HESI assessment

A client with chronic depression has a history of suicidal ideations. Place the following nursing assessment questions in the appropriate order to best ensure client safety. Correct 1. "Are you thinking about hurting yourself?" Correct 2. "Have you decided upon a plan to harm yourself?" Correct 3. "What is your plan for killing yourself?" Correct 4. "How would you get what you need to end your life?"

...

A woman is admitted to the emergency department with trauma that indicates possible abuse. List in priority order the appropriate nursing interventions. Correct 1. Assisting in the treatment of the client's physical injuries Correct 2. Gathering a more in-depth history Correct 3. Encouraging the client to express her feelings Correct 4. Providing information about safe houses

...

A 9-year-old child is admitted to the pediatric unit with a tentative diagnosis of an infratentorial brain tumor. What presenting sign does the nurse anticipate when assessing the child? 1 Ataxia 2 Papilledema 3 Cranial enlargement 4 Generalized seizures

1

A client has bright-red erythematosus macules and papules on the skin. What could be the diagnosis? 1Drug eruption 2 Atopic dermatitis 3 Contact dermatitis 4 Nonspecific eczematous dermatitis

1

A client is admitted via the emergency department with the tentative diagnosis of diverticulitis. Which test commonly is prescribed to assess for this problem? 1 Computed tomography (CT) scan 2 Gastroscopy 3 Colonoscopy 4 Barium enema

1

A couple arrives at the mental health clinic for counseling because the husband consistently believes that his wife is having multiple affairs. After several sessions a delusional disorder is diagnosed. What specific subtype of the delusion does the nurse identify? 1 Jealousy 2 Somatic 3 Grandiose 4 Persecutory

1

A nurse is caring for a client with type 1 diabetes who developed ketoacidosis. Which laboratory value supports the presence of diabetic ketoacidosis? 1 Increased serum lipids 2 Decreased hematocrit level 3 Increased serum calcium levels 4 Decreased blood urea nitrogen level

1

After assessing a client's vision, the nurse observes the client has difficulty seeing objects that are far away. Which condition does the nurse suspect the client is experiencing? 1 Myopia 2 Hyperopia 3 Presbyopia 4 Astigmatism

1

After surgery a 2-month-old infant is returned to the pediatric unit with an intravenous infusion running and a nasogastric tube in place. What is the initial nursing action? 1 Assessing the infant's status 2 Giving the infant a mild sedative 3 Connecting the nasogastric tube to wall suction 4 Placing the intravenous tubing through an infusion pump

1

During a follow-up office visit, an older client who has been undergoing treatment for the last 5 months for osteomyelitis notes perianal itching and diarrhea. Which other finding does the nurse correlate with this information? 1 Whitish-yellow lesions in the oral cavity 2 Presence of glucose and ketones in urine 3 Flexion contracture of the lower extremities 4 Overgrowth of genital wart-like lesions

1

The nurse is assessing a client with multiple injuries due to a severe motor vehicle accident. Which nursing intervention should the nurse perform first? 1 Providing bag-valve-mask ventilation 2 Administering glucose by intravenous (IV) route 3 Applying direct pressure to the severe bleeding areas 4 Inserting large bore peripheral IV lines in the antecubital area

1

The nurse is teaching the client about wound healing. Which feature is associated with the "maturation phase" of normal wound healing? 1 The scar is firm and inelastic on palpation. 2 Fibrin strands form a scaffold or framework. 3 White blood cells migrate into the wound. 4 Epithelial cells are grown over the granulation tissue bed.

1

Upon assessment of a client, the nurse finds the following lesion. Which condition is most likely present in this client? 1 Varicella 2 Athlete's foot 3 Chronic dermatitis 4 Stage 3 pressure sore

1

Which is the most common opportunistic infection in a client infected with human immunodeficiency virus (HIV)? 1 Oropharyngeal candidiasis 2 Cryptosporidiosis 3 Toxoplasmosis encephalitis 4 Pneumocystis jiroveci pneumonia

1

While assessing the skin of a client, the nurse notices an elevated, solid lesion measuring 4 mm × 4 mm in size. Which type of lesion is observed in the client? 1 Papule 2 Vesicle 3 Pustule 4 Macule

1

While conducting an eye examination, the ophthalmologist shines a light into the client's pupil and observes that there is a slow recovery of the pupil size. Which muscular atrophy is responsible for this condition? 1 The iris dilator muscle 2 The iris sphincter muscle 3 The medial rectus muscle 4 The lateral rectus muscle

1

Why is it important for the nurse to know the infant's gestational age and how it compares with the birth weight? 1 Potential problems may be identified. 2 Infants lose weight during the first few days of life. 3 Hospitals need this information to calculate census. 4 Infants' weight must be included on the admission record.

1

The registered nurse (RN) is teaching a student nurse about taking a current history from a client who is suspected to have a neurologic disorder. Which statement made by the student nurse indicates the RN needs to follow up? Select all that apply. 1 "I should ask the client about insomnia." 2 "I should ask the client about diabetes mellitus." 3 "I should ask the client about weakness and clumsiness." 4 "I should ask the client about any difficulty in swallowing." 5 "I should ask the client about numbness and tingling sensations."

1,2

While conducting an assessment, the nurse finds that the client shivers uncontrollably and experiences memory loss, depression, and poor judgment. What might the client's body temperature be? 1 29° C 2 33° C 3 36° C 4 38° C

2

What should the nurse assess when inspecting the mouth and pharynx of a client suspected of having a pulmonary disorder? Select all that apply. 1 Polyps 2 Gag reflex 3 Shotty nodes 4 Poor dentition 5 Gum retraction

2,4,5

A client with a skin infection on the hand reports itching near the site of infection. Upon assessment, the nurse notices serpiginous patches with elevated borders. What could be the possible diagnosis? 1 Tinea pedis 2 Tinea capitis 3 Tinea manus 4 Tinea corporis

3

A multipara whose membranes have ruptured is admitted in early labor. Assessment reveals a breech presentation, cervical dilation of 3 cm, and fetal station at -2. For what complication should the nurse assess when caring for this client? 1 Vaginal bleeding 2 Urinary tract infection 3 Prolapse of the umbilical cord 4 Meconium in the amniotic fluid

3

At which stage of development should the nurse anticipate that pediatric clients will begin to show differences in play activities that are related to gender? 1 Preschool 2 Adolescence 3 Late school-age 4 Early school-age

3

For what clinical indicator should a nurse assess a client who is having a gastric lavage? 1 Decreased serum pH 2 Increased serum oxygen level 3 Increased serum bicarbonate level 4 Decreased serum osmotic pressure

3

The nurse is performing an assessment and notes that the client has exophthalmos and complains of double vision. These assessment findings are found with which condition? 1 Glaucoma 2 Hypertension 3 Hyperthyroidism 4 Sinus infection

3

The nurse is verbally interviewing and taking a history of a client who was admitted to the hospital. Which phase of the nursing process is being used in this situation? 1 Planning 2 Evaluation 3 Assessment 4 Diagnosis

3

Two clients with polydipsia and polyuria arrived at the hospital. Both were having similar symptoms but were diagnosed with different types of diabetes insipidus. Which assessment finding helped to differentiate the diagnosis? 1 Urine output 2 Specific gravity 3 Urine osmolarity 4 Serum osmolarity

3

Which assessing technique involves tapping a client's skin with the fingertips to cause vibrations in the underlying tissues? 1 Palpation 2 Inspection 3 Percussion 4 Auscultation

3

While assessing a client recovering from a head injury, the nurse notices a loss of movement in the client's tongue while attempting to talk. Which could be the possible reason for the client's condition? 1 Damage to the facial nerve 2 Damage to the trigeminal nerve 3 Damage to the hypoglossal nerve 4 Damage to the glossopharyngeal nerve

3

While completing an assessment, the nurse finds that a client has decreased thickness and excessive dryness of the epidermis. Which clinical finding is associated with this skin assessment? 1 Skin tears 2 Skin cancer 3 Skin fragility 4 Skin hyperplasia

3

A nurse is reviewing the physical examination and laboratory tests of a client with malaria. Which important clinical indicators should the nurse watch for when reviewing data about this client? Select all that apply. 1 Polyuria 2 Leukopenia 3 Hyperthermia 4 Splenomegaly 5 Erythrocytosis

3,4

The nurse is assessing a client with severe nodule-forming rheumatoid arthritis for possible Felty syndrome. Which assessment findings are consistent with Felty syndrome? Select all that apply. 1 Itchy eyes 2 Dry mouth 3 Leukopenia 4 Splenomegaly 5 Photosensitivity

3,4

A 50-year-old client with a 30-year history of smoking reports a chronic cough and shortness of breath related to chronic obstructive pulmonary disease (COPD). The clinical data on admission are as follows: a heart rate of 100, a blood pressure of 138/82, a respiratory rate of 32, a tympanic temperature 36.8 °C, and an oxygen saturation of 80%. Which vital signs obtained by the nurse during the therapy indicates a positive outcome? Select all that apply. 1 Radial pulse: 70 2 Temperature: 37 °C 3 Respiratory rate: 14 4 Blood pressure: 110/70 5 Oxygen saturation: 92%

3,4,5

The parents of a toddler tell the nurse the family has been living in a very old building. The nurse should carefully assess the child for the irreversible effects of possible lead poisoning by focusing on the what? 1 Urinary system 2 Skeletal system 3 Hematologic system 4 Central nervous system

4

Which disease is caused by Coronaviruses? 1 Pertussis 2 Inhalation anthrax 3 Coccidioidomycosis 4 Severe acute respiratory syndrome

4

Which positioning should be avoided while assessing a client with a history of asthma? 1 Sitting 2 Supine 3 Dorsal recumbent 4 Lateral recumbent

4

Which question should the nurse ask the parents of a 3-year-old client to assess fine motor skills? 1 "Is your child able to use scissors?" 2 "Is your child able to ride a tricycle?" 3 "Is your child able to climb stairs using alternate feet?" 4 "Is your child able to build a tower using 9 or 10 blocks?"

4

A client is admitted to the hospital due to inhaling noxious chemicals. During an examination, the primary healthcare provider identifies damage to the upper airway. Which manifestations will the nurse most likely observe related to upper airway damage? Select all that apply. 1 Edema 2 Stridor 3 Blisters 4 Dyspnea 5 Wheezing

1,2,3

A client with a history of heart failure is admitted to the hospital with the diagnosis of pulmonary edema. For which signs and symptoms specific to pulmonary edema should the nurse assess the client? Select all that apply. 1 Crackles 2 Coughing 3 Orthopnea 4 Yellow sputum 5 Dependent edema

1,2,3

The nurse is admitting a client with a history of bipolar disorder. The nurse determines that the client is in the manic phase. Which signs and symptoms contribute to the nurse's conclusion? Select all that apply. 1 Irritability 2 Grandiosity 3 Pressured speech 4 Thought blocking 5 Psychomotor retardation

1,2,3

What clinical manifestations does a nurse expect a client with systemic lupus erythematosus (SLE) most likely to exhibit? Select all that apply. 1 Joint pain 2 Facial rash 3 Pericarditis 4 Weight gain 5 Hypotension

1,2,3

Which questions regarding gross motor skills should the nurse include when conducting the interview portion of the developmental assessment with the parent of an infant between 10 and 12 months of age? Select all that apply. 1 "Does your baby stand independently?" 2 "Is your baby able to walk with assistance?" 3 "Does your baby sit from a standing position?" 4 "Is your baby able to place objects into a container?" 5 "Does your baby hold a crayon and make marks on paper?"

1,2,3

What questions should a nurse ask when, during the assessment of an older adult, the nurse suspects suicidal intent? Select all that apply. 1 "Do you think about killing yourself?" 2 "How often do you have these thoughts?" 3 "Do you have the means to kill yourself?" 4 "Have you thought about your loved ones?" 5 "How would you kill yourself if you decided to do it?"

1,2,3,5

A client with kidney dysfunction is about to undergo renal testing using a contrast medium. Which nursing interventions should be conducted before the procedure to ensure the client's safety? Select all that apply. 1 Assessing the client for a history of cirrhosis 2 Asking the client if he or she has a known shellfish allergy 3 Assessing the client for a history of lactic acidosis 4 Assessing the client's hydration status by checking blood pressure and respiratory rate 5 Asking the client to discontinue metformin 12 hours before the procedure

1,2,4

Which growth and developmental assessments should the nurse include when conducting a health maintenance visit for a 15-month-old toddler? Select all that apply. 1 Length 2 Weight 3 Body mass index 4 Head circumference 5 Developmental screening

1,2,4

A nurse is assessing a female client with Cushing syndrome. Which clinical findings can the nurse expect to identify? Select all that apply. 1 Hirsutism 2 Menorrhagia 3 Buffalo hump 4 Dependent edema 5 Migraine headaches

1,3

A nurse is interviewing a client who was diagnosed with systemic lupus erythematosus (SLE). Which common responses to this disease can the nurse expect the client to exhibit? Select all that apply. 1 Butterfly facial rash 2 Firm skin fixed to tissue 3 Inflammation of the joints 4 Muscle mass degeneration 5 Inflammation of small arteries

1,3

The registered nurse asks a client to rate his or her pain on a scale from 0 to 10, then instructs the nursing student to perform a physical assessment. Which assessments performed by the nursing student would be appropriate? Select all that apply. 1 Palpating for tenderness 2 Observing nonverbal cues 3 Inspecting any areas of discomfort 4 Noticing if the pain localized or radiated 5 Noticing if the client gives nonverbal signs of pain

1,3

A client with preeclampsia is admitted to the labor and birthing suite. Her blood pressure is 130/90 mm Hg, and she has 2+ protein in her urine along with edema of the hands and face. Which signs or symptoms would the client display if she were developing hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome)? Select all that apply. 1 Headache 2 Constipation 3 Abdominal pain 4 Vaginal bleeding 5 Flulike symptoms

1,3,5

A new mother's laboratory results indicate the presence of cocaine and alcohol. Which craniofacial characteristics indicate to the nurse that the newborn has fetal alcohol syndrome (FAS)? Select all that apply. 1 Thin upper lip 2 Wide-open eyes 3 Small upturned nose 4 Larger-than-average head 5 Smooth vertical ridge in the upper lip

1,3,5

The nurse is involved in a therapeutic relationship with a depressed client. Which question and/or statement by the nurse is appropriate for stage 1 of this relationship? Select all that apply. 1 "I'm here to talk with you about how you've been feeling." 2 "How do you feel about keeping a journal regarding how you are feeling?" 3 "Are you experiencing any suicidal or homicidal thought?" 4 "Are you open to the prospect of being prescribed antidepressant medication?" 5 "What we talk about will be shared only with your treatment team."

1,3,5

Which conservation exercises should the nurse include in the assessment process of a child who is 6 years of age? Select all that apply. 1 Asking the child to compare the mass of two balls 2 Asking the child to compare the weight of two balls 3 Asking the child to compare the length of pencils 4 Asking the child to compare the volume in two cups 5 Asking the child to compare the number of marbles

1,3,5

Which symptoms are common during the fulminant stage of inhalation of anthrax? Select all that apply. 1 Dyspnea 2 Dry cough 3 Diaphoresis 4 Mild chest pain 5 High temperature

1,3,5

A 6-month-old infant is admitted to the pediatric unit with severe diarrhea. What nursing assessment is most indicative of dehydration? 1 Level anterior fontanel 2 Decreased urine output 3 Warm skin temperature 4 Slow, labored respirations

2

A client complains of sudden muscle weakness during times of anger or laughter that may occur at any time during the day. Which condition should be suspected in this client? 1 Insomnia 2 Cataplexy 3 Narcolepsy 4 Sleep apnea

2

A client is bleeding excessively after the birth of her newborn. The healthcare provider prescribes fundal massage and an IV infusion containing 10 units of oxytocin at a rate of 100 mL/hr. The nurse's evaluation of the client's responses to these interventions reveals a blood pressure of 135/90 mm Hg, a boggy uterus 3 cm above the umbilicus and displaced to the right, and a perineal pad saturated with bright-red lochia. What is the nurse's next action? 1 Increasing the infusion rate 2 Checking for a distended bladder 3 Continuing to perform fundal massage 4 Continuing to assess the blood pressure

2

A nurse completes the assessment of a female client who cannot function because of an impending divorce. What is the most effective nursing intervention for this client at this time? 1 Helping her identify precipitating factors 2 Assisting her in exploring new coping abilities 3 Limiting her support system to promote independence 4 Developing her plan of care to fit her perception of the events

2

A nurse is assessing a newborn with caput succedaneum. How does the nurse explain the cause of this fetal condition to the new mother? 1 Overlap of fetal bones as they pass through the maternal birth canal 2 Swelling of the soft tissue of the scalp as a result of pressure during labor 3 Hemorrhage of ruptured blood vessels that does not cross the suture lines 4 Accumulation of fluid resulting from partial blockage of cerebrospinal fluid drainage

2

A nurse is caring for a male client who was admitted to the mental health unit with the diagnosis of schizophrenia. The client is hostile and experiencing auditory hallucinations and states that the voices are saying that they are going to poison him because he is bad. What type of schizophrenic behavior does the nurse identify? 1 Residual 2 Paranoid 3 Catatonic 4 Disorganized

2

A nurse is working with a couple and their two children. The 14-year-old son has been in trouble at school because of truancy and poor grades. The 16-year-old daughter is quiet and withdrawn and refuses to talk to her parents. The parents have had severe marital problems for the past 10 years. What is the priority nursing concern at this time? 1 How the parents can set limits on their children's behavior 2 How the couple's marital problems are affecting their children 3 How the son's behavior in school will impair his relationships with peers 4 How the daughter's withdrawn behavior limits her ability to talk with her friends

2

A nurse who is assessing a full-term newborn elicits the Babinski reflex. How is this reflex elicited? 1 Striking the surface of the crib suddenly 2 Stroking the outer sole of the foot from the heel to the little toe 3 Maintaining the supine position and applying pressure to the soles of the feet 4 Holding the infant's body upright and allowing the feet to touch the surface of the crib

2

After reviewing the client's laboratory reports, the physician concludes that the client has primary hypofunction of the adrenal gland. Which clinical manifestation is likely to be observed in that client? 1 Edema at extremities 2 Uneven patches of pigment loss 3 Reddish-purple stretch marks on the abdomen 4 "Buffalo hump" between shoulders on the back

2

During an assessment interview the client reports overwhelming, irresistible attacks of sleep. Which sleep disorder does the nurse conclude that the client is experiencing? 1 Insomnia 2 Narcolepsy 3 Sleep terror 4 Sleep apnea

2

In which stage of Kohlberg's theory of moral development does the nurse anticipate a client to realize there is more than one right point of view? 1 Stage 1 2 Stage 2 3 Stage 3 4 Stage 4

2

Postoperatively, a client who had a thyroidectomy complains of tingling and numbness of the fingers and toes, and the nurse observes muscle twitching. Which complication does the nurse suspect the client is experiencing? 1 Hypokalemia 2 Hypocalcemia 3 Thyrotoxic crisis 4 Hypovolemic shock

2

The nurse is assessing four clients with infections in the mouth. Which client can be treated by nystatin as an oral suspension? 1 Client A 2 Client B 3 Client C 4 Client D

2

The nurse is caring for a newborn with caput succedaneum. The nurse is able to differentiate caput succedaneum from cephalhematoma because of what characteristic of the scalp edema in caput succedaneum? 1 Becomes ecchymotic 2 Crosses the suture line 3 Increases after several hours 4 Is tender in the surrounding area

2

The registered nurse is evaluating the statements of a new orienting nurse about wound dressing. Which statement made by the new orienting nurse indicates the need for further teaching? 1 "I should wash my hands with alcohol." 2 "I should take the cotton swab placed on the table." 3 "I should wash my hands before touching the wound." 4 "I should wear gloves before touching the site of injury."

2

What birth weight in a neonate indicates that the infant is a very low birth weight (VLBW) infant? 1 900 g 2 1300 g 3 1700 g 4 2000 g

2

What should the nurse ask while assessing a Latina woman with depression for the risk of self-harm? 1 "When did you last spend time with friends?" 2 "How do you express yourself when you're angry?" 3 "When did you first notice that you were depressed?" 4 "Do you have interests outside your work and home?"

2

Which assessment question should the nurse ask the parents of a 1-year-old client to assess language development? 1 "Does your child form sentences?" 2 "Does your child say three to five words?" 3 "Does your child understand 10 words?" 4 "Does your child respond when you say his name?"

2

Which changes to the client's skin are caused by the atrophy of eccrine sweat glands? 1 Bruises 2 Dry skin 3 Wrinkles 4 Skin shearing

2

Which statement does the nurse know is true regarding a grade 2 goiter? 1 A goiter mass is impalpable. 2 A goiter is usually asymmetrical. 3 A goiter mass moves up while swallowing. 4 A goiter is invisible with the neck in normal position.

2

A client is admitted with a diagnosis of Cushing syndrome. Which clinical manifestations should the nurse expect the client to exhibit? Select all that apply. 1 Polyuria 2 Weakness 3 Hypertension 4 Truncal obesity 5 Intermittent tonic spasms

2,3,4

A nursing instructor asks a nursing student about tips for examining a 4-year-old sick child. Which statements made by the nurse indicate adequate teaching? Select all that apply. 1"I should call the child as 'Mr.' or 'Ms.'" 2 "I should give the child time to play around." 3 "I should start the examination with the child's fingers and hands." 4 "I should gather all information related to the child's sickness from the parents." 5 "I should make judgments when parents share the details of their child's sickness."

2,3,4

Which findings should the nurse expect to see in a client with chronic obstructive pulmonary disease? Select all that apply. 1 Elevated levels of partial arterial oxygen 2 Elevated levels of eosinophils 3 Elevated levels of neutrophils 4 Elevated levels of red blood cells 5 Elevated levels of peripheral capillary oxygen saturation

2,3,4

The nurse is caring for four different clients in an emergency department. In which order should the nurse care for the clients according to priority for receiving care? 1. Client reporting a neck sprain 2. Client reporting shortness of breath 3.Client reporting severe abdominal pain 4. Client reporting a simple hip fracture

2,3,4,1

The nurse is teaching growth and development activities to the parents of a 3-month-old infant. Which statements does the nurse include in the teaching plan? Select all that apply. 1 "Your child should be able to show the grasp reflex." 2 "Your child should be able to coo, babble, and chuckle." 3 "Your child should be able to pull at blankets or clothes." 4 "Your child should be able to put the feet into the mouth when supine." 5 "Your child's head can come up to a 45- to 90-degree angle from the table."

2,3,5

A nurse is assessing a newborn with suspected retention of a fetal structure that will result in a congenital heart defect. Which fetal structures should undergo change after birth? Select all that apply. 1 Mitral valve 2 Foramen ovale 3 Pulmonary veins 4 Ductus arteriosus 5 Pulmonary arteries

2,4

A nurse is caring for a school-aged child with type 1 diabetes and determines that the child is experiencing an episode of hyperglycemia. What assessments led the nurse to this conclusion? Select all that apply. 1 Irritability 2 Dry skin 3 Diaphoresis 4 Increased thirst 5 Deep, rapid breathing

2,4,5

A nurse inserts a nasogastric tube into a preterm infant's esophagus for feedings. Which assessment findings signify correct placement of the tube? Select all that apply. 1 The infant cries without noise. 2 Aspiration produces a small quantity of light-yellow or light-green liquid. 3 The tube is inserted to a depth from the ear to the tip of the nose to the sternum. 4 A whooshing sound is auscultated in the epigastric area when air is introduced into the tube. 5 Testing of the aspirate with the use of a Nitrazine strip reveals that the gastric fluid is acidic.

2,5

The nurse is assessing a client suspected of having hypercortisolism. Which questions should the nurse ask to help confirm the diagnosis? Select all that apply. 1 "Did you lose any weight unintentionally?" 2 "Did you notice your extremities to be thin?" 3 "Did you notice any roughness of your skin?" 4 "Did you notice any skin darkening recently?" 5 "Did the hair on your body become thicker?"

2,5

A 10-year-old child who was rescued from a house fire is brought to the emergency department with burns of the extremities. During assessment of the child, what finding is of most concern to the nurse? 1 Increased temperature 2 Increasing activity level 3 Burns around the mouth 4 Edema distal to the burns

3

A 3-year-old child is brought to the emergency department by the mother, who reports that her child fell down the stairs and sustained injuries to the right arm and leg. During the physical assessment the nurse identifies a number of old bruises on the child's back, buttocks, and upper arms. What should the nurse say to the child to obtain additional information? 1 "Why did you fall down the stairs?" 2 "Did you really fall down those stairs?" 3 "Show me how you fell down the stairs." 4 "Your mommy must have told you to say you fell down the stairs."

3

A nurse in an outpatient mental health setting has been assigned to care for a new client who has been found to have an antisocial personality disorder. What does the nurse expect to observe in the client during the assessment? 1 Pays great attention to detail and demonstrates a high level of anxiety 2 Has scars from self-mutilation and a history of many negative relationships 3 Displays charm, has an above-average intelligence, and tends to manipulate others 4 Demonstrates suspiciousness, avoids eye contact, and engages in limited conversation

3

A nurse is assessing a client with the diagnosis of primary hypertension. Which clinical finding does the nurse identify as an indicator of primary hypertension? 1 Mild but persistent depression 2 Transient temporary memory loss 3 Occipital headache in the morning 4 Cardiac palpitation during periods of stress

3

A nurse is evaluating a client's fluid loss resulting from extensive burns. Which laboratory result will the nurse check? 1 Blood urea nitrogen (BUN) 2 Sedimentation rate 3 Hematocrit (Hct) 4 Blood pH

3

A nurse reviews the assessment findings of four different clients with burns. Which client most likely has chemical burns? 1 Client A 2 Client B 3 Client C 4 Client D

3

After breast cancer is diagnosed, the client decides on a modified radical mastectomy followed by a combination therapy protocol that includes doxorubicin. What assessment finding does the nurse recognize as a toxic effect of this drug? 1 Paralytic ileus 2 Red-tinged urine 3 Cardiac dysrhythmias 4 Increased serum magnesium

3

An electrocardiogram (ECG) is prescribed for a client who reports chest pain. Which early finding does the nurse expect on the lead over the infarcted area? 1 Flattened T waves 2 Absence of P waves 3 Elevated ST segments 4 Disappearance of Q waves

3

A client with the diagnosis of chronic kidney disease develops hypocalcemia. Which clinical manifestations should the nurse expect the client with hypocalcemia to exhibit? Select all that apply. 1 Acidosis 2 Lethargy 3 Fractures 4 Osteomalacia 5 Eye calcium deposits

3,4,5

A 42-year-old client undergoes amniocentesis during the 16th week of gestation because of concern about Down syndrome. Which additional information about the fetus will examination of the amniotic fluid reveal at this time? 1 Lung maturity 2 Type 1 diabetes 3 Cardiac anomaly 4 Neural tube defect

4

A client is admitted to the hospital with a diagnosis of laryngeal cancer. What is a common early sign of laryngeal cancer for which the nurse should assess in this client? 1 Aphasia 2 Dyspnea 3 Dysphagia 4 Hoarseness

4

A client visits a primary healthcare provider with a report of burning and a sharp pain in the sole of the foot that intensifies in the morning. Which abnormal condition does the nurse anticipate in the client? 1 Torticollis 2 Pes planus 3 Tenosynovitis 4 Plantar fasciitis

4

A nurse is assessing a 38-year-old female client who has been admitted for a biopsy of a lump in her right breast. Which finding may indicate a malignancy? 1 A soft mass that is movable and nontender 2 Hard, hot, reddened areas that are tender and painful 3 Multiple bilateral lesions that are well delineated and movable 4 A lesion in the upper outer quadrant that is poorly delineated and immobile

4

A nurse is assessing growth and development in a 6-month-old infant. What behaviors does the nurse expect the infant to demonstrate? 1 Sitting alone, displaying pincer grasp, and waving bye-bye 2 Pulling up to a standing position, releasing a toy by choice, and playing peek-a-boo 3 Crawling, transferring a toy from one hand to the other, and displaying fear of strangers 4 Turning over completely, sitting momentarily without support, and reaching to be picked up

4

A nurse is determining a client's heart rate on an ECG strip. Which action should the nurse take? 1 Count the P waves 2 Count the T waves 3 Count the PR interval 4 Count the QRS complexes

4

A school-aged child with leukemia is receiving vincristine as part of the medical regimen. For what toxic response does the nurse assess the child? 1 Diarrhea 2 Alopecia 3 Hemorrhagic cystitis 4 Peripheral neuropathy

4

After a head injury, a client develops a deficiency of antidiuretic hormone (ADH). What should the nurse consider before assessing the patient about the response to secretion of ADH? 1 Serum osmolarity increases 2 Urine concentration decreases 3 Glomerular filtration decreases 4 Tubular reabsorption of water increases

4

During a client's routine physical examination, an abdominal aortic aneurysm is diagnosed. The client is admitted to the hospital immediately, and surgery is scheduled for the next morning. Which clinical finding should the nurse expect when completing the admission assessment? 1 Signs of shock 2 Visible peristaltic waves 3 Radiating abdominal pain 4 Pulsating abdominal mass

4

Listening to a client's heart sounds using a stethoscope, a nurse hears these sounds. What should the nurse document on the client's report? 00:00/00:11 1 Cardiac murmurs 2 First heart sound (S1) 3 Fourth heart sound (S4) 4 Pericardial friction rubs

4

The nurse instructs parents to avoid placing their infant in a prone position while sleeping. Which risk does the nurse seek to prevent with this instruction? 1 Otitis media of the ear 2 Conjunctivitis of the eye 3 Infantile colic or baby colic 4 Sudden infant death syndrome

4

The nurse is caring for a client who is admitted to the hospital with early heart failure. Which client statement indicates a clinical manifestation that is uniquely related to heart failure? 1 "I see spots before my eyes." 2 "I am tired at the end of the day." 3 "I feel bloated when I eat a large meal." 4 "I have trouble breathing when I climb a flight of stairs."

4

The nurse is providing care to a client from another culture who is involved in a motor vehicle accident. Which is the priority nursing action to provide culturally sensitive care for this client? 1 Reviewing information from the client's culture 2 Notifying the medical interpreter that translation is needed 3 Requesting that a male nurse provide care due to the documented culture 4 Asking the client and family if there is any special care related to their culture

4

The parent of a 4-week-old boy reports, "He cries all the time and always acts hungry, but he throws up everything. He looks like a skinny old man." In light of this information, what is the focus of the nurse's assessment? 1 Inspecting the anus to confirm rectal prolapse 2 Obtaining the elimination history to confirm celiac disease 3 Noting the color of vomitus to confirm a bile duct obstruction 4 Palpating the abdomen to confirm hypertrophic pyloric stenosis

4

Within minutes of giving birth to a healthy infant, the client displays symptoms of respiratory distress. An amniotic fluid embolism is suspected. In addition to respiratory distress, for what other complication should the nurse assess the client? 1 Hypertension 2 Uterine atony 3 Thrombophlebitis 4 Uncontrolled bleeding

4 (associated with DIC)

While caring for a client with heat stroke, the nurse measured the temperature and noted it as 109o F. Convert this temperature into Celsius and record your number using one decimal place. _____o C

42.8

What are the effects of long-term exposure to mustard gas? Select all that apply. A Skin burns B Skin blisters C Irritation of eyes D Pulmonary edema E Respiratory depression

A,B,C