, causing an increase in the curvature of the lens. (less)
Varriations in the fluid content from the normal 50% to 60% of the body's weight can occur, depending on such factors as the
age body fat gender
he client is positioned on the left side if exhibiting signs of
air embolism
Sphygmomanometer
an instrument for measuring blood pressure, typically consisting of an inflatable rubber cuff that is applied to the arm and connected to a column of mercury next to a graduated scale, enabling the determination of systolic and diastolic blood pressure by increasing and gradually releasing the pressure in the cuff.
When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which of the following interventions should the nurse perform for this complication?
apply a warm compress Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV. The nurse need not elevate the client's head, position the client on the left side, or apply antiseptic and a dressing. The client's head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if exhibiting signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection.
The nurse is preparing to perform a head and neck assessment of an adult client who has immigrated to the United States from Cambodia. The nurse should first A. explain to the client why the assessment is necessary. B. ask the client if touching the head is permissible. C. determine whether the client desires a family member present. D. examine the lymph nodes of the neck before examining the head.
ask the client if touching the head is permissible.
The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should
ask the client to breathe deeply through her mouth. To best assess lung sounds, you will need to hear the sounds as directly as possible. Ask the client to breathe deeply through the mouth for each area of auscultation.
A nurse is working on a medical surgical unit with a licensed practical/vocational nurse (LPN/LVN). Which action made by the nurse is considered negligent if injury results from this action? A. asking the LPN/LVN to teach a new diabetic client how to administer insulin B. calling the healthcare provider about abnormal lab results C. completing a physical assessment on a newly admitted client D. delegating all wound care and oral medication administration to the LPN/LVN
asking the LPN/LVN to teach a new diabetic client how to administer insulin
The semilunar valves are located
at the exit of each ventricle at the beginning of the great vessels. The semilunar valves are located at the exit of each ventricle at the beginning of the great vessels.
16. When evaluating a client's risk for cerebrovascular accident, which client should the nurse identify as being at highest risk? A) A 42-year-old Caucasian female who smokes B) A 68-year-old African-American male with hypertension C) A 70-year-old Caucasian male who has one to two beers a day D) A 35-year-old African-American male who has sleep apnea
b
A nurse is providing care based on Maslow's hierarchy of basic human needs. For which of the following nursing activities is this approach useful? a) Making accurate nursing diagnoses. b) Establishing priorities of care. c) Communicating concerns more concisely. d) Integrating science into nursing care.
b) Establishing priorities of care. Maslow's hierarchy of basic human needs is useful for establishing priorities of care.
In caring for a patient, the nurse recognizes which of the following as the primary educational and support structure for an individual? a) Teachers and coaches. b) Family members. c) Clergy. d) Peers
b) Family members: The family is the primary educational and support structure for an individual. The family, as a social unit, provides the environment and relationships necessary for members to meet their basic human needs.
Which of the following is one element of a healthy community? a) Meets all the needs of its inhabitants b) Offers access to healthcare services c) Has mixed residential and industrial areas d) Is little concerned with air and water quality
b) Offers access to healthcare services A healthy community offers access to healthcare services to treat illness and to promote health.
The community health nurse is creating a plan of care for a patient with Parkinson's disease. The patient's spouse has provided care to the patient for the past 5 years and the patient's care needs are increasing. The nurse determines that an appropriate nursing diagnosis for the patient and family is: a) Parental Role Conflict. b) Risk for Caregiver Role Strain. c) Readiness for Enhanced Family Processes. d) Health Seeking Behaviors
b) Risk for Caregiver Role Strain: Long-term care of a family member with a chronic illness may lead to caregiver role strain, so the most appropriate nursing diagnosis is "Risk for Caregiver Role Strain"
The parents raising two school-aged children incorporate their religious beliefs into the family's daily life. The family's beliefs regarding religion include dietary considerations, worship practices, attitudes, and values. This is an example of which function of the family? a) Reproductive. b) Socialization. c) Affective and coping. d) Physical
b) Socialization: Through socialization, the family teaches; transmits beliefs, values, attitudes, and coping mechanisms; provides feedback; and guides problem solving. Incorporating religious beliefs, values, and attitudes is an example of socialization.
Which of the following statements is true regarding Friedman's theory of family-centered nursing care? a) Illness of one family member strengthens the roles of the sick member in the family structure. b) The role of the family is essential in every level of nursing care. c) The family is composed of independent members who live and function individually. d) The focus on health should be directed at improving the health of the sickest member of the family.
b) The role of the family is essential in every level of nursing care: Friedman and associates identified the importance of family-centered nursing care, based on four rationales. First, the family is composed of interdependent members who affect one another. If some form of illness occurs in one member, all other members become part of the illness. Second, a strong relationship exists between the family and the health status of its members; therefore, the role of the family is essential in every level of nursing care. The third rationale is that the level of health of the family and, in turn, each member can be significantly improved through health-promotion activities. Finally, illness of one family member may suggest the possibility of the same problem in other members; through assessment and intervention, the nurse can assist in improving the health status of all members.
How is the nursing profession becoming more culturally diverse? Select all that apply. A. by admitting a required number of foreign-born nursing students B. through meeting admission quotas for minority nursing students C. by the increased number of foreign-born nurses in the profession D. through meeting the mission of Sigma Theta Tau International E. by the increased number of male nurses in the profession
by the increased number of foreign-born nurses in the profession by the increased number of male nurses in the profession
17. After teaching a group of students about the brain and spinal cord, the instructor determines that the students demonstrate the need for additional teaching when they identify which of the following as being controlled by the brain stem? A) Respiratory function B) Heart rate C) Equilibrium D) Reflex actions
c
The parents of a blended family have a 6-month-old baby boy who is due for immunizations. The clinic closest to their home has recently closed, and they feel intimidated by the prospect of going to the large, university hospital near their home. Which of the following factors is the primary influence on this aspect of the family's health? a) Economic factors b) Lifestyle influences c) Community healthcare structure d) Family risk factors
c) Community healthcare structure The size, location, and services of healthcare offerings in a geographical area are components of the community healthcare structure and its influence on health. Family functioning, lifestyle and economic considerations are not primary influences on the family's actions.
A 26-year-old member of the armed forces was severely injured while serving overseas and now lives with the effects of a spinal cord injury. The man's wife is now forced to get a job in order to provide care for both him and their young son, since the man was the family's soled wage earner. In addition, the family realizes that they may have to move into the basement of the wife's parents in order to survive financially. The family is at greatest risk of which of the following nursing diagnoses? a) Powerlessness b) Ineffective Coping c) Interrupted Family Process d) Impaired Parenting
c) Interrupted Family Process These events presents the possibility of numerous nursing diagnoses. Paramount among these, however, is the fact that the functioning of the family itself has been fundamentally changed. This presents the risk of Interrupted Family Process.
The nurse assists a postoperative patient with ambulation. The nurse recognizes that assisting the patient when performing this skill meets which of Maslow's basic human needs? a) Self-actualization. b) Self-esteem. c) Safety and security. d) Love and belonging
c) Safety and Security: Nurses carry out a wide variety of activities to meet patients' physical safety needs, such as moving and ambulating patients. Assisting the patient to ambulate ensures that the patient will not experience a fall.
Of the following statements, which one is true of self-actualization? a) Humans are born with fully developed self-actualization. b) Self-actualization needs are met by having confidence and independence. c) The self-actualization process continues throughout life. d) Loneliness and isolation occur when self-actualization needs are unmet.
c) The self-actualization process continues throughout life. Self-actualization, or reaching one's full potential, is a process that continues through life.
John and Mary, each parents of one child, are both divorced. When they marry, the family structure that is formed will be described as which of the following? a) Nuclear family b) Extended family c) Blended family d) Cohabiting family
c) blended family A blended family is formed when parents bring unrelated children from previous relationships together to form a new family.
A client's blood pressure is affected by
cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity. Blood pressure is affected by cardiac output, distensibility of the arteries, blood volume, blood velocity, and blood viscosity (thickness).
The nurse is caring for elderly patients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these patients?
cardiac volume intolerence related to the heart having less efficient pumping ability.
While assessing the neurologic system of a confused older adult, the nurse observes that the client is unable to recall past events. The nurse suspects that the client may be exhibiting signs of
cerebral cortex disorder. Remote memory (past dates and historical accounts) may be impaired in cerebral cortex disorders.
A nurse asks the client to describe the pain associated with a headache by rating the pain on a scale from 1 to 10. This subjective data should be documented in which section of the assessment? A. characteristic symptoms B. associated manifestations C. relieving factors D. location
characteristic symptoms
Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should:
check the temperature of the room and offer blankets to the patient if he or she feels cold.
Sodium (Na+):
chief electrolyte of ECF; the normal serum concentration of sodium: 135-145 mEq/L
When assessing a patients pain, the nurse knows that an example of visceral pain would be:
cholecystitis
The middle layer of the eye is known as the choroid layer. scleral layer. retinal layer. optic layer.
choroid layer.
The client's head is elevated if the client exhibits symptoms of
circulatory overload.
The chambers of the eye contain aqueous humor, which helps to maintain intraocular pressure and transmit light rays. maintain the retinal vessels. change refractory of the lens. cleanse the cornea and the lens.
cleanse the cornea and the lens.
RHONCHI
coarse, low pitched snoring (continuous) sound. Indicates secretions (fluid/mucous) in or narrowing of large airways. Maybe be cleared with coughing.
The nurse is administering a Mini-Cog test to an older adult woman. When asked to draw a clock showing the time of 10:45, the patient drew a clock with the numbers out of order and with an incorrect time. This result indicates which finding?
cognitive impairment
alkalosis
condition, characterized by a proportionate lack of hydrogen ions in the extracellular fluid concentration, in which the pH exceeds 7.45
The nurse notes that the pupil of a client's left eye constricts when a light is shined into the right eye. How should the nurse document this finding? A. direct light response present in left eye B. pupils equal and react to accommodation C. consensual light response present in left eye D. consensual light response present in right eye
consensual light response present in left eye
When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should:
consider this a normal finding
A 30-year-old woman has recently moved to the United States with her husband. They are living with the womans sister until they can get a home of their own. When company arrives to visit with the womans sister, the woman feels suddenly shy and retreats to the back bedroom to hide until the company leaves. She explains that her reaction to guests is simply because she does not know how to speak perfect English. This woman could be experiencing:
culture shock
1. The nurse is assessing the eyes of a client who has a lesion of the sympathetic nervous system. What assessment finding should the nurse anticipate? A) Bilateral dilated pupils B) Nystagmus (involuntary eye movement) C) Argyll-Robertson pupils D) Constricted pupils, unresponsive to light
d
What is the best broad definition of a family? a) A father, a mother, and children. b) A group whose members are biologically related. c) A unit that includes aunts, uncles, and cousins. d) A group of people who live together.
d) A group of people who live together. Although all the responses may be true, the best definition is a group of people who live together.
An adolescent confides in the school nurse that she is arguing daily with her mother and she often wonders if her mother loves her. The school nurse recognizes that the student faces which of the following risk factors for altered family health? a) A biologic risk factor. b) A lifestyle risk factor. c) A developmental risk factor. d) A psychosocial risk factor
d) A psychosocial risk factor: Conflicts between family members are considered psychosocial risk factors.
Which of the following is one of the developmental tasks of the older adult family? a) Maintain a supportive home base b) Prepare for retirement c) Cope with loss of energy and privacy d) Adjust to loss of spouse
d) Adjust to loss of spouse A developmental task of the older adult family is adjusting to the loss of a spouse.
The nurse recognizes the importance of including patients' families in assessment, care, decision-making, education, and discharge planning. When determining who constitutes a patient's family, which of the following criteria should the nurse prioritize? a) Interdependence b) Time commitment c) Genetic relationship d) Emotional bonding
d) Emotional bonding Family can be defined simply as any group of people who live together and are emotionally bonded. This consideration supersedes the significance of genetics, time commitment, or interdependence.
During the course of assessing the family structure and behaviors of a pediatric patient's family, the nurse has identified a number of highly significant risk factors. Which of the following actions should the nurse prioritize when addressing these risk factors? a) Validate the family's unique way of being. b) Introduce the family to a family that possesses fewer risk factors. c) Enlist the help of community and social support. d) Engage in appropriate health promotion activities.
d) Engage in appropriate health promotion activities. The role of the nurse in reducing risk factors involves activities that promote health for all family members at any level of development. This consideration supersedes the importance of validating the family's present way of being or enlisting the help of others. Introducing the family to a "model" family is ethically and logistically questionable.
A home healthcare nurse is performing a home visit to a 58-year-old man and his 56-year-old wife who receives home chemotherapy as part of her treatment regimen for breast cancer. The nurse will recognize that this family is likely to be engaged in which of the following development tasks? a) Adjusting to retirement b) Moving from the family home c) Adjusting to the loss of a spouse d) Maintaining ties with older and younger generations
d) Maintaining ties with older and younger generations This couple is likely to have children who are middle-aged adults, in which case the task of maintaining ties with older and younger generations is important. The couple is less likely to be retired or moving from their home and it would be presumptuous to assume the loss of a spouse.
alkaline
having a low concentration on hydrogen ions HAVING A PH GREATER THAN 7
Isotonic
having about the same concentration as the solution with which it is being compared
Coarse
heard at end expiration (discontinuous), do not clear with coughing, are loud, low pitched moist &/or bubbling (sounds like velcro slowly separating).
A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status?
daily weights Due to the possible numerous sources of inaccuracies in fluid intake and output measurement, the record of a client's daily weight may be the more accurate measurement of a client's fluid status. Laboratory tests are helpful in assessing kidney function and electrolyte values, but do not provide the precise information on fluid losses or gains as is provided by a daily weight (at the same time, using the same scale). Output measurements are not meaningful without intake measurements. (less)
The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The otoscope:
directs light into the ear canal and onto the tympanic membrane.
A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?
distended neck veins Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.
The nurse is obtaining a history from a 30-year-old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient
do you perform testicular self-examinations?
During morning rounds, the nurse asks a patient, How are you today? The patient responds, You today, you today, you today! and mumbles the words. This speech pattern is an example of:
echolalia
Hyperchlloremia
electrolyte disturbance in which there is an abnormally elevated level of the chloride ion in the blood. The normal serum range for chloride is 97 to 107 mEq/L. Hyperchloremia is defined as a chloride concentration exceeding this level.Hyperchloremia can affect oxygen transport.
Hypochloremia
electrolyte disturbance in which there is an abnormally low level of the chloride ion in the blood. The normal serum range for chloride is 97 to 107 mEq/L.
Muscle twitching, and nausea and vomiting may signify
electrolyte imbalances
Edema happens when there is which fluid volume imbalance?
extracellular fluid volume excess When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space.
A nurse observes another nurse place an unused dose of narcotics in their pocket. If caught, the nurse could be charged with which type of crime? A. negligence B. misdemeanor C. felony D. tort
felony
When an older adult client receiving a blood transfusion presents with an elevated blood pressure, distended neck veins, and shortness of breath, the client is most likely experiencing:
fluid overload Fluid overload can occur when blood components are infused too quickly or too voluminously. Symptoms include increased venous pressure, distended neck veins, dyspnea, coughing, and abnormal breath sounds.
Excessive use of laxatives, diaphoresis, and increased cardiac output may lead to a
fluid volume deficit
A dialysis unit nurse caring for a client with renal failure will expect the client to exhibit which fluid and electrolyte imbalances?
fluid volume exceess and acidosis Explanation: Fluid volume excess can be caused by malfunction of the kidneys (i.e., renal failure). The kidneys are also responsible for acid-base balance, and in the presence of renal failure, the kidneys cannot regulate hydrogen ions and bicarbonate ions, so the client develops metabolic acidosis (low ph, low bicarbonate)
A nurse is measuring intake and output for a patient who has congestive heart failure. What does not need to be recorded?
fruit consumption Any water consumption must be recorded in order to closely monitor a patient who has congestive heart failure. Many of these patients are on fluid restrictions. Sips of water, parenteral fluids, and frozen fluids count as fluid intake. The amount of water in fruits cannot be measured
An adult client tells the nurse that her peripheral vision is not what it used to be and she has a blind spot in her left eye. The nurse should refer the client for evaluation of possible
glaucoma A scotoma is a blind spot that is surrounded by either normal or slightly diminished peripheral vision. It may be from glaucoma.
Hypertonic
having a greater concentration than the solution with which it is being compared
STRIDOR
high pitched sound that is musical, whistling or squeaky (sibilant), or low pitched, hissing sound (sonorous). May be discontinuous (either inspiratory or expiratory) or continuous (throughout respiration). Indicates air movement through narrowed airway. Not cleared by coughing.
WHEEZING
high pitched sound that is musical, whistling or squeaky (sibilant), or low pitched, hissing sound (sonorous). May be discontinuous (either inspiratory or expiratory) or continuous (throughout respiration). Indicates air movement through narrowed airway. Not cleared by coughing.
An adult client tells the nurse that his father died of a massive coronary attack at the age of 65. The nurse should explain to the client that one of the risk factors for coronary heart disease is
high serum level of low-density lipoproteins. Dyslipidemia presents the greatest risk for the developing coronary artery disease. Elevated cholesterol levels have been linked to the development of atherosclerosis.
LOWER PH IS ACIDIC, WHILE HIHGHER PH IS ALKALINE, The character of acidic, basic and neutral is defined by the concentration of
hydrogen ions [H+](mol/L)
Diminished cognitive ability and hypertension may result from
hyperchloremia.
Jugular Vein may be enlarged if
hyperkalemia (too much fluid)
A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of:
hypokalemia. The frequent use of laxatives and diuretics promotes the excretion of potassium and magnesium from the body, increasing the risk for fluid and electrolyte deficits.
A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of:
hypokalemia. (low potassium) The frequent use of laxatives and diuretics promotes the excretion of potassium and magnesium from the body, increasing the risk for fluid and electrolyte deficits.
Which nursing intervention reflects practice according to Madeline Leininger's transcultural nursing theory? A. contacting a chaplain for every client B. providing the same care to each client who has had a myocardial infarction C. planning dietary interventions according to physiological condition D. incorporating client's request for complementary treatment therapy
incorporating client's request for complementary treatment therapy
The nurse assesses a hospitalized adult client and observes that the client's jugular veins are fully extended. The nurse contacts the client's physician because the client's signs are indicative of
increased central venous pressure. The level of the jugular venous pressure reflects right atrial (central venous) pressure and, usually, right ventricular diastolic filling pressure. Right-sided heart failure raises pressure and volume, thus raising jugular venous pressure. (less)
The client is exercising. The nurse understands that exercise has what effect on the body? Select all that apply.
increased heartrate increased blood pressure increased cardiac output During exercise, the blood pressure, heart rate and cardiac output increase. Peripheral vascular resistance is related to circulatory disorders.
An adult client visits the clinic and tells the nurse that he has been experiencing double vision for the past few days. The nurse refers the client to a physician for evaluation of possible A. glaucoma. B. increased intracranial pressure. C. hypertension. D. ophthalmic migraine.
increased intracranial pressure.
An adult client visits the clinic and tells the nurse that he has been experiencing double vision for the past few days. The nurse refers the client to a physician for evaluation of possible glaucoma. increased intracranial pressure. hypertension. ophthalmic migraine.
increased intracranial pressure.
Arterial blood gases reveal that a client's pH is 7.20. What physiologic process will contribute to a restoration of correct acid-base balance?
increased respiratory rate Hyperventilation results in increased CO exhalation and a consequent increase in pH, with the goal of attaining the ideal of 7.35 to 7.45. Retention of hydrogen ions, increased excretion of bicarbonate ions, and hypoventilation are all processes that contribute to decreased pH and an exacerbation of acidosis
A client is diagnosed with metabolic acidosis. The nurse develops a plan of care for this client based on the understanding that the body compensates for this condition by:
increasing ventilation through the lungs thus, increasing cabonic acid excretion, resulting in a fall of pac02
The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm:
is used to listen for high-pitched sounds.
Because women have more body fat than men do, they have
less body fluid than men
WHITE BLOOD CELLS FIGHT INFECTION
leukocytes or leucocytes, are the cells of the immune system that are involved in protecting the body against both infectious disease and foreign invaders. All white blood cells are produced and derived from a multipotent cell in the bone marrow known as a hematopoietic stem cell. Leukocytes are found throughout the body, including the blood and lymphatic system.[1]
solvents
liquid holding a substance in solution
A client visits the clinic and tells the nurse that she had a mastectomy 2 years ago. The nurse should assess the client for
lymphedema. Lymphedema results from blocked lymphatic circulation, which may be caused by breast surgery. It usually affects one extremity, causing induration and nonpitting edema.
A patient complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent A. macular degeneration B. open-angle glaucoma C. hemianopsia D. retinal detachment
macular degeneration
A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid?
maintenance of cell size Explanation: The main function of the intracellular fluid is to maintain cell size. Vascular fluid is essential for the maintenance of adequate blood volume, blood pressure, and cardiovascular system functioning. Interstitial fluid, which surrounds the body's cells, is important for the transportation of oxygen, nutrients, hormones, and other essential chemicals between the blood and the cell cytoplasm. Vascular and interstitial fluids also are important for waste removal. (less)
What is the nurse accountable for, according to state nurse practice acts? managing the care team effectively making nursing diagnoses prescribing PRN (as needed) medications mentoring other nurses
making nursing diagnoses
As the nurse palpates the lymph nodes of the neck, hard and fixed nodes are noted in the supra-clavicular region. This finding is consistent with which condition? A. malignancy B. inflammation C. enlargement D. hypothyroidism
malignancy
LOWER AIRWAY "RESPITORY AIRWAY" FUNCTION
mechanical movement: "work of breathing" WOB gas exchange: provides oxygen & removes carbon dioxide at the pulmonary & systemic levels assists in regulating acid-base balance
Because plasma proteins and hemoglobin possess chemical groups that can combine with or liberate hydrogen ions, they tend to DO WHAT? GIVE AN EXAMPLE
minimize changes in pH and serve as excellent buffering agents over a wide range of pH values working both inside and outside the cells For example, excess hydrogen ions in the blood cross over the plasma membrane of red blood cells and bind to the hemoglobin molecules that are plentiful in each red blood cell.
active transport
movement of ions or molecules across cell membranes, usually against a pressure gradient and with the expenditure of metabolic energy
hyperkalemia (acidosis)
murder, machine m- muscle wweakness u- urine oliguria (small urine amounts, and anuria (less than 100 ml per day) absent or defective urine output r- respiritary distress d- decreased cardiac contractibilirty, DIARRHEA e- ecg changes, r- reflexxes- hyperflexion, or areflexia (flaccid, loose, flabby)
Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL. For what assessment findings will the nurse be looking?
muscle cramping and tetany
Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL. For what assessment findings will the nurse be looking?
muscle cramping and tetany Manifestations of hypocalcemia include numbness and tingling of fingers, mouth, or feet; tetany; muscle cramps; and seizures
Manifestations of hypercalcemia include
nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech
Which client has more extracellular fluid?
newborn Newborns have more extracellular fluid than intracellular fluid.
In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking?
note-taking may impede the nurse's observations of the patient's nonverbal behaviors
Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse? Ask the client to: A. open the mouth B. sit upright C. sit without moving D. perform a chewing action
open the mouth
The optic nerves from each eyeball cross at the A. optic chiasma. B. vitreous humor. C. optic disc. D. visual cortex.
optic chiasma.
Which of the following is an average normal temperature in Centigrade for a healthy adult?
oral: 37.0°C
The mechanisms responsible for regulating this shift of fluids and transporting materials to and from intracellular compartments include
organs and body systems osmosis diffusion active transport , capillary filtration
The current blood pressure measurement on a 24-hour uncomplicated postoperative patient while standing at the bedside is 105/65. The last two readings were 130/75 and 125/70 while resting in bed. The nurse should be alert for signs of
orthostatic hypotension
The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations?
palpation
While assessing an adult client's head and neck, the nurse observes asymmetry in front of the client's ear lobes. The nurse refers the client to the physician because the nurse suspects the client is most likely experiencing a/an enlarged thyroid. lymph node abscess. neurologic disorder. parotid gland enlargement.
parotid gland enlargement.
osmosis
passage of a solvent through a semipermeable membrane from an area of lesser concentration to an area of greater concentration until equilibrium is established
The nurse assesses an adult client's thoracic area and observes a markedly sunken sternum and adjacent cartilages. The nurse should document the client's
pectus excavatum. Pectus excavatum is a markedly sunken sternum and adjacent cartilages (often referred to as funnel chest). It is a congenital malformation that seldom causes symptoms other than self-consciousness. (less)
Which situation is an example of battery that the nurse may experience while performing her duties at the health care facility? A. telling the client that he cannot leave the hospital B. performing a surgical procedure without getting consent C. taking the client's photographs without consent D. witnessing a procedure done on a client without his consent
performing a surgical procedure without getting consent
the protein buffer system is a mixture of
plasma proetins and the globin portion of hemoglobin in RBC.
After assessing pitting edema below the knee in a patient, the nurse would suspect that which vein may be occluded?
popliteal Although normal popliteal arteries may be nonpalpable, an absent pulse may also be the result of an occluded artery. Further circulatory assessment such as temperature changes, skin-color differences, edema, hair distribution variations, and dependent rubor (dusky redness) distal to the popliteal artery assists in determining the significance of an absent pulse. (less)
The anterior chest area that overlies the heart and great vessels is called the
precordium The anterior chest area that overlies the heart and great vessels is called the precordium.
With which of these patients would it be most appropriate for the nurse to use games during the assessment, such as having the patient blow out the light on the penlight?
preschool child
colloid osmotic pressure
pressure exerted by plasma proteins on permeable membranes in the body; synonym for oncotic pressure
A nurse is assessing a client after surgery and obtains the client's vital signs: pulse rate is 65 bpm, blood pressure is 122/76 mm Hg in the supine position. The nurse then obtains the client's vital signs on standing. Which finding would alert the nurse to the possibility of a an ECF volume deficit? Select all that apply.
pulse rate 90 bpm blood pressure 104/68 An increase in pulse rate of more than 20 beats per minute is a more sensitive indicator of ECF volume deficit than is a decrease in blood pressure. A drop of more than 15 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure with an increase in pulse rate frequently means the client is experiencing ECF volume depletion
The nurse suspects that a client has Cushing's syndrome. What assessment finding did the nurse use to make this clinical determination? red cheeks mask-like face swelling around the eyes elongated prominent forehead
red cheeks
A client reports using pain medication and sitting in a dark room on the onset of a migraine headache. In which part of the subjective section of the physical examination should the nurse document this information? A. onset B. location C. treatment D. relieving factors
relieving factors
The nurse is reviewing concepts related to ones heritage and beliefs. The belief in divine or superhuman power(s) to be obeyed and worshipped as the creator(s) and ruler(s) of the universe is known as:
religion
The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client?
renal failure Excess fluid volume may result from increased fluid intake or from decreased excretion, such as occurs with progressive renal disease. Excessive use of laxatives, diaphoresis, and increased cardiac output may lead to a fluid volume deficit. (less)
The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client?
renal failure Excess fluid volume may result from increased fluid intake or from decreased excretion, such as occurs with progressive renal disease.
A decrease in arterial blood pressure will result in the release of:
renin Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release. Renin is a protein (enzyme) released by special kidney cells when you have a decreased salt (sodium) level or low blood volume. angiotensinogenase
As more CO2 is exhaled
the H2CO3 (carbonic acid) level in the blood decreases, and the pH of the blood becomes more alkaline.
Auscultation
the act of listening for sounds within the body.
A woman age 58 years is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires:
replacement of fluids for those lost from vomiting and diarrhea. The therapeutic goal may be maintenance, replacement, treatment, diagnosis, monitoring, palliation, or a combination. This client requires intravenous fluids for replacement of those lost from vomiting and diarrhea.
A woman age 58 years is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires:
replacement of fluids for those lost from vomiting and diarrhea. The therapeutic goal may be maintenance, replacement, treatment, diagnosis, monitoring, palliation, or a combination. This client requires intravenous fluids for replacement of those lost from vomiting and diarrhea. (less)
A nurse is working with a culturally diverse group of clients. The nurse understands that cultural norms: A. allow nurses to predict a client's response. B. can be generalized to anyone of that culture. C. are fairly consistent across cultural groups. D. require an individualized approach by the nurse.
require an individualized approach by the nurse.
Photoreceptors of the eye are located in the eye's
retina The innermost layer, the retina, extends only to the ciliary body anteriorly. It receives visual stimuli and sends it to the brain. The retina consists of numerous layers of nerve cells, including the cells commonly called rods and cones. These specialized nerve cells are often referred to as "photoreceptors" because they are responsive to light (less)
VISIBLE SIGNS OF BREAST CANCER NODULE IS BETTER THAN A "CANCER PATCH"
retraction, or inward turning of the nipple. enlargement of one breast. dimpling of the breast surface. an existing lump that gets bigger. an "orange peel" texture to the skin. peau d'orang vaginal pain. unintentional weight loss. enlarged lymph nodes in the armpit.
The wife of a client asks the nurse if she could bring in a cream from home to apply to her husband's skin. She says, "Whenever anyone gets sick we always use this cream." The nurse interprets this as: A. ritual. B. ethnocentrism. C. stereotyping. D. subculture.
ritual
The capillary walls and cell membranes
separate the intracellular and extracellular compartments.
LYMPH NODES
small swellings in the lymphatic system where lymph is filtered and lymphocytes are formed. small, bean-shaped organs located throughout the lymphatic system. The lymph nodes are important in the function of the immune response and also store special cells that can trap cancer cells or bacteria that are traveling through the body through the lymph. Also known as lymph gland.
The primary extracellular electrolytes are:
sodium, chloride, and bicarbonate.
The nurse is preparing to perform the Romberg test on an adult male client. The nurse should instruct the client to
stand erect with arms at the sides and feet together. Perform the Romberg test. Ask the client to stand erect with arms at side and feet together. Note any unsteadiness or swaying. Then with the client in the same body position, ask the client to close the eyes for 20 seconds. Again note any imbalance or swaying. (less)
The nurse is preparing to perform the Romberg test on an adult male client. The nurse should instruct the client to
stand erect with arms at the sides and feet together. Perform the Romberg test. Ask the client to stand erect with arms at side and feet together. Note any unsteadiness or swaying. Then with the client in the same body position, ask the client to close the eyes for 20 seconds. Again note any imbalance or swaying.
The nurse is caring for a Native American/First Nations client who has been given a diagnosis of terminal cancer. Which reaction does the nurse anticipate? A. overwhelming grief B. stoic listening without display of emotion C. loud crying and vocalization D. requesting multiple family members to be contacted immediately
stoic listening without display of emotion
Which of the following factors affect blood pressure? Select all that apply.
stress weight ethinicty smoking Variations in blood pressure occur normally and are influenced by many factors including age, gender, ethnicity, weight, circadian cycle, position, exercise, emotions, stress, medications, and smoking. Gender is not a factor that affects blood pressure. (less)
The nurse is assessing a patients pain. The nurse knows that the most reliable indicator of pain would be the:
subjective report
Electrolytes
substance capable of breaking into ions and developing an electric charge when dissolved in solution
base
substance that can accept or trap a hydrogen ion; synonym for alkali
Buffer
substance that prevents body fluid from becoming overly acid or alkaline
colloids are
substances that do not dissolve into a true solution and do not pass through a semipermeable membrane
The nurse is going to take a blood pressure on a patient who has had a previous left mastectomy with lymph node dissection. What would be an appropriate action by the nurse?
take the blood pressure in the right arm
The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase:
takes time and reveals a surprising amount of information.
Stroke Volume (NORMAL= 60-80ml in each beat)
the amount of blood ejected by the left ventricle in one contraction. Although stroke volume can refer to either left or right side of the heart, it is most associated with the left side. It is measured in ml/beat and generally has a normal value of about 1 cc/kg stroke volume = cardiac output / heart rate OR subtract the end systolic volume from the end diastolic volume
A student has joined the marching band at his high school. The band begins practicing outside in August. This student and other band members need to be instructed that:
the band members should drink large amounts of water. Caution children and adolescents against the potential dangers of excessive exercise without adequate fluid replacement, especially in hot weather, because muscle damage and fluid and electrolyte imbalances can occur. (less)
Which client admitted to the emergency department (ED) might require the nurse to include interventions aimed at addressing cultural shock in the plan of care? A. the white client who is reporting chest pain B. the client who recently immigrated from Mexico who fell from a ladder C. the client who is Native American/First Nations who was admitted with flu-like symptoms D. the black client who has a history of asthma
the client who recently immigrated from Mexico who fell from a ladder
PRELOAD
the end diastolic volume that stretches the right or left ventricle of the heart to its greatest dimensions under variable physiologic demand.
When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into
the interstitial space.
NA+ IS A chief electrolyte of ECF; NORMAL LEVELS ARE.
the normal serum concentration of sodium: 135-145 mEq/L
The newly employed nurse working in a physician's office seeks advice on the job responsibilities and how best to implement these responsibilities. Who is the key informant for this nurse? A. the physician B. the nurse who has been working in this office for 8 years C. the office manager who has been employed by this physician for 14 years D. the unlicensed assistive personnel who has worked in this office for 22 years
the nurse who has been working in this office for 8 years
When the amount of CO2 in the blood increases, the sensitive chemoreceptors in the respiratory center in the medulla are stimulated to increase
the rate and depth of respirations to eliminate more CO2
Sodium along with chloride and a proportionate volume of water are regulated by
the renin-angiotensin-aldosterone system and natriuretic peptides
A 60-year-old woman has developed reflexive sympathetic dystrophy after arthroscopic repair of her shoulder. A key feature of this condition is that the:
the slightest touch, such as a sleeve brushing against her arm, causes severe, intense pain.
Total body water also differs by gender and the amount of fat cells in the body. Fat cells contain little water, whereas lean tissue is rich in water. Thus, the more obese a person is,
the smaller the person's percentage of total body water is when compared with body weight
The term total body water or fluid refers to
the total amount of water, which is approximately 50% to 60% of body weight in a healthy person.
The nurse is auscultating the heart sounds of an adult client. To auscultate Erb point, the nurse should place the stethoscope at the
third to fifth intercostal space at the left sternal border. Erb's point: Third to fifth intercostal space at the left sternal border.
Professional regulations and laws that govern nursing practice are primarily in place for which reason? A. to limit the number of nurses in practice B. to ensure that practicing nurses are of good moral standing C. to protect the safety of the public D. to ensure that enough new nurses are always available
to protect the safety of the public
1 mEq of any cation is equivalent to 1 mEq of any anion. The total cations in the body are normally equal
to the total anions, maintaining homeostasis (balanced statTE).
An adult client visits the clinic and tells the nurse that he has been "spitting up rust-colored sputum." The nurse should refer the client to the physician for possible
tuberculosis. Rust-colored sputum is associated with tuberculosis or pneumococcal pneumonia.
An older client visits the clinic accompanied by his daughter. The daughter tells the nurse that her father has been experiencing severe headaches that usually begin in the morning and become worse when he coughs. The client tells the nurse that he feels dizzy when he has the headaches. The nurse refers the client for further evaluation because these symptoms are characteristic of a A. migraine headache. B. cluster headache. C. tension headache. D. tumor-related headache.
tumor-related headache.
When preparing to examine a patient's sclera and conjunctiva during an eye examination, the nurse should instruct the patient to move both eyes to look in which direction?
up The correct technique to use when examining a patient's sclera and conjunctiva during an eye examination is to instruct the patient to look up. Having the patient look down, to the right, or to the left will not provide visualization of the sclera or conjunctiva during the examination. (less)
The nurse is unable to palpate the right radial pulse on a patient. The best action would be to:
use a Doppler device to check for pulsations over the area.
Older adults are at increased risk for electrolyte imbalances during and after bowel preparation for procedures such as a colonoscopy or barium enema. Research has shown that bowel preparation solutions in clients over age 65 years are associated with
vascular volume deficit, hyperphosphatemia , hypokalemia, hypocalcemia
The nurse explains to the client that smoking has what effect on the body? Select all that apply.
vasoconstriction hypertension periphreal vascular disease
Body fluid is located in two fluid compartments
—the intracellular fluid or extracellular fluid, based on its location in the body
Which statement by the patient would the nurse consider to be a functional goal? Select all that apply.
• "I want to walk without a walker at my daughter's wedding." • "I want to play tennis with my friends by May." • "I want to sleep uninterrupted for 6 hours each night Patient statements the nurse would consider to be functional goals include walking without a walker, sleeping uninterrupted, and playing tennis. Rating pain as a 4 or less is a pain management goal. Imagining being on a beach is an example of imagery, a non-pharmacological pain management strategy. (less)
A nurse has just finished assessing a client. Which of the following are objective data that the nurse would likely have gathered?
• A description of a large bruise on the client's thigh • The client's weight • The presence of a lump in the client's breast discovered on palpation Subjective data include information that the client or significant others tell the nurse and typically consist of biographic data, present health concern(s) and symptoms, personal health history, family history, and lifestyle and health practices information. Objective data are what the nurse observes through inspection, palpation, percussion, or auscultation. (less)
The nurse is determining the number of annual influenza inoculations that will need to be provided to a group of community members. Which members would benefit from receiving this vaccination? (Select all that apply.)
• Adult patient with chronic obstructive pulmonary disease • Adult patient caring for children under age 5 • Older adult attending adult day care The Centers for Disease Control and Prevention recommend the annual influenza vaccination for any adult with a chronic pulmonary condition, any adult who attends a chronic care facility, and caregivers of children younger than 5 years. The Centers for Disease Control and Prevention do not specifically identify the populations that include a young adult patient who lives alone or the adolescent patient being home schooled for the annual influenza vaccination, although all people wishing to reduce the risk of infection should be vaccinated. (less)
The nurse is reviewing the patient's medical record. Which of the following does the nurse recognize as accurate documentation? (Select all that apply.)
• Bowel sounds are hyperactive in all 4 quadrants. • Coarse rhonchi noted throughout lung fields • Left dorsalis pedis pulse weaker than right. Accurate documentation is detailed and explicit, such as the information regarding bowel sounds, lung sounds, and pedal pulses. Examples of ambiguous documentation include the data regarding pain - a pain rating should be specified. Specific descriptions should be documented to support the judgment of confusion and inappropriate behavior. (less)
How does Urie Bronfenbrenner describe development in his systems model of development? Select all that apply.
• Development is important at all ages • Development is continuous • Development is an active rather than a passive process Urie Bronfenbrenner proposed a systems model of development, which describes the individual's development in interaction with the immediate environment. In this approach, development is continuous, important at all ages, and active rather than passive
When considering eye safety, what instructions should the nurse provide to a patient newly prescribed contact lenses? (Select all that apply.)
• Do not share lenses. • Keep the lenses clean. • Wash hands before inserting or removing the lenses. • Discard unused portions of contact solutions at the expiration date. The nurse should instruct the patient to not share the lenses, to keep the lenses clean, to wash hands before inserting or removing the lenses, and to discard unused portions of contact solutions at the expiration date. The lenses should be inspected for scratches or damage every year. (less)
A nurse is interviewing a client who complains of dyspnea. Which of the following findings would tend to indicate an underlying cardiovascular problem in the client? Select all that apply.
• Edema • Angina • Orthopnea Edema or angina that occurs with dyspnea may indicate a cardiovascular problem. Orthopnea (difficulty breathing when lying supine) may be associated with heart failure. Sleep apnea (periods of breathing cessation during sleep) may be the source of snoring and gasping sounds. White or mucoid sputum is often seen with common colds, viral infections, or bronchitis. (less)
A 70-year-old client is scheduled for a colonoscopy and is prescribed a bowel preparation solution. The nurse would be alert for which potential imbalance? Select all that apply.
• Hypokalemia ( low potassium) • Hypocalcemia ( low calcium) • Hyperphosphatemia (high phosphate) Explanation: Older adults are at increased risk for electrolyte imbalances during and after bowel preparation for procedures such as a colonoscopy or barium enema. Research has shown that bowel preparation solutions in clients over age 65 years are associated with vascular volume deficit, hyperphosphatemia, hypokalemia, and hypocalcemia.
The nurse when caring for patients of a culture different from the nurse's should be respectful of different viewpoints and aware that culture can affect the following areas of growth and development: (Check all that apply.)
• Independence/dependence • Self-motivation/interdependence • Intimate relationships/family relationships Culture profoundly affects the individual development of all patients. Depending on Eastern or Western viewpoints, culture can affect a person's independence/dependence as well as self-motivation and interdependence. Culture also influences intimate and family relationships. The rate of physical growth and motor development are not influenced by a patient's culture. (less)
What nursing interventions would be appropriate for a patient diagnosed with deficient fluid volume? (Select all that apply.)
• Intravenous therapy • Electrolyte management • Nutrition management Explanation: If a patient is at a fluid volume deficit intravenous therapy may be ordered by the primary care provider to replenish fluids and electrolytes, warranting fluid and electrolyte management. Nutrition management may help to increase and maintain electrolyte levels by adding foods high in certain electrolytes to the diet. Hypervolemia refers to fluid volume excess. Fluid restriction would be contraindicated because the patient is already at a deficit. Edema would be monitored in the case of fluid volume excess. (less)
The thoracic cavity contains which of the following organs? Select all that apply.
• Most of the esophagus • Heart • Lungs The cavity contains the heart, lungs, thymus, distal part of the trachea, and most of the esophagus. It does not contain the stomach or the pancreas.
Goals, although not specific for peripheral vascular disease, focus on areas of risk. What are these areas of modifiable risk? Select all that apply.
• Overweight • Smoking • Lack of exercise Goals are not specific for peripheral vascular disease but instead focus on areas of risks for such disease, such as smoking, overweight, and lack of regular exercise. Family history and ethnicity are not modifiable risk factors. (less)
The nursing instructor informs students that Healthy People contains several goals associated with growth and development. Some of these include which of the following? (Check all that apply.)
• Reduce the indigenous cases of vaccine-preventable diseases. • Reduce the occurrence of spina bifida and other neural tube defects. • Increase abstinence from alcohol, cigarettes, and illicit drugs among pregnant women. Healthy People has some goals associated with growth and development, including reducing indigenous cases of vaccine-preventable diseases, reducing spina bifida and other defects, and increasing abstinence from alcohol, drugs, and cigarettes among pregnant women. Nurses would be focused on optimizing activity in the eldery. Reducing the number of hours worked in young adults is not a goal of Healthy People. (less)
The nurse is providing teaching about cardiovascular disease in a community setting. What risk factors would the nurse identify to the group as those they can modify through lifestyle choices? Select all that apply.
• Smoking • Blood pressure • Cholesterol Correct Explanation: Smoking, cholesterol and blood pressure can be controlled through lifestyle choices. Age and family history are non-modifiable risk factors.
A nursing instructor is teaching the class about different theories of pain. The instructor informs the students that the most common clinical interpretation of pain transmission is called "nociception." The instructor includes the following components in nociception: (Check all that apply.)
• Transduction • Modulation • Perception • Transmission The most common clinical interpretation of pain is a concept called nociception, which means the perception of pain by sensory receptors located throughout the body and nociceptors. The following are the four steps in nociception: transduction, transmission, perception, and modulation. Initiation is not associated with this process. (less)
The nurse prepares to perform a cardiovascular examination. The nurse understands the components of this examination include (Select all that apply.)
• examining the face • examining the neck • inspecting and palpating the precordium • inspecting the hands and lower legs
